Indication of CPAP in Patients with Suspected Obstructive Sleep Apnea, Based on Clinical Parameters and a Novel Two-Channel Recording Device (ApneaLink): A Pilot Study
Objective. To evaluate the accuracy and reliability of the medical decision based on the results of the hand scoring from a two-channel recording device (ApneaLink) plus clinical data for the prescription of a CPAP assay in patients with suspected OSA. Methods. 39 subjects were assessed in the sleep laboratory with polysomnography and ApneaLink. The patients completed the Epworth sleepiness scale and a clinical history. Two blinded independent observers decided to prescribe CPAP according to the results of the PSG (gold standard, observer A), ApneaLink (alternative method, observer B), and the clinical parameters. Sensitivity and specificity of observer B on the indication of CPAP were calculated. The interobserver agreement for the indication of CPAP was assessed using kappa statistics. Results. 38 subjects were included (26 men, mean age 47.5, mean RDI 28.7, mean BMI 31.4？kg/m2). The prevalence of OSA was 84%. The sensitivity and specificity of observer B to initiate a CPAP trial were 90.6% and 100%, respectively. The interrater agreement for the prescription of CPAP was good (kappa: 0.75). Conclusion. This study has shown that the use of ApneaLink plus clinical data has made it possible to indicate CPAP reliably in most patients with high-clinical pretest for OSA. 1. Introduction Obstructive sleep apnea (OSA) is a major health problem due to its prevalence rates of 2–4% in middle-aged people [1] and significant morbidity [2, 3] and mortality [4] reported in patients with this condition. Continuous positive airway pressure (CPAP) is an effective treatment commonly prescribed for symptomatic patients with obstructive sleep apnea. It is costeffective [5] and reduces daytime sleepiness [6], rates of motor vehicle accidents [7], and blood pressure [8]. The American Thoracic Society [9] and the American Academy of Sleep Medicine [10] recommend supervised polysomnography (PSG) in the sleep laboratory over two nights for the diagnosis of obstructive sleep apnea and initiation of CPAP. This approach to a highly prevalent condition results in inevitable discrepancies between the demand for services and the current capacity of sleep laboratories [11]. Because the treatment of sleep apnea provides many benefits to patients and society, it is imperative to develop strategies that are less complex than the traditional approach based on PSG to expedite the diagnosis and treatment of patients with OSA. The ApneaLink is a two-channel screening tool for sleep apnea. The device consists of a nasal cannula attached to a small case that houses a pressure transducer and a
References
[1]
T. Young, M. Palta, J. Dempsey, J. Skatrud, S. Weber, and S. Badr, “The occurrence of sleep-disordered breathing among middle-aged adults,” New England Journal of Medicine, vol. 328, no. 17, pp. 1230–1235, 1993.
[2]
P. E. Peppard, T. Young, M. Palta, and J. Skatrud, “Prospective study of the association between sleep-disordered breathing and hypertension,” New England Journal of Medicine, vol. 342, no. 19, pp. 1378–1384, 2000.
[3]
A. B. Newman, F. J. Nieto, U. Guidry et al., “Relation of sleep-disordered breathing to cardiovascular disease risk factors: the Sleep Heart Health study,” American Journal of Epidemiology, vol. 154, no. 1, pp. 50–59, 2001.
[4]
P. Lavie, P. Herer, R. Peled et al., “Mortality in sleep apnea patients: a multivariate analysis of risk factors,” Sleep, vol. 18, no. 3, pp. 149–157, 1995.
[5]
N. T. Ayas and C. Marra, “Continuous positive airway pressure therapy for obstructive sleep apnea syndrome: do the dollars make sense?” Sleep, vol. 28, no. 10, pp. 1211–1213, 2005.
[6]
H. M. Engleman, S. E. Martin, R. N. Kingshott, T. W. Mackay, I. J. Deary, and N. J. Douglas, “Randomised placebo controlled trial of daytime function after continuous positive airway pressure (CPAP) therapy for the sleep apnoea/hypopnoea syndrome,” Thorax, vol. 53, no. 5, pp. 341–345, 1998.
[7]
W. Cassel, T. Ploch, C. Becker, D. Dugnus, J. H. Peter, and P. Von Wichert, “Risk of traffic accidents in patients with sleep-disordered breathing: reduction with nasal CPAP,” European Respiratory Journal, vol. 9, no. 12, pp. 2606–2611, 1996.
[8]
J. F. Faccenda, T. W. Mackay, N. A. Boon, and N. J. Douglas, “Randomized placebo-controlled trial of continuous positive airway pressure on blood pressure in the sleep apnea-hypopnea syndrome,” American Journal of Respiratory and Critical Care Medicine, vol. 163, no. 2, pp. 344–348, 2001.
[9]
“Indications and standards for use of nasal continuous positive airway pressure (CPAP) in sleep apnea syndromes. American Thoracic Society. Official statement,” American Journal of Respiratory and Critical Care Medicine, vol. 150, no. 6 I, pp. 1738–1745, 1994.
[10]
Jr. Chesson A.L., R. A. Ferber, J. M. Fry et al., “Practice parameters for the indications for polysomnography and related procedures,” Sleep, vol. 20, no. 6, pp. 406–422, 1997.
[11]
W. W. Flemons, N. J. Douglas, S. T. Kuna, D. O. Rodenstein, and J. Wheatley, “Access to diagnosis and treatment of patients with suspected sleep apnea,” American Journal of Respiratory and Critical Care Medicine, vol. 169, no. 6, pp. 668–672, 2004.
[12]
M. K. Erman, D. Stewