An algorithm to stratify sleep apnea risk in a sleep disorders clinic population

Effects of Age, Metabolic and Socioeconomic Factors on Cardiovascular Risk among Saudi Women: A Subgroup Analysis from the Heart Health Promotion Study

Background: Cardiovascular disease (CVD) remains the leading cause of death in women. Along with the effect of age on the risk of CVD, the reproductive profile of women can influence cardiac health among women. Objectives: The objective of this study is to investigate the influence of age and reproductive stages on the development and progression of cardiovascular disease risks in Saudi women. Methods: For this study, we included 1907 Saudi women from the Heart Health Promotion Study. The study cohort was divided into five age groups (less than 40 years, 40-45 years, 46-50 years, 51-55 years, and ≥56 years). The cohort stratification was meant to correspond to the social and hormonal changes in women's life, including reproductive, perimenopausal, menopausal, and postmenopausal age groups. The groups were compared with respect to the prevalence of metabolic, socioeconomic, and cardiac risks, and the age group of less than 40 years was considered as the reference group. The World Health Organization stepwise approach to chronic disease risk factor Surveillance-Instrument v2.1 was used in this study to collect the anthropometric and biochemical measurements and the Framingham Coronary Heart Risk Score was used to calculate the cardiovascular risk (CVR). Logistic regression analysis was conducted to assess the independent effect of age on CVD risks after adjustment of sociodemographic factors. Results: Metabolic and CVR increased progressively with the increase in age. There was a sharp increase in obesity, hypertension, diabetes, and metabolic syndrome, from the age group <40 years to 41-45 years and then again between the age groups of 46-50 and ≥56 years. A similar noticeable increase in metabolic risk factors (high cholesterol, high triglyceride, high Low-Density Lipoprotein) was observed between the age group <40 years and 41-45 years, but with a steady increase with the increase in age between the other age groups. The high and intermediate Framingham Coronary Heart Risk Scores showed a progressive increase in prevalence with the increase in age, where the proportion doubled from 9.4% at the age group 46-50 years, to 22% at the age group 51-55 years. It doubled again at the age group ≥56 years to 53%-these sharp inflections in the risk of CVD correspond to the women's reproductive lives. Conclusions: In Saudi women, CVR increases with the increase of age. The influence of pregnancy and menopause is apparent in the prevalence of increased risks for cardiovascular and metabolic diseases.

Describing economic benefits and costs of nonstandard work hours: A scoping review

BACKGROUND

The benefits of nonstandard work hours include increased production time and the number of jobs. While for some sectors, such as emergency services, around-the-clock work is a necessary and critical societal obligation, work outside of traditional daytime schedules has been associated with many occupational safety and health hazards and their associated costs. Thus, organizational- and policy-level decisions on nonstandard work hours can be difficult and are based on several factors including economic evaluation. However, there is a lack of systematic knowledge of economic benefits and costs associated with these schedules.

METHODS

We conducted a scoping review of the methodology and data used to examine the economic benefits and costs of nonstandard work hours and related interventions to mitigate risks.

RESULTS

Ten studies met all our inclusion criteria. Most studies used aggregation and analysis of national and other large datasets. Costs estimated include health-related expenses, productivity losses, and projections of future loss of earnings. Cost analyses of interventions were provided for an obstructive sleep apnea screening program, implementation of an employer-based educational program, and increased staffing to cover overtime hours.

CONCLUSIONS

A paucity of studies assess nonstandard work hours using economic terms. Future studies are needed to expand economic evaluations beyond the employer level to include those at the societal level because impacts of nonstandard work go beyond the workplace and are important for policy analysis and formulation. We pose the opportunity for researchers and employers to share data and resources in the development of more analyses that fill these research gaps.

A new tool to screen patients with severe obstructive sleep apnea in the primary care setting: a prospective multicenter study

Background

The coordination between different levels of care is essential for the management of obstructive sleep apnea (OSA). The objective of this multicenter project was to develop a screening model for OSA in the primary care setting.

Methods

Anthropometric data, clinical history, and symptoms of OSA were recorded in randomly selected primary care patients, who also underwent a home sleep apnea test (HSAT). Respiratory polygraphy or polysomnography were performed at the sleep unit to establish definite indication for continuous positive airway pressure (CPAP). By means of cross-validation, a logistic regression model (CPAP yes/no) was designed, and with the clinical variables included in the model, a scoring system was established using the β coefficients (PASHOS Test). In a second stage, results of HSAT were added, and the final accuracy of the model was assessed.

Results

194 patients completed the study. The clinical test included the body mass index, neck circumference and observed apneas during sleep (AUC 0.824, 95% CI 0.763–0.886, P < 0.001). In a second stage, the oxygen desaturation index (ODI) of 3% (ODI3% ≥ 15%) from the HSAT was added (AUC 0.911, 95% CI 0.863–0.960, P < 0.001), with a sensitivity of 85.5% (95% CI 74.7–92.1) and specificity of 67.8% (95% CI 55.1–78.3).

Conclusions

The use of this model would prevent referral to the sleep unit for 55.1% of the patients. The two-stage PASHOS model is a useful and practical screening tool for OSA in primary care for detecting candidates for CPAP treatment.

Clinical Trial Registration Registry: ClinicalTrials.gov; Name: PASHOS Project: Advanced Platform for Sleep Apnea Syndrome Assessment; URL: https://clinicaltrials.gov/ct2/show/NCT02591979; Identifier: NCT02591979. Date of registration: October 30, 2015.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12890-022-01827-0.

Feasibility of Single Channel Oximetry for Mass Screening of Obstructive Sleep Apnea

BACKGROUND

The growing awareness for the high prevalence of obstructive sleep apnea (OSA) coupled with the dramatic proportion of undiagnosed individuals motivates the elaboration of a simple but accurate screening test. This study assesses, for the first time, the performance of oximetry combined with demographic information as a screening tool for identifying OSA in a representative (i.e. non-referred) population sample.

METHODS

A polysomnography (PSG) clinical database of 887 individuals from a representative population sample of São Paulo's city (Brazil) was used. Using features derived from the oxygen saturation signal during sleep periods and demographic information, a logistic regression model (termed OxyDOSA) was trained to distinguish between non-OSA and OSA individuals (mild, moderate, and severe). The OxyDOSA model performance was assessed against the PSG-based diagnosis of OSA (AASM 2017) and compared to the NoSAS and STOP-BANG questionnaires.

FINDINGS

The OxyDOSA model had mean AUROC = 0.94 ± 0.02, Se = 0.87 ± 0.04 and Sp = 0.85 ± 0.03. In particular, it did not miss any of the 75 severe OSA individuals. In comparison, the NoSAS questionnaire had AUROC = 0.83 ± 0.03, and missed 23/75 severe OSA individuals. The STOP-BANG had AUROC = 0.77 ± 0.04 and missed 14/75 severe OSA individuals.

