Diagnosis and initial management of obstructive sleep apnea without polysomnography: A randomized validation study

University of British Columbia and Vancouver Coastal Health Research Institute, Vancouver, British Columbia, Canada.
Annals of internal medicine (Impact Factor: 17.81). 02/2007; 146(3):157-66.
Source: PubMed


Polysomnography (PSG), despite limited availability and high cost, is currently recommended for diagnosis of obstructive sleep apnea and titration of effective continuous positive airway pressure (CPAP).
To test the utility of a diagnostic algorithm in conjunction with ambulatory CPAP titration in initial management of obstructive sleep apnea.
A randomized, controlled, open-label trial that compared standard PSG with ambulatory CPAP titration in high-risk patients identified by a diagnostic algorithm.
A tertiary referral sleep disorders program in Vancouver, British Columbia, Canada.
68 patients with a high pretest probability of moderate to severe obstructive sleep apnea (apnea-hypopnea index [AHI] >15 episodes/h) identified by sequential application of the Epworth Sleepiness Scale (ESS) score, Sleep Apnea Clinical Score, and overnight oximetry.
Patients were randomly assigned to PSG or ambulatory titration by using a combination of auto-CPAP and overnight oximetry. They were observed for 3 months.
Apnea-hypopnea index on CPAP, ESS score, quality of life, and CPAP adherence.
The PSG and ambulatory groups had similar median BMI (38 kg/m2), age (55 years), ESS score (14 points), and respiratory disturbance index (31 episodes of respiratory disturbance/h). Each episode is determined by a computer algorithm based on analysis of oxygen saturation measured by pulse oximetry. After 3 months, there were no differences in the primary outcome, AHI on CPAP (median, 3.2 vs. 2.5; difference, 0.8/h [95% CI, -0.9 to 2.3]) (P = 0.31), between the PSG and ambulatory groups, or in the secondary outcomes, ESS score, Sleep Apnea Quality of Life Index, and CPAP. Adherence to CPAP therapy was better in the ambulatory group than in the PSG group (median, 5.4 vs. 6.0; difference, -1.12 h/night [CI, -2.0 to 0.2]) (P = 0.021).
In the initial management of patients with a high probability of obstructive sleep apnea, PSG confers no advantage over the ambulatory approach in terms of diagnosis and CPAP titration. The ambulatory approach may improve adherence to treatment. When access to PSG is inadequate, the ambulatory approach can be used to expedite management of patients most in need of treatment.

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    • "This increased prevalence of obesity is strongly linked to higher incidence of SDB and OSAHS; therefore screening this type of population for early detection of morbid conditions is vital in the clinical assessment by any clinician or health care provider. Other risk factors include chronic heart failure patients (estimated prevalence of 40–80%),[19] cervical spinal cord injury patients (estimated prevalence of 60%),[16] and stroke (estimated prevalence of 44–72%).[20–23] "
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    ABSTRACT: Sleep disordered breathing is a common chronic condition in the general population. This review will highlight the prevalence of different types of sleep apnea in general and obstructive type in particular in the United States and Middle East. Despite the extensive research studies on the sleep apnea pathogenesis, the exact mechanism is not well known. Obesity, however, is the leading risk factor to upper airway narrowing and obstruction and main contributor to the escalating prevalence of morbidity worldwide including the Arab countries. Due to the serious consequences of the untreated sleep disordered breathing, this article will emphasize on the importance of early recognition, key clinical manifestations, and how to treat and prevent the disease.
    03/2012; 2(1):3-8. DOI:10.4103/2231-0770.94803
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    • "O 2 -saturation (SaO 2 ), heart rate, electrocardiogram (ECG), respiration, flow or snoring, are not useful for the final diagnosis of any sleep disorder. This procedure may be helpful in cases of suspected sleep-related breathing disorders in certain patient groups with a high pre-test probability (Mulgrew et al., 2007), but in the majority of cases it is not suited for the diagnosis of sleep-related breathing disorders (Collop et al., 2007; Kushida et al., 2005; Mayer et al., 2009; McNicholas, 2008; Ndegwa et al., 2009) ()). "
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    ABSTRACT: The present paper describes standardized procedures within clinical sleep medicine. As such, it is a continuation of the previously published European guidelines for the accreditation of sleep medicine centres and European guidelines for the certification of professionals in sleep medicine, aimed at creating standards of practice in European sleep medicine. It is also part of a broader action plan of the European Sleep Research Society, including the process of accreditation of sleep medicine centres and certification of sleep medicine experts, as well as publishing the Catalogue of Knowledge and Skills for sleep medicine experts (physicians, non-medical health care providers, nurses and technologists), which will be a basis for the development of relevant educational curricula. In the current paper, the standard operational procedures sleep medicine centres regarding the diagnostic and therapeutic management of patients evaluated at sleep medicine centres, accredited according to the European Guidelines, are based primarily on prevailing evidence-based medicine principles. In addition, parts of the standard operational procedures are based on a formalized consensus procedure applied by a group of Sleep Medicine Experts from the European National Sleep Societies. The final recommendations for standard operational procedures are categorized either as 'standard practice', 'procedure that could be useful', 'procedure that is not useful' or 'procedure with insufficient information available'. Standard operational procedures described here include both subjective and objective testing, as well as recommendations for follow-up visits and for ensuring patients' safety in sleep medicine. The overall goal of the actual standard operational procedures is to further develop excellence in the practice and quality assurance of sleep medicine in Europe.
    Journal of Sleep Research 12/2011; 21(4):357-68. DOI:10.1111/j.1365-2869.2011.00987.x · 3.35 Impact Factor
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    • "Although PSG is considered the 'gold standard' diagnostic test for OSA, an ambulatory monitoring device has proven to have excellent agreement, sensitivity and specificity with PSG [36]. In addition, the use of ambulatory monitoring has been validated as a clinical management tool [37,38]. "
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    ABSTRACT: Observational outcome studies of patients with obstructive sleep apnea (OSA) require adjustment for co-morbidity to produce valid results. The aim of this study was to evaluate whether the combination of administrative data and self-reported data provided a more complete estimate of co-morbidity among patients referred for sleep diagnostic testing. A retrospective observational study of 2149 patients referred for sleep diagnostic testing in Calgary, Canada. Self-reported co-morbidity was obtained with a questionnaire; administrative data and validated algorithms (when available) were also used to define the presence of these co-morbid conditions within a two-year period prior to sleep testing. Patient self-report of co-morbid conditions had varying levels of agreement with those derived from administrative data, ranging from substantial agreement for diabetes (kappa = 0.79) to poor agreement for cardiac arrhythmia (kappa = 0.14). The enhanced measure of co-morbidity using either self-report or administrative data had face validity, and provided clinically meaningful trends in the prevalence of co-morbidity among this population. An enhanced measure of co-morbidity using self-report and administrative data can provide a more complete measure of the co-morbidity among patients with OSA when agreement between the two sources is poor. This methodology will aid in the adjustment of these coexisting conditions in observational studies in this area.
    BMC Medical Research Methodology 02/2009; 9(1):50. DOI:10.1186/1471-2288-9-50 · 2.27 Impact Factor
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