Efficacy of home single-channel nasal pressure for recommending continuous positive airway pressure treatment in sleep apnea

Primary care and sleep unit agreement in management decisions for sleep apnea: a prospective study in Spain

STUDY OBJECTIVES

Involvement of primary care teams in the care of patients with OSA is a focus of interest. The study objective was to compare diagnostic and therapeutic agreement between decisions taken by primary care professionals and sleep unit specialists.

METHODS

This was a prospective multicenter study conducted at primary care and specialized care centers in the urban area of Barcelona, Spain. Men and women aged 18-75 years who visited the participating primary care centers for any reason were recruited. Both primary care physicians and sleep specialists made a diagnostic and therapeutic decision with clinical data and results of a home sleep apnea test. All patients were finally assessed with respiratory polygraphy or polysomnography as a gold-standard test.

RESULTS

A total of 229 patients underwent a home sleep apnea test and were evaluated at the primary care centers and the sleep units. Diagnostic agreement using the same tools and excluding indeterminate decisions was 69.8% (Cohen's kappa = 0.64; 95% confidence interval, 0.56-0.72). Agreement for therapeutic decisions (PAP vs conservative treatment) was obtained in 82.5% of patients (Cohen's kappa = 0.62; 95% confidence interval, 0.51-0.73), increasing to 92.5% (Cohen's kappa = 0.49, 95% confidence interval, 0.40-0.58) when indeterminate options were excluded. As compared with the final therapeutic decisions made at the sleep unit with respiratory polygraphy/polysomnography, primary care physicians agreed regarding 83.3% (Cohen's kappa = 0.62; 95% confidence interval, 0.49-0.74) of patients.

CONCLUSIONS

Primary care professionals may assume an important role in the management of OSA in coordination with sleep centers, identifying patients who require specific treatment and should be referred to specialized care.

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.

Intra- and Inter-Physician Agreement in Therapeutic Decision for Sleep Apnea Syndrome

BACKGROUND

Large variation in diagnostic procedures and treatment recommendations may hinder the management of obstructive sleep apnea (OSA) and also compromise correct interpretation of the results of multicenter clinical trials, especially in subjects with non-severe OSA. The aim of this study was to analyze the therapeutic decision-making between different sleep physicians in patients with AHI<40events/h.

METHODS

Six experienced senior sleep specialists from different sleep centers of Spain were asked to make a therapeutic decision (CPAP treatment) based on anonymized recordings of patients with suspected OSA that has previously performed a sleep study. The clinical data was shown in an online database and included anthropometric features, clinical questionnaires, comorbidities, physical examination and sleep study results. Intra- and inter-observer decision-making were analyzed by the Fleiss' Kappa statistics (Kappa).

RESULTS

A total of 720 medical decisions were taken to analyze the agreement between sleep professionals. Overall intra-observer evaluation reliability was almost perfect (Kappa=0.83, 95% CI, 0.75-0.90, p<0.001). However, overall inter-observer concordance decreased to moderate agreement (Kappa=0.46, 95% CI, 0.42-0.51, p<0.001). Nevertheless, it was especially low when considering AHI<15events/h.

CONCLUSIONS

This study demonstrates a good intra-observer concordance in the therapeutic decision-making of different sleep physicians treating patients with low/moderate OSA. However, when analyzing inter-observer agreement the results were considerably worse. These findings underline the importance of developing improved consensus management protocols.

Comparing the effects and compliance between volume-assured and pressure support non-invasive ventilation in patients with chronic respiratory failure

INTRODUCTION

Standard bi-level non-invasive ventilation with fixed-level pressure support (PS) delivery may not maintain ventilation during the changes in pulmonary mechanics that occur throughout day and night, so average volume-assured pressure support (AVAPS) modes that target a preset volume by adjustment of PS may be effective.

OBJECTIVE

Our meta-analysis wants to compare AVAPS and pressure support non-invasive ventilation (PS-NIV) regarding arterial blood gases (ABGs), sleep efficiency and compliance.

METHOD

Relevant publications indexed in PubMed, Cochrane Library, Embase, Web of Science, Wanfang Data, China National Knowledge Infrastructure and VIPI were identified. Appropriate articles identified from the reference lists of the above searches were also reviewed. We included randomized controlled trials involved the use of AVAPS and PS-NIV ventilation for chronic respiratory failure. Each included study weighted mean differences, and 95% confidence intervals (CI) were calculated for continuous outcomes. Statistical heterogeneity was assessed using the I² value ≤ 50% were considered as no statistical heterogeneity and used fixed effects model. Otherwise, a random effects model was used.

RESULTS

Eight trials were eligible. No significant difference was observed between AVAPS and PS-NIV groups to compare PaCO₂ (OR -0.97, CI-2.54-0.61, P = 0.23) and PaO₂ (OR -1.81, CI-4.29-0.67, P = 0.15) in ABGs. There was no significant difference between the two groups with sleep efficiency (OR -3.31, CI-7.58-0.95, P = 0.13) and visual analog scale (OR 0.32, CI-6.97-7.61, P = 0.93).

CONCLUSIONS

The evidence shows there is no significant difference in clinical outcomes when comparing AVAPS and PS-NIV used for chronic respiratory failure patients.

CPAP indication based on clinical data and oximetry for patients with suspicion of obstructive sleep apnea: A multicenter trial

BACKGROUND AND OBJECTIVE

The usefulness of pulse oximetry for the management of obstructive sleep apnea is controversial. The aim of this study was to assess the accuracy for indication of Continuous Positive Airway Pressure (CPAP) treatment in patients with suspected obstructive sleep apnea (OSA) based on clinical and oximetry data as compared to polysomnography (PSG).