INTERPRETATION

We provide strong evidence on a representative population sample that oximetry biomarkers combined with few demographic information, the OxyDOSA model, is an effective screening tool for OSA. Our results suggest that sleep questionnaires should be used with caution for OSA screening as they fail to identify many moderate and even some severe cases. The OxyDOSA model will need to be further validated on data recorded using overnight portable oximetry.

Screening for Obstructive Sleep Apnea in Commercial Drivers Using EKG-Derived Respiratory Power Index

STUDY OBJECTIVES

Obstructive sleep apnea (OSA) is common in commercial motor vehicle operators (CMVOs); however, polysomnography (PSG), the gold-standard diagnostic test, is expensive and inconvenient for screening. OSA is associated with changes in heart rate and voltage on electrocardiography (EKG). We evaluated the utility of EKG parameters in identifying CMVOs at greater risk for sleepiness-related crashes (apnea-hypopnea index [AHI] ≥ 30 events/h).

METHODS

In this prospective study of CMVOs, we performed EKGs with concurrent PSG, and calculated the respiratory power index (RPI) on EKG, a surrogate for AHI calculated from PSG. We evaluated the utility of two-stage predictive models using simple clinical measures (age, body mass index [BMI], neck circumference, Epworth Sleepiness Scale score, and the Multi-Variable Apnea Prediction [MVAP] score) in the first stage, followed by RPI in a subset as the second-stage. We assessed area under the receiver operating characteristic curve (AUC), sensitivity, and negative posttest probability (NPTP) for this two-stage approach and for RPI alone.

RESULTS

The best-performing model used the MVAP, which combines BMI, age, and sex with three OSA symptoms, in the first stage, followed by RPI in the second. The model yielded an estimated (95% confidence interval) AUC of 0.883 (0.767-0.924), sensitivity of 0.917 (0.706-0.962), and NPTP of 0.034 (0.015-0.133). Predictive characteristics were similar using a model with only BMI as the first-stage screen.

CONCLUSIONS

A two-stage model that combines BMI or the MVAP score in the first stage, with EKG in the second, had robust discriminatory power to identify severe OSA in CMVOs.

Clinical Trial Enrollment Enrichment in Resource-Constrained Research Environments: Multivariable Apnea Prediction (MAP) Index in SCIP-PA Trial

STUDY OBJECTIVES

Determine the Multivariable Apnea Prediction (MAP) index predictive utility for enrollment enrichment in a clinical trial wherein enrollment was prior to obstructive sleep apnea diagnosis.

METHODS

Secondary analysis of screening data (n = 264) from randomized, double-blind, pilot trial. Clinical sleep center patients with complete screening and polysomnography data were included. To determine diagnostic test accuracy of the MAP index using apnea-hypopnea index criterion ≥ 10 events/h (primary) and ≥ 5, ≥ 15, and ≥ 30 events/h (secondary), sensitivity, specificity, negative and positive predictive values, likelihood positive and negative ratios, and receiver operating characteristic curves were calculated. Predictive utility was examined by characteristic variables.

RESULTS

Middle-aged, overweight or obese, men and women were included. Employing a MAP index threshold ≥ 0.5, sensitivity for obstructive sleep apnea (apnea-hypopnea index ≥ 10 events/h) was 83.6%; specificity was 46.4%; area under the curve = 0.74. Sensitivity was higher in males than females (95.3%, 68.7%, respectively); specificity was lower in males than females (30.4%, 57.6%, respectively) with similar area under the curve (0.74 versus 0.72, respectively). MAP accuracy was higher in younger versus older adults (younger than 50 years, or 50 years or older; area under the curve 0.82 versus 0.63, respectively). Varied apnea-hypopnea index criteria produced stable accuracy estimates.

CONCLUSIONS

Recruitment/enrollment is a high-cost endeavor. Screening procedures may confer resource savings but careful evaluation prior to study implementation assures effectiveness and efficiency.

CLINICAL TRIAL REGISTRATION

The secondary analysis reports data from the SCIP-PA Trial (NCT 01454830); study information available at: https://clinicaltrials.gov.

Evaluación del síndrome de apnea-hipopnea obstructiva del sueño (SAHOS) mediante instrumentos de medición como escalas y fórmulas matemáticas

La psicometría del síndrome de apnea-hipopnea obstructiva del sueño (SAHOS) se puede proporcionar con el uso de variados métodos de evaluación como entrevistas clínicas, escalas, cuestionarios de sueño, autoregistros y registros psicofisiológicos. La prueba de oro para el diagnóstico de esta enfermedad sigue siendo la polisomnografía, la cual puede llegar a tener altos costos y dificultades para acceder al estudio. Debido a la alta morbimortalidad asociada a este síndrome, se requieren instrumentos que permitan la identificación rápida de individuos que puedan estar en riesgo de padecerlo. Por tales motivos, se han desarrollado herramientas que permiten detectar los pacientes en riesgo de presentar SAHOS, tales como el Cuestionario de Berlín, el STOP-Bang y la Escala de Somnolencia de Epworth. Es importante tener en cuenta los alcances y limitaciones de estas herramientas para escoger el instrumento indicado según lo que se desee evaluar.

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).

During economic crisis can sleep questionnaires improve the value of oximetry for assessing sleep apnea?

BACKGROUND

The diagnosis of obstructive sleep apnea/hypopnea syndrome (OSAHS) is essential but polysomnography (PSG) is expensive and time consuming. Oximetry has been used as a less expensive indicator of OSAHS. The aim of the study was to evaluate the clinical utility of the combination of oximetry with four different questionnaires: Stop, Stop Bang (S-B), Berlin questionnaire (BQ), Epworth Sleepiness Scale (ESS) in order to identify patients at risk for OSAHS compared with in-laboratory PSG.

METHODS

Patients visiting a sleep clinic were prospectively studied. They completed Stop, S-B, BQ and ESS. Home oximetry and in laboratory PSG were performed within 3-20 days.

RESULTS

A total of 204 patients were included in the study (77.5% males, mean age 51.8±13.8 years, BMI 32.8±6.2 kg/m², SaO₂% awake 95.7±2). S-B had the highest sensitivity (Se) (97.5%) and negative predictive value (NPV) (62.5%) but the lowest specificity (Sp) (9%), whereas ESS had the best Sp (75%) and positive predictive values (PPV) (81.4%). The predictive values of questionnaires improved as the severity of OSAHS worsened. The predictive values of oximetry were high for severe but low for mild and moderate OSAHS. For that oximetry was combined with different sleep questionnaires in different OSAHS severity groups, but with no improvement in the predictive values.

