PURLs

Can sleep apnea be accurately diagnosed at home?

J Fam Pract. 2019 October;68(8):459-461

References

1. Corral J, Sánchez-Quiroga MÁ, Carmona-Bernal C, et al. Conventional polysomnography is not necessary for the management of most patients with suspected obstructive sleep apnea. Noninferiority, randomized controlled trial. Am J Respir Crit Care Med. 2017;196:1181-1190.

2. Epstein LJ, Kristo D, Strollo PJ, et al. Clinical guideline for the evaluation, management and long-term care of obstructive sleep apnea in adults. J Clin Sleep Med. 2009;5:263-276.

3. Colten H, Abboud F, Block G, et al. Sleep disorders and sleep deprivation: an unmet public health problem. 2006. Washington, DC: National Academy of Sciences.

4. Punjabi NM. The epidemiology of adult obstructive sleep apnea. Proc Am Thorac Soc. 2008;5:136-143.

5. Lloberes P, Durán-Cantolla J, Martinez-Garcia MA, et al. Diagnosis and treatment of sleep apnea-hypopnea syndrome. Spanish Society of Pulmonology and Thoracic Surgery. Arch Bronconeumol. 2011;47:143-156.

6. Rosen IM, Kirsch DB, Chervin RD; American Academy of Sleep Medicine Board of Directors. Clinical use of a home sleep apnea test: an American Academy of Sleep Medicine position statement. J Clin Sleep Med. 2017;13:1205-1207.

7. Chiu HY, Chen PY, Chuang, LP, et al. Diagnostic accuracy of the Berlin questionnaire, STOP-BANG, STOP and Epworth Sleepiness scale in detecting obstructive sleep apnea: a bivariate meta-analysis. Sleep Med Rev. 2017;36:57-70.

8. Chung, F, Yegneswaran B, Lio P, et al. STOP questionnaire: a tool to screen patients for obstructive sleep apnea. Anesthesiology. 2008;108:812-821.

9. Centers for Medicare and Medicaid Services. Decision Memo for Continuous Positive Airway Pressure (CPAP) Therapy for Obstructive Sleep Apnea (OSA) (CAG-00093R2). March 13, 2008. https://www.cms.gov/medicare-coverage-database/details/nca-decision-memo.aspx?NCAId=204. Accessed September 6, 2019.

CAVEATS

Recommendations are somewhat ambiguous

This study, as well as current guidelines, recommend home sleep studies for patients with a high clinical suspicion or high pre-test probability of OSA and who lack comorbid conditions that could affect sleep. The comorbid conditions are well identified: COPD, heart failure hypoventilation syndromes, insomnia, hypersomnia, parasomnia, periodic limb movement disorder, narcolepsy, and chronic opioid use.⁶ However, what constitutes “a high clinical suspicion” or “high pre-test probability” was not well defined in this study.

Several clinical screening tools are available and include the ESS, Berlin Questionnaire, and STOP-BANG Scoring System (Snoring, Tiredness, Observed apnea, Pressure [systemic hypertension], Body mass index > 35, Age > 50 years, Neck circumference > 16 inches, male Gender). An ESS score ≥ 10 warrants further evaluation, but is not very sensitive. Two or more positive categories on the Berlin Questionnaire indicates a high risk of OSA with a sensitivity of 76%, 77%, and 77% for mild, moderate, and severe OSA, respectively.⁷ A score of ≥ 3 on the STOP-BANG Scoring System has been validated and has a sensitivity of 83.6%, 92.9%, and 100% for an AHI > 5, > 15, and > 30, respectively.⁸

Home sleep studies should not be used to screen the general population.

CHALLENGES TO IMPLEMENTATION

Recommendations may present a challenge but insurance should not

The American Academy of Sleep Medicine recommends that portable monitoring must record airflow, respiratory effort, and blood oxygenation, and the device must be able to display the raw data to be interpreted by a board-certified sleep medicine physician according to current published standards.⁶ Implementation would require appropriate selection of a home monitoring device, consultation with a sleep medicine specialist, and significant patient education to ensure interpretable results.

Insurance should not be a barrier to implementation as the Centers for Medicare and Medicaid Services accept home sleep apnea testing results for CPAP prescriptions.⁹ However, variability currently exists regarding the extent to which private insurers provide coverage for home sleep apnea testing.

ACKNOWLEDGMENT

The PURLs Surveillance System was supported in part by Grant Number UL1RR024999 from the National Center For Research Resources, a Clinical Translational Science Award to the University of Chicago. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Center For Research Resources or the National Institutes of Health.

Online-Only Materials

Attachment	Size
jfp06810459_methodology.pdf	234.19 KB