METHODS

This multicenter observational study involved seven sleep laboratories. Patients with suspicion of OSA who completed a standardized sleep questionnaire and a diagnostic PSG were enrolled. Eight observers logged on to a website independently and blindly. Seven observers only accessed the clinical data, curve and pulse oximetry results (Os-SO2-test method), while the eighth observer had full access to all indicators of PSG (O-PSG-reference method). Once observers assessed the information available on the website, they had to choose between three CPAP treatment options (yes/no/do not know) based on their knowledge and criteria.

RESULTS

411 subjects (228 men), median age 54 years, were available for evaluation. Os-SO2 had lower sensitivity (S), greater specificity (Sp) and positive likelihood ratio (PLR) to prescribe CPAP in patients more symptomatic (Epworth Sleepiness Scale-ESS > 10 or comorbidities) than those with fewer symptoms (ESS < 11 without comorbidities) (S 45-75% versus 45-91%, p 0.028); Sp 93.8-100% versus 68.5-96.6%, p 0.004; PLR > 10 versus 2.9-17, p<0.01).

CONCLUSIONS

Due to its low false positive rate, a strategy based on pulse oximetry and clinical data was a consistent tool to indicate CPAP treatment in most symptomatic patients with a suspicion of OSA.

Primary Care Physicians Can Comprehensively Manage Patients with Sleep Apnea. A Noninferiority Randomized Controlled Trial

Rationale: General practitioners play a passive role in obstructive sleep apnea (OSA) management. Simplification of the diagnosis and use of a semiautomatic algorithm for treatment can facilitate the integration of general practitioners, which has cost advantages.Objectives: To determine differences in effectiveness between primary health care area (PHA) and in-laboratory specialized management protocols during 6 months of follow-up.Methods: A multicenter, noninferiority, randomized, controlled trial with two open parallel arms and a cost-effectiveness analysis was performed in six tertiary hospitals in Spain. Sequentially screened patients with an intermediate to high OSA probability were randomized to PHA or in-laboratory management. The PHA arm involved a portable monitor with automatic scoring and semiautomatic therapeutic decision-making. The in-laboratory arm included polysomnography and specialized therapeutic decision-making. Patients in both arms received continuous positive airway pressure treatment or sleep hygiene and dietary treatment alone. The primary outcome measure was the Epworth Sleepiness Scale. Secondary outcomes were health-related quality of life, blood pressure, incidence of cardiovascular events, hospital resource utilization, continuous positive airway pressure adherence, and within-trial costs.Measurements and Main Results: In total, 307 patients were randomized and 303 were included in the intention-to-treat analysis. Based on the Epworth Sleepiness Scale, the PHA protocol was noninferior to the in-laboratory protocol. Secondary outcome variables were similar between the protocols. The cost-effectiveness relationship favored the PHA arm, with a cost difference of €537.8 per patient.Conclusions: PHA management may be an alternative to in-laboratory management for patients with an intermediate to high OSA probability. Given the clear economic advantage of outpatient management, this finding could change established clinical practice.Clinical trial registered with www.clinicaltrials.gov (NCT02141165).

Methodological strategies in using home sleep apnea testing in research and practice

PURPOSE

Home sleep apnea testing (HSAT) has increased due to improvements in technology, accessibility, and changes in third party reimbursement requirements. Research studies using HSAT have not consistently reported procedures and methodological challenges. This paper had two objectives: (1) summarize the literature on use of HSAT in research of adults and (2) identify methodological strategies to use in research and practice to standardize HSAT procedures and information.

METHODS

Search strategy included studies of participants undergoing sleep testing for OSA using HSAT. MEDLINE via PubMed, CINAHL, and Embase with the following search terms: "polysomnography," "home," "level III," "obstructive sleep apnea," and "out of center testing."

RESULTS

Research articles that met inclusion criteria (n = 34) inconsistently reported methods and methodological challenges in terms of: (a) participant sampling; (b) instrumentation issues; (c) clinical variables; (d) data processing; and (e) patient acceptability. Ten methodological strategies were identified for adoption when using HSAT in research and practice.

CONCLUSIONS

Future studies need to address the methodological challenges summarized in this paper as well as identify and report consistent HSAT procedures and information.

Should the diagnosis and management of OSA move into general practice?

Sleep apnoea is a common disease that for accurate management requires the participation of primary care medicine http://ow.ly/G6Mq301zcaM.

Mild obstructive sleep apnoea: clinical relevance and approaches to management

Obstructive sleep apnoea is highly prevalent in the general population worldwide, especially in its mild form. Clinical manifestations correlate poorly with disease severity measured by the apnoea-hypopnoea index (AHI), which complicates diagnosis. Full polysomnography might be more appropriate to assess suspected mild cases because limited ambulatory diagnostic systems are least accurate in mild disease. Treatment options in mild obstructive sleep apnoea include continuous positive airway pressure (CPAP) and oral appliance therapy, in addition to positional therapy and weight reduction when appropriate. The superior efficacy of CPAP in reducing AHI is offset by greater tolerance of oral appliances, especially in mild disease. Although severe obstructive sleep apnoea is associated with adverse health consequences, including cardiometabolic comorbidities, the association with mild disease is unclear, and reports differ regarding the clinical relevance of mild obstructive sleep apnoea. Improved diagnostic techniques and evidence-based approaches to management in mild obstructive sleep apnoea require further research.