CONCLUSIONS

Oximetry may be used as a tool for identifying severe OSAHS. For mild and moderate disease the combination of questionnaires did not improve the diagnostic accuracy and especially for symptomatic patients with negative results, the need of PSG is essential.

Relationship of Snoring and Sleepiness as Presenting Symptoms in a Sleep Clinic Population

Objectives:

Sleepiness has traditionally been considered medically the cardinal symptom of obstructive sleep apnea syndrome. Snoring is perceived as a social or cosmetic complaint. Without independent medical morbidity, snoring identification and treatment is not a major focus in sleep medicine. We speculate that snoring is a major independent symptom. To evaluate how patients rated snoring symptom severity, we compared the relative significance of a sleep clinic population's presenting symptoms of snoring and sleepiness.

Methods:

We performed a retrospective analysis of 770 consecutive patients who completed sleep intake evaluation forms at the initial clinic visit, including standardized forms for both sleepiness and snoring using previously validated visual analog scales. Data on symptom magnitude (scale of 1 to 10), symptom importance (scale of 1 to 5), a combined symptom product score consisting of magnitude multiplied by importance (MIP; scale of 1 to 50), the Epworth Sleepiness Scale (ESS; n = 599), and the apnea-hypopnea index (AHI; n = 482; mean ± SD, 35.6 ± 31.9 events per hour) were collected.

Results:

The mean snoring measures (magnitude, importance, and MIP) were greater than those for sleepiness (MIPsnoring of 32.7 ± 14.8 versus MIPsleepiness of 22.4 ± 14.2, p <.001). Snoring scored higher than sleepiness in 72% of individuals. To assess whether sleep apnea or sleepiness severity affected symptom scores, we stratified the subgroup with sleep studies into quartiles by AHI and ESS score. Snoring consistently scored higher than sleepiness in most AHI and ESS quartiles (p <.01). Only in the most severe ESS quartile did any sleepiness measure (importance) score higher than the snoring measure (p <.05).

Conclusions:

The presenting symptoms of snoring are larger in magnitude, importance, and severity than those of sleepiness in a broad population of patients with sleep disorders and sleep-disordered breathing irrespective of severity of sleep apnea or sleepiness. Symptoms of major significance are clinically relevant to identifying, diagnosing, and treating patients. Failure of medical providers to appreciate the impact of snoring on this population may affect attempts to identify, diagnose, and treat patients with sleep-disordered breathing.

Utility of portable monitoring in the diagnosis of obstructive sleep apnea

Obstructive sleep apnea (OSA) is a common but underdiagnosed sleep disorder, which is associated with systemic consequences such as hypertension, stroke, metabolic syndrome, and ischemic heart disease. Nocturnal laboratory-based polysomnography (PSG) is the gold standard test for diagnosis of OSA. PSG consists of a simultaneous recording of multiple physiologic parameters related to sleep and wakefulness including electroencephalography (EEG), electrooculography (EOG), surface electromyography (EMG), airflow measurement using thermistor and nasal pressure transducer, pulse oximetry and respiratory effort (thoracic and abdominal). Multiple alternative and simpler methods that record respiratory parameters alone for diagnosing OSA have been developed in the past two decades. These devices are called portable monitors (PMs) and enable performing sleep studies at a lower cost with shorter waiting times. It has been observed and reported that comprehensive sleep evaluation coupled with the use of PMs can fulfill the unmet need for diagnostic testing in various out-of-hospital settings in patients with suspected OSA. This article reviews the available medical literature on PMs in order to justify the utility of PMs in the diagnosis of OSA, especially in resource-poor, high-disease burden settings. The published practice parameters for the use of these devices have also been reviewed with respect to their relevance in the Indian setting.

A Prognosis Tool Based on Fuzzy Anthropometric and Questionnaire Data for Obstructive Sleep Apnea Severity

Obstructive sleep apnea (OSA) are linked to the augmented risk of morbidity and mortality. Although polysomnography is considered a well-established method for diagnosing OSA, it suffers the weakness of time consuming and labor intensive, and requires doctors and attending personnel to conduct an overnight evaluation in sleep laboratories with dedicated systems. This study aims at proposing an efficient diagnosis approach for OSA on the basis of anthropometric and questionnaire data. The proposed approach integrates fuzzy set theory and decision tree to predict OSA patterns. A total of 3343 subjects who were referred for clinical suspicion of OSA (eventually 2869 confirmed with OSA and 474 otherwise) were collected, and then classified by the degree of severity. According to an assessment of experiment results on g-means, our proposed method outperforms other methods such as linear regression, decision tree, back propagation neural network, support vector machine, and learning vector quantization. The proposed method is highly viable and capable of detecting the severity of OSA. It can assist doctors in pre-diagnosis of OSA before running the formal PSG test, thereby enabling the more effective use of medical resources.

Predictors of Obstructive Sleep Apnea on Polysomnography after a Technically Inadequate or Normal Home Sleep Test

STUDY OBJECTIVES

Home sleep testing (HST) is an accepted alternative to polysomnography (PSG) for diagnosing obstructive sleep apnea (OSA) in high-risk populations. Clinical guidelines recommend PSG in cases where the HST is technically inadequate (TI) or fails to establish the diagnosis of OSA in patients with high pretest probability. This retrospective study evaluated predictors of OSA on PSG within patients who had a TI or normal HST.

METHODS

Electronic medical records were reviewed on 1,157 patients referred for HST at our sleep center. Two hundred thirty-eight patients had a TI or normal HST with subsequent PSG. Age, BMI, Epworth score, HST result, and PSG-based apnea-hypopnea index (AHI) were abstracted.

RESULTS

Two hundred thirty-eight consecutive patients with either a normal HST (n = 127) or TI HST (n = 111) underwent subsequent PSG. Of 127 who had a normal HST, 76% had a normal PSG and 24% had OSA (23 mild, 6 moderate, 1 severe). Of 111 who had a TI HST, 29% had a normal PSG and 71% had OSA (43 mild, 19 moderate, 17 severe). Individuals younger than 50 years old with a normal HST were more likely to have a normal PSG. Older age predicted diagnosis of OSA on PSG among individuals with a TI HST.

CONCLUSION

In this retrospective analysis of a clinical sample, when the HST is interpreted as normal in a younger patient population, the subsequent PSG is likewise normal in majority of the patients, although significant OSA is sometimes discovered. When a HST is read as TI, the majority of patients have OSA.

