International Consensus Statement on Obstructive Sleep Apnea

BACKGROUND

Evaluation and interpretation of the literature on obstructive sleep apnea (OSA) allows for consolidation and determination of the key factors important for clinical management of the adult OSA patient. Toward this goal, an international collaborative of multidisciplinary experts in sleep apnea evaluation and treatment have produced the International Consensus statement on Obstructive Sleep Apnea (ICS:OSA).

METHODS

Using previously defined methodology, focal topics in OSA were assigned as literature review (LR), evidence-based review (EBR), or evidence-based review with recommendations (EBR-R) formats. Each topic incorporated the available and relevant evidence which was summarized and graded on study quality. Each topic and section underwent iterative review and the ICS:OSA was created and reviewed by all authors for consensus.

RESULTS

The ICS:OSA addresses OSA syndrome definitions, pathophysiology, epidemiology, risk factors for disease, screening methods, diagnostic testing types, multiple treatment modalities, and effects of OSA treatment on multiple OSA-associated comorbidities. Specific focus on outcomes with positive airway pressure (PAP) and surgical treatments were evaluated.

CONCLUSION

This review of the literature consolidates the available knowledge and identifies the limitations of the current evidence on OSA. This effort aims to create a resource for OSA evidence-based practice and identify future research needs. Knowledge gaps and research opportunities include improving the metrics of OSA disease, determining the optimal OSA screening paradigms, developing strategies for PAP adherence and longitudinal care, enhancing selection of PAP alternatives and surgery, understanding health risk outcomes, and translating evidence into individualized approaches to therapy.

A comparison of 2 visual methods for classifying obstructive vs central hypopneas

STUDY OBJECTIVES

Rules for classifying apneas as obstructive, central, or mixed are well established. Although hypopneas are given equal weight when calculating the apnea-hypopnea index, classification is not standardized. Visual methods for classifying hypopneas have been proposed by the American Academy of Sleep Medicine and by Randerath et al (Sleep. 2013;36[3]:363-368) but never compared. We evaluated the clinical suitability of the 2 visual methods for classifying hypopneas as central or obstructive.

METHODS

Fifty hypopnea-containing polysomnographic segments were selected from patients with clear obstructive or clear central physiology to serve as standard obstructive or central hypopneas. These 100 hypopnea-containing polysomnographic segments were deidentified, randomized, and scored by 2 groups. We assigned 1 group to use the American Academy of Sleep Medicine criteria and the other the Randerath algorithm. After a washout period, re-randomized hypopnea-containing polysomnographic segments were scored using the alternative method. We determined the accuracy (agreement with standard), interrater (Fleiss's κ), and intrarater agreement (Cohen's κ) for obtained scores.

RESULTS

Accuracy of the 2 methods was similar: 67% vs 69.3% for Randerath et al and the American Academy of Sleep Medicine, respectively. Cohen's κ was 0.01-0.75, showing that some raters scored similarly using the 2 methods, while others scored them markedly differently. Fleiss's κ for the American Academy of Sleep Medicine algorithm was 0.32 (95% confidence interval, 0.29-0.36) and for the Randerath algorithm was 0.27 (95% confidence interval, 0.23-0.30).

CONCLUSIONS

More work is needed to discover a noninvasive way to accurately characterize hypopneas. Studies like ours may lay the foundation for discovering the full spectrum of physiologic consequences of obstructive sleep apnea and central sleep apnea.

Prevalence and Sources of Errors in Positive Airway Pressure Therapy Provisioning

STUDY OBJECTIVES

The prevalence and mechanism of medication errors have been well characterized in the literature. However, no prior studies have investigated the frequency and characteristics of errors in the positive airway pressure (PAP) therapy provisioning process when treating patients with sleep-disordered breathing. Just as medication errors may result in unwanted outcomes, it might be anticipated that errors in providing PAP to patients might lead to suboptimal outcomes. Our study seeks to examine the characteristics and frequency of PAP provisioning errors.

METHODS

This was a retrospective analysis of a cohort of patients in whom sleep-disordered breathing had been diagnosed and subsequently PAP therapy was prescribed. At a 90-day return visit, the PAP therapy the patient was receiving was compared with the intended therapy. Discrepancies were categorized as either prescribing errors (the prescription did not match the intended modality or settings), or setup errors (the modality or settings did not match the prescription).

RESULTS

The overall PAP provisioning error rate was 8%, with errors most commonly occurring during the set-up process. In univariate analysis, insurance type (P = .003), treatment modality (P = .002), and device brand (P = .05) were associated with error and remained significant in multivariate analysis (model fit P = .002). Compliance, residual AHI, and difference in Epworth Sleepiness Scale were not affected by the presence of error.

CONCLUSIONS

PAP provisioning errors are common and might contribute to poor treatment outcomes. Errors might be reduced by standardizing terminology across devices, standardizing prescription forms to improve clarity, and by enhanced quality assurance at durable medical equipment suppliers.