Use of oximetry as a screening tool for obstructive sleep apnea: a case study in Taiwan

Obstructive sleep apnea (OSA) is a relatively common disease in the general population. Patients with OSA have a high risk of various comorbid medical diseases. Polysomnography (PSG) is the current gold standard for diagnosing OSA but is time consuming and expensive. This study aims to identify a sensitive screening parameter that can be used by clinicians to determine the time of referral for PSG examination in Taiwan. Eighty-seven patients, including 67 males and 20 females, were included in this study. We divided the patients into two groups: training data (n = 58) and testing group (n = 29). Pearson χ(2) test was used to perform bivariate analysis, and a decision tree was used to build a model. The decision model selected the frequency of desaturation > 4% per hour (DI4) as the indicator of OSA influence. The testing data accuracy of the C4.5 decision tree was 82.80%. External data were also used to validate the model reliability. The accuracy of the external data was 95.96%. Approximately one-third of patients with DI4 between 11 and 33 suffered from OSA. This population requires further diagnosis. Oximetry is an important and widely available screening method in Taiwan. This study proposes the need for PSG referral if DI4 is between 11 and 33.

Comparative effectiveness research in obstructive sleep apnea: bridging gaps between efficacy studies and clinical practice

Comparative effectiveness research encompasses research that compares two interventions to each other, and takes place in real-world settings without strict inclusion and exclusion criteria, according to the established standard of care. There is a need for comparative evaluations of the treatments for obstructive sleep apnea, a disease associated with increased cardiovascular risk, stroke and metabolic derangement. This article reviews the recent, representative literature that addresses obstructive sleep apnea intervention and treatment, paradigms for diagnosis and randomized control trials addressing the efficacy of interventions, in an effort to demonstrate examples of both traditional observational and randomized control trials, as well as to illustrate the considerable overlap between some traditional studies and comparative effectiveness research. Despite methodological challenges, the potentially large clinical and public health impact of obstructive sleep apnea, accompanied by considerable cost, mandates that randomized controlled trials and comparative effectiveness research be systematically applied to identify both the efficacy and effectiveness of alternative diagnosis and treatment strategies.

Traditional and nontraditional cardiovascular risk factors in comorbid insomnia and sleep apnea

OBJECTIVES

Insomnia and sleep apnea frequently co-occur and are independently associated with an increased risk of cardiovascular disease, but little is known about cardiovascular disease risk among individuals with comorbid insomnia and sleep apnea. The current study examined traditional risk factors and a physiologic biomarker of cardiovascular risk in comorbid insomnia and sleep apnea.

DESIGN

Community-based participatory research study.

PARTICIPANTS

The sample comprised 795 participants without preexisting cardiovascular disease from the Heart Strategies Concentrating On Risk Evaluation (Heart SCORE) study.

MEASUREMENTS AND RESULTS

Participants were assessed for symptoms of insomnia and sleep apnea risk, as well as for presence of obesity, smoking, a sedentary lifestyle, hypertension, dyslipidemia, and diabetes. Baseline resting brachial artery diameter was measured by B-mode ultrasonography. A total of 138 participants (17.4%) met criteria for insomnia syndrome alone, 179 (22.5%) were at high risk for sleep apnea alone, 95 (11.9%) reported both insomnia syndrome and high sleep apnea risk, and 383 (48.2%) reported having neither insomnia nor sleep apnea symptoms Both high sleep apnea risk alone and comorbid insomnia and high sleep apnea risk groups had greater frequencies of obesity, sedentary lifestyle, hypertension, and three or more traditional cardiovascular risk factors and significantly larger brachial artery diameters than the insomnia alone group and those without insomnia or sleep apnea symptoms. No differences in traditional cardiovascular risk factors or brachial artery diameter were found between the high sleep apnea risk and comorbid groups.

CONCLUSIONS

These findings suggest that sleep apnea is a major contributor to cardiovascular risk and co-occurring insomnia does not appear to add to this risk.

Examination of pulse oximetry tracings to detect obstructive sleep apnea in patients with advanced chronic obstructive pulmonary disease

Nocturnal hypoxemia and obstructive sleep apnea (OSA) are common comorbidities in patients with chronic obstructive pulmonary disease (COPD). The authors sought to develop a strategy to interpret nocturnal pulse oximetry and assess its capacity for detection of OSA in patients with stage 3 to stage 4 COPD. A review of consecutive patients with COPD who were clinically prescribed oximetry and polysomnography was conducted. OSA was diagnosed if the polysomnographic apnea-hypopnea index was >15 events⁄h. Comprehensive criteria were developed for interpretation of pulse oximetry tracings through iterative validation and interscorer concordance of ≥80%. Criteria consisted of visually identified desaturation 'events' (sustained desaturation ≥4%, 1 h time scale), 'patterns' (≥3 similar desaturation⁄saturation cycles, 15 min time scale) and the automated oxygen desaturation index. The area under the curve (AUC), sensitivity, specificity and accuracy were calculated. Of 59 patients (27 male), 31 had OSA (53%). The mean forced expiratory volume in 1 s was 46% of predicted (range 21% to 74% of predicted) and 52% of patients were on long-term oxygen therapy. Among 59 patients, 35 were correctly identified as having OSA or not having OSA, corresponding to an accuracy of 59%, with a sensitivity and specificity of 59% and 60%, respectively. The AUC was 0.57 (95% CI 0.55 to 0.59). Using software-computed desaturation events (hypoxemia ≥4% for ≥10 s) indexed at ≥15 events⁄h of sleep as diagnostic criteria, sensitivity was 60%, specificity was 63% and the AUC was 0.64 (95%CI 0.62 to 0.66). No single criterion demonstrated important diagnostic utility. Pulse oximetry tracing interpretation had a modest diagnostic value in identifying OSA in patients with moderate to severe COPD.

Screening for sleep apnoea in mild cognitive impairment: the utility of the multivariable apnoea prediction index

Purpose. Mild cognitive impairment (MCI) is considered an “at risk” state for dementia and efforts are needed to target modifiable risk factors, of which Obstructive sleep apnoea (OSA) is one. This study aims to evaluate the predictive utility of the multivariate apnoea prediction index (MAPI), a patient self-report survey, to assess OSA in MCI. Methods. Thirty-seven participants with MCI and 37 age-matched controls completed the MAPI and underwent polysomnography (PSG). Correlations were used to compare the MAPI and PSG measures including oxygen desaturation index and apnoea-hypopnoea index (AHI). Receiver-operating characteristics (ROC) curve analyses were performed using various cut-off scores for apnoea severity. Results. In controls, there was a significant moderate correlation between higher MAPI scores and more severe apnoea (AHI: r = 0.47, P = 0.017). However, this relationship was not significant in the MCI sample. ROC curve analysis indicated much lower area under the curve (AUC) in the MCI sample compared to the controls across all AHI severity cut-off scores. Conclusions. In older people, the MAPI moderately correlates with AHI severity but only in those who are cognitively intact. Development of further screening tools is required in order to accurately screen for OSA in MCI.

Obstructive sleep apnea in North American commercial drivers

The most common medical cause of excessive daytime sleepiness (EDS) is obstructive sleep apnea (OSA). Specifically, among an estimated 14 million US commercial drivers, 17-28% or 2.4 to 3.9 million are expected to have OSA. Based on existing epidemiologic evidence, most of these drivers are undiagnosed and not adequately treated. Untreated OSA increases the risk of vehicular crashes as documented in multiple independent studies and by meta-analysis. Therefore, identifying commercial drivers with OSA and having them effectively treated should decrease crash-related fatalities and injuries. Several strategies are available for screening and identifying drivers with OSA. The simplest and most effective objective strategies use body mass index (BMI) cutoffs for obesity. Functional screens are promising adjuncts to other objective tests. The most effective approach will likely be a combination of a good questionnaire; BMI measures; and a careful physician-obtained history complemented by a functional screen.

Berlin questionnaire study in surgical patient in Alzahra Hospital in year 2010

Background:

To examine the prevalence of high-risk subjects of obstructive sleep apnea (OSA) and its predictive factors in patients undergoing elective surgery by using the Berlin Questionnaire.

Materials and Methods:

300 surgical ASA physical status I, II, III, and IV patients were surveyed. Patients were screened with the Berlin questionnaire for obstructive sleep apnea. Data of sex, age, BMI and HTN also evaluated. Data were analyzed by Chi-square test and P < 0.05 was meaningful.

Results:

The Berlin questionnaire identified 25.3% (76/300) of patients as being at high risk of sleep apnea (95% confidence interval, 20%-28%). This group consisted of 195 (65%) males and 105 (35%) females. The prevalence of high-risk subjects in men were more significantly than women (P = 0.001). High-risk subjects also were increasing with age (P = 0.000) and increasing with obesity (P = 0.000) and arterial hypertension (P = 0.000).

Conclusions:

Predictors of high risk for OSA-related symptoms were female sex, age more than 50 years, and body mass index.

The use of sub-mental ultrasonography for identifying patients with severe obstructive sleep apnea

OBJECTIVE

This study aimed to explore the association between obstructive sleep apnea (OSA) severity and pharyngeal parameters using sub-mental ultrasonography (US), and investigate the accuracy of US for identifying severe OSA patients.

METHODS

One hundred and five consecutive referrals for suspected OSA were enrolled. The diameters of the retro-glossal (RG) and retro-palatal (RP) regions were measured via sub-mental US upon expiration during tidal breathing, forced inspiration, and Müller maneuver (MM). Independent factors associated with severe OSA identified from two-thirds of randomly-selected patients (model-development group) were used to construct a model for predicting severe OSA. The accuracy of the model was validated in the remaining one-third of patients (validation group).

RESULTS

Fifty severe OSA patients, 30 with mild-moderate OSA, and 25 without OSA were enrolled. Compared to non-OSA and mild-moderate OSA patients, those with severe OSA had narrower RP diameter in all three maneuvers. Using the prediction model constructed with changes of RP diameters at MM and neck circumference, the independent predictors of severe OSA in the model-development group had 100% sensitivity and 65% specificity.

CONCLUSION

Sub-mental US can accurately discriminate the severity of OSA and be used to identify patients with severe OSA.

TRIAL REGISTRATION

ClinicalTrials.gov NCT00674076.

Screening for severe obstructive sleep apnea syndrome in hypertensive outpatients

The authors attempted to validate a 2-stage strategy to screen for severe obstructive sleep apnea syndrome (s-OSAS) among hypertensive outpatients, with polysomnography (PSG) as the gold standard. Using a prospective design, outpatients with hypertension were recruited from medical outpatient clinics. Interventions included (1) assessment of clinical data; (2) home sleep testing (HST); and (3) 12-channnel, in-laboratory PSG. The authors developed models using clinical or HST data alone (single-stage models) or clinical data in tandem with HST (2-stage models) to predict s-OSAS. For each model, area under receiver operating characteristic curves (AUCs), sensitivity, specificity, negative likelihood ratio, and negative post-test probability (NPTP) were computed. Models were then rank-ordered based on AUC values and NPTP. HST used alone had limited accuracy (AUC=0.727, NPTP=2.9%). However, models that used clinical data in tandem with HST were more accurate in identifying s-OSAS, with lower NPTP: (1) facial morphometrics (AUC=0.816, NPTP=0.6%); (2) neck circumference (AUC=0.803, NPTP=1.7%); and Multivariable Apnea Prediction Score (AUC=0.799, NPTP=1.5%) where sensitivity, specificity, and NPTP were evaluated at optimal thresholds. Therefore, HST combined with clinical data can be useful in identifying s-OSAS in hypertensive outpatients, without incurring greater cost and patient burden associated with in-laboratory PSG. These models were less useful in identifying obstructive sleep apnea syndrome of any severity.

In-home, self-assembled sleep studies are useful in diagnosing sleep apnea in the elderly

OBJECTIVES

Obstructive sleep apnea (OSA) is common and treatable among the elderly. Yet, few older adults seek evaluation for OSA at sleep disorders centers. The authors assessed the feasibility of a two-stage screening procedure for obstructive sleep apnea syndrome (OSAS) in a community-based sample of older adults.

DESIGN

Prospective cohort study.

SETTING

Participants' domicile (in-home) and academic sleep research center.

PARTICIPANTS

There were 452 Medicare recipients residing in the greater Philadelphia metropolitan area with the complaint of daytime sleepiness.

INTERVENTIONS

None.

MEASUREMENTS AND RESULTS

All participants underwent in-home unattended sleep studies that recorded airflow, and standard in-laboratory polysomnography. Additional measures included symptoms of sleep apnea, body mass index, neck circumference, age, and sex. When comparing diagnostic approaches, the best-performing single-stage model was one that combined apnea symptoms with age and neck circumference. This model had an area under the receiver operating characteristic curve (AUC) of 0.774 and negative posttest probability of 1.2%. The best-performing two-stage model combined symptoms, neck circumference, age, and sex in the first stage, followed by an unattended portable study with a corresponding AUC of 0.85 and negative posttest probability of 0.5%.

CONCLUSIONS

Unattended, self-assembled, in-home sleep studies recording airflow and respiratory effort are most useful if applied in tandem with clinical data, including a carefully obtained sleep history. This two-stage model is accurate in identifying severe OSAS in older adults and represents a practical diagnostic approach for older adults. Incorporating clinical data was vital and increased accuracy well above that of unattended studies of airflow and effort alone.

Portable diagnostic devices for identifying obstructive sleep apnea among commercial motor vehicle drivers: considerations and unanswered questions

Obstructive sleep apnea (OSA), a syndrome defined by breathing abnormalities during sleep, can lead to fatigue and excessive daytime sleepiness (EDS) with an increased risk of motor vehicle crashes. Identifying commercial motor vehicle operators with unrecognized OSA is a major public health priority. Portable monitors (PMs) are being actively marketed to trucking firms as potentially lower-cost and more accessible alternatives to the reference standard of in-laboratory polysomnography (PSG) in the diagnosis of OSA among commercial motor vehicle operators. Several factors regarding PMs remain uncertain in this unique patient population: their sensitivity and specificity; the cost-benefit ratio of the PMs versus PSG; potential barriers from human factors; and evolving technologic advancement. Human factors that alter test accuracy are a major concern among commercial drivers motivated to gain/maintain employment. Current available data using PMs as a diagnostic tool among CMV operators indicate relatively high data loss and high loss to follow-up. Loss to follow-up has also been an issue using PSG in commercial motor vehicle operators. Furthermore, PM testing and PM results interpretation protocols may have no sleep specialist oversight, and sometimes minimal physician oversight and involvement. Additional studies comparing unattended and unmonitored PMs directly against full in-laboratory PSG are needed to provide evidence for their efficacy among commercial motor vehicle operators.

Poor sleep quality and sleep apnea are associated with higher resting energy expenditure in obese individuals with short sleep duration

CONTEXT

Epidemiological studies reported an inverse or U-shaped relationship between sleep duration and weight. The relationship between sleep and resting energy expenditure (REE) has not been well characterized.

OBJECTIVE

The aim of the study was to determine the relationship between sleep, REE, and stress hormones.

DESIGN AND SETTING

We conducted a cross-sectional evaluation of a prospective cohort study at a tertiary referral research clinical center.

SUBJECTS

Subjects included 126 obese individuals (30 males, 96 females; age, 40.5 ± 6.9 yr; body mass index, 38.6 ± 6.5 kg/m(2); sleep duration, 360 ± 50 min/night; and sleep efficiency, 79.5 ± 7.5%).

MAIN OUTCOME MEASURE(S)

REE and respiratory quotient (RQ) were assessed by indirect calorimetry. Sleep duration and sleep efficiency were assessed by actigraphy. Sleep quality was estimated by questionnaires, and sleep apnea was evaluated by respiratory disturbance index (RDI). Morning plasma ACTH, serum cortisol, and 24-h urinary free cortisol and catecholamines were also measured.

RESULTS

RDI was positively correlated with REE adjusted by fat-free mass (r = 0.307; P = 0.003) and RQ (r = 0.377; P < 0.001). Sleep efficiency was inversely correlated with RQ (r = -0.200; P = 0.033). The relationship of RDI score and REE was stronger in men than women (P = 0.03). In women, serum cortisol was positively correlated (r = 0.407; P < 0.001), and Epworth sleepiness score tended to be inversely (r = -0.190; P = 0.086) correlated with adjusted REE. The RQ was positively related to RDI in women, whereas subjective sleep time was related to RQ in men. In a multiple regression model, RDI, serum cortisol, and urinary norepinephrine were directly related to REE, whereas serum cortisol also directly related to adjusted REE.

CONCLUSION

Poor sleep quality was associated with increased REE, a higher RQ indicating a shift from fat toward carbohydrate oxidation, and activation of the stress system.

Prediagnosis of obstructive sleep apnea via multiclass MTS

Obstructive sleep apnea (OSA) has become an important public health concern. Polysomnography (PSG) is traditionally considered an established and effective diagnostic tool providing information on the severity of OSA and the degree of sleep fragmentation. However, the numerous steps in the PSG test to diagnose OSA are costly and time consuming. This study aimed to apply the multiclass Mahalanobis-Taguchi system (MMTS) based on anthropometric information and questionnaire data to predict OSA. Implementation results showed that MMTS had an accuracy of 84.38% on the OSA prediction and achieved better performance compared to other approaches such as logistic regression, neural networks, support vector machine, C4.5 decision tree, and rough set. Therefore, MMTS can assist doctors in prediagnosis of OSA before running the PSG test, thereby enabling the more effective use of medical resources.

Assessing sleepiness and sleep disorders in Australian long-distance commercial vehicle drivers: self-report versus an "at home" monitoring device

STUDY OBJECTIVES

As obstructive sleep apnea (OSA) is associated with a higher risk of motor vehicle crashes, there is increasing regulatory interest in the identification of commercial motor vehicle (CMV) drivers with this condition. This study aimed to determine the relationship between subjective versus objective assessment of OSA in CMV drivers.

DESIGN

Cross-sectional survey.

SETTINGS

Heavy vehicle truck stops located across the road network of 2 large Australian states.

PARTICIPANTS

A random sample of long distance commercial vehicle drivers (n = 517).

INTERVENTIONS

None.

MEASUREMENTS AND RESULTS

Drivers were interviewed regarding their driving experience, personal health, shift schedules, payments, and various questions on sleep and tiredness in order to describe their sleep health across a range of variables. In addition, home recordings using a flow monitor were used during one night of sleep. Only 4.4% of drivers reported a previous diagnosis of sleep apnea, while our at home diagnostic test found a further 41% of long-distance heavy vehicle drivers likely to have sleep apnea. The multivariable apnea prediction index, based on self-report measures, showed poor agreement with the home-monitor detected sleep apnea (AUC 0.58, 95%CI = 0.49-0.62), and only 12% of drivers reported daytime sleepiness (Epworth Sleepiness Scale score > 10). Thirty-six percent of drivers were overweight and a further 50% obese; 49% of drivers were cigarette smokers.

CONCLUSIONS

Sleep apnea remains a significant and unrecognized problem in CMV drivers, who we found to have multiple health risks. Objective testing for this sleep disorder needs to be considered, as symptom reports and self-identification appear insufficient to accurately identify those at risk.

Frequently used sleep questionnaires in epidemiological and genetic research for obstructive sleep apnea: a review

BACKGROUND & AIMS

Many sleep questionnaires are utilized by the epidemiological and genetic research communities. This paper reviewed sleep-related questions and answers commonly used in epidemiological studies (focused on sleep apnea and snoring), with an emphasis on the utility of the response options.

METHODS

A literature search was conducted to identify relevant sleep questionnaires. Questionnaires were limited to the English language and had to include questions specific to snoring or stop breathing during sleep. Questionnaires had to demonstrate a citation count >10 through Web of Science. A comparison of questions and answers, and elements important in the design of good quality instruments was conducted.

RESULTS

Fourteen questionnaires met the inclusion criteria for final review. Validation was conducted for many of these instruments, though the methods and validation populations were highly variable. Study sample sizes were also relatively small and differed in methods of data analysis. These questionnaires were very heterogeneous, with only some (n = 6) allowing a "don't know" alternative. Six specified the time period referred to as "past month", one referred to "last three months" and the remaining questionnaires had no specific timeframe. The response alternatives to specific questions were Yes/No (n = 5), wording only like "never", "seldom", "often" (n = 4), or a frequency scale indicating times per week (n = 8).

CONCLUSIONS

There is a need for improved standardized instruments not only to capture relevant sleep information but also to allow greater comparability between studies.

Occupational sleep medicine: practice and promise

Occupational sleep medicine is a new field within sleep medicine. Occupational sleep medicine applies (1) the science of sleep, frequently as instantiated into mathematical modeling; (2) the tactics, techniques, and procedures of sleep and performance measurement in the operational environment; and (3) the clinical practice of sleep medicine to reduce the risks of poor performance, lost productivity, and error, incident, and accident in the workplace. As envisioned here, occupational sleep medicine will play a crucial role in fatigue risk management to, in the short term, improve performance, productivity, and safety and in the longer term improve worker health and well-being.

A two-tier screening model using quality-of-life measures and pulse oximetry to screen adults with sleep-disordered breathing

PURPOSE

Using quality-of-life measures and pulse oximetry, this study developed a two-tiered prediction algorithm with an aim to prioritize sleep-disordered breathing patients for polysomnography.

METHODS

Data from 355 patients were evaluated to obtain their clinical information, Chinese version of Epworth sleepiness scale, and snore outcomes survey scores against respiratory disturbance index (RDI). In the first-tier screening, receiver-operating characteristics were calculated with an initial strategy of choosing optimal prediction sensitivity. The second-tier strategy investigated the association between pulse oximetry data (desaturation index of 3%) against RDI to optimize prediction specificity.

RESULTS

The "SOS score of 55 and ESS score of 9" was the optimal combination that yielded the highest sensitivity (0.603) in the first-tier screening. The strategy can includ 94.93% possible patients (probability = 0.6) with positive predictive value of 0.997. The area under the curve (AUC) was 0.88 (p < 0.001). Desaturation index of 3% would optimized specificity (0.966, probability = 0.5) in the second-tier screening to exclude 54% of innocent patients, with negative predictive values of 0.93 and AUC of 0.951 (p < 0.001). The two-tier screening model jointly excluded 4.8% of innocent subjects and prioritized 40% of severe patients for polysomnography.

CONCLUSIONS

The prediction model is sufficiently accurate and feasible for large-scale population screening.

Diagnostic characteristics of clinical prediction models for obstructive sleep apnea in different clinic populations

PURPOSE

As predictive factors and their diagnostic values are affected by the characteristics of the population studied, clinical prediction model for obstructive sleep apnea (OSA) may exhibit different diagnostic characteristics in different populations. We aimed to compare the diagnostic characteristics of clinical prediction models developed in two different populations.

METHODS

One hundred seventeen consecutive clinic patients (group 1) were evaluated to develop a clinical prediction model for OSA (local model). The diagnostic characteristics of this local model were compared with those of a foreign model by applying both models to another group of 52 patients who were referred to the same clinic (group 2). All patients underwent overnight polysomnography.

RESULTS

The local model had an area under receiver operator characteristics curve of 79%. A cutoff of 0.6 was associated with sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of 77.9%, 72.5%, 84.5%, and 63.0%, respectively. The overall diagnostic accuracy, sensitivity, specificity, PPV, and NPV of the local model using data from patients in group 2 were 69.0%, 78.1%, 45.0%, 69.4%, and 56.3%, respectively. The foreign model had an overall diagnostic accuracy of 64.0% when applied to data from patients in group 2. At the optimal cutoff of 17, the foreign model was associated with sensitivity of 38.2%, specificity of 83.3%, NPV of 41.7% and PPV of 81.3%.

CONCLUSIONS

Clinical prediction model for OSA derived from a foreign population exhibits markedly different diagnostic characteristics from one that is developed locally, even though the overall accuracy is similar. Our findings challenge the predictive usefulness and the external validity of clinical prediction models.

A systematic review of screening questionnaires for obstructive sleep apnea

PURPOSE

Obstructive sleep apnea (OSA) may lead to life-threatening problems if it is left undiagnosed. Polysomnography is the "gold standard" for OSA diagnosis; however, it is expensive and not widely available. The objective of this systematic review is to identify and evaluate the available questionnaires for screening OSA.

SOURCE

We carried out a literature search through MEDLINE, EMBASE, and CINAHL to identify eligible studies. The methodological validity of each study was assessed using the Cochrane Methods Group's guideline.

PRINCIPAL FINDINGS

Ten studies (n = 1,484 patients) met the inclusion criteria. The Berlin questionnaire was the most common questionnaire (four studies) followed by the Wisconsin sleep questionnaire (two studies). Four studies were conducted exclusively on "sleep-disorder patients", and six studies were conducted on "patients without history of sleep disorders". For the first group, pooled sensitivity was 72.0% (95% confidence interval [CI]: 66.0-78.0%; I(2) = 23.0%) and pooled specificity was 61.0% (95% CI: 55.0-67.0%; I(2) = 43.8%). For the second group, pooled sensitivity was 77.0% (95% CI: 73.0-80.0%; I(2) = 78.1%) and pooled specificity was 53.0% (95% CI: 50-57%; I(2) = 88.8%). The risk of verification bias could not be eliminated in eight studies due to insufficient reporting. Studies on snoring, tiredness, observed apnea, and high blood pressure (STOP) and STOP including body mass index, age, neck circumference, gender (Bang) questionnaires had the highest methodological quality.

CONCLUSION

The existing evidence regarding the accuracy of OSA questionnaires is associated with promising but inconsistent results. This inconsistency could be due to studies with heterogeneous design (population, questionnaire type, validity). STOP and STOP-Bang questionnaires for screening of OSA in the surgical population are suggested due to their higher methodological quality and easy-to-use features.

Risk factors for obstructive sleep apnea syndrome screening in mood disorder patients

AIMS

Previous studies have reported that the incidence of obstructive sleep apnea syndrome (OSAS) in patients with depression is higher than in the general population. We examined the risk factors to predict OSAS in mood disorder patients with depressive symptoms.

METHOD

We conducted polysomnography for patients who satisfied the following criteria: (i) diagnosis of major depressive disorder or bipolar disorder according to the Mini-International Neuropsychiatric Interview (MINI); (ii) a score of > or =10 on the Hamilton Rating Scale for Depression (HAM-D); (iii) fulfillment of either (a) or (b) below: (a) at least one of the following: severe snoring, witnessed apnea during sleep, excessive daytime sleepiness; (b) at least one of the following plus an oxygen desaturation index of 4% > or =5 times/h by pulse oximeter: mild snoring, sleep disturbance, headache, high blood pressure. The patients with apnea hypopnea index > or =5 were diagnosed with OSAS.

RESULTS

Of the 32 mood disorder patients who met the subject conditions, 59.4% had OSAS. The diagnosis rate with our criteria was significantly higher than the previously reported incidence of OSAS in patients with depression. There was no significant difference among diagnosis rates as to individual risk factors or the number of risk factors. A multiple regression test showed no significant association between apnea-hypopnea index and other clinical factors including depression severity.

CONCLUSION

The present results showed that OSAS can be detected at a remarkably higher rate by considering appropriate OSAS risk factors in mood disorder patients, and suggested that there is a high rate of undetected and therefore untreated OSAS among mood disorder patients.

Obstructive sleep apnoea among professional taxi drivers: a pilot study

PURPOSE

This study aimed to describe the distribution of risk factors for obstructive sleep apnoea syndrome (OSAS) among taxi drivers, and to investigate differences by ethnicity in OSAS symptoms among drivers.

METHODS

A two-page postal questionnaire was completed by 241 professional taxi drivers from Wellington, New Zealand. Obstructive sleep apnoea syndrome was defined as having an estimated 15 or more respiratory disturbances, per hour of sleep (Respiratory Disturbance Index (RDI)> or =15) and self-reported daytime sleepiness.

RESULTS

Pacific and Māori taxi drivers were more likely to have symptoms and risk factors for OSAS, compared to non-Māori non-Pacific drivers. In particular, Pacific drivers had a significantly increased pre-test probability of having moderate-severe OSA (RDI> or =15).

CONCLUSIONS

Some professional taxi drivers are at increased risk for moderate-severe OSAS, especially Pacific and Māori taxi drivers. Untreated OSAS increases motor vehicle crash risk, so these findings have implications for the health and safety of drivers and their passengers. They suggest a need for more comprehensive research to guide policy on medical examinations required for licensing professional drivers as fit to drive.

Estimated cost of crashes in commercial drivers supports screening and treatment of obstructive sleep apnea

Sleep apnea among commercial drivers may increase the risk of fall-asleep crashes, which incur large expenses. Drivers of passenger cars whose apnea is treated experience lower crash risk. Among community-based holders of commercial driver's licenses, we considered three methods for identifying sleep apnea syndrome: (1) in-lab polysomnography; (2) selective in-lab polysomnography for high-risk drivers, where high risk is first identified by body mass index, age and gender, followed by oximetry in a subset of drivers; (3) not screening. The costs for each of these three programs equaled the sum of the costs of testing, treatment of identified cases, and crashes. Assuming that treatment prevents apnea-related crashes, polysomnography is not cost-effective, because it was more expensive than the cost of crashes when no screening is done. Screening with BMI, age and gender, however, with confirmatory in-lab polysomnography only on high-risk drivers was cost-effective, as long as a high proportion (73.8%) of screened drivers accepts treatment. These findings indicate that strategies that reduce reliance on in-laboratory polysomnography may be more cost-effective than not screening, and that treatment acceptance may need to be a condition of employment for affected drivers.

Preoperative identification of sleep apnea risk in elective surgical patients, using the Berlin questionnaire

STUDY OBJECTIVE

To examine the prevalence of risk of sleep apnea in patients undergoing elective surgery by using the Berlin Questionnaire.

DESIGN

Survey instrument.

SETTINGS

Preoperative assessment clinic.

PATIENTS

305 surgical ASA physical status I, II, III, and IV patients.

INTERVENTIONS

Patients were screened with the Berlin questionnaire for obstructive sleep apnea. For patients deemed at high risk of sleep apnea by the Berlin questionnaire, a letter was sent to their family physician requesting referral of patient to have an overnight polysomnography test for the diagnosis of obstructive sleep apnea.

MEASUREMENTS

The number of patients identified by the Berlin questionnaire as being at high risk of obstructive sleep apnea was identified. The number of patients with a history of obstructive sleep apnea and those newly confirmed by polysomnography were also identified.

MAIN RESULTS

The Berlin questionnaire identified 24% (73/305) of patients as being at high risk of sleep apnea (95% confidence interval, 19%-29%). Thirteen patients were confirmed to have obstructive sleep apnea, resulting in a frequency of 4.2%; 9 patients had a history of obstructive sleep apnea, and 5 patients were identified by polysomnography.

CONCLUSIONS

The Berlin questionnaire correctly identified all patients previously diagnosed with sleep apnea as being at high risk.

Pilot randomized trial of the effect of wireless telemonitoring on compliance and treatment efficacy in obstructive sleep apnea

Background

Obstructive sleep apnea (OSA) is a prevalent and serious medical condition characterized by repeated complete or partial obstructions of the upper airway during sleep and is prevalent in 2% to 4% of working middle-aged adults. Nasal continuous positive airway pressure (CPAP) is the gold-standard treatment for OSA. Because compliance rates with CPAP therapy are disappointingly low, effective interventions are needed to improve CPAP compliance among patients diagnosed with OSA.

Objective

The aim was to determine whether wireless telemonitoring of CPAP compliance and efficacy data, compared to usual clinical care, results in higher CPAP compliance and improved OSA outcomes.

Methods

45 patients newly diagnosed with OSA were randomized to either telemonitored clinical care or usual clinical care and were followed for their first 2 months of treatment with CPAP therapy. CPAP therapists were not blinded to the participants’ treatment group.

Results

20 participants in each group received the designated intervention. Patients randomized to telemonitored clinical care used CPAP an average of 4.1 ± 1.8 hours per night, while the usual clinical care patients averaged 2.8 ± 2.2 hours per night (P = .07). Telemonitored patients used CPAP on 78% ± 22% of the possible nights, while usual care patients used CPAP on 60% ± 32% of the nights (P = .07). No statistically significant differences between the groups were found on measures of CPAP efficacy, including measures of mask leak and the Apnea-Hypopnea Index. Patients in the telemonitored group rated their likelihood to continue using CPAP significantly higher than the patients in the usual care group. Patients in both groups were highly satisfied with the care they received and rated themselves as “not concerned” that their CPAP data were being wirelessly monitored.

Conclusions

Telemonitoring of CPAP compliance and efficacy data and rapid use of those data by the clinical sleep team to guide the collaborative (ie, patient and provider) management of CPAP treatment is as effective as usual care in improving compliance rates and outcomes in new CPAP users. This study was designed as a pilot—larger, well-powered studies are necessary to fully evaluate the clinical and economic efficacy of telemonitoring for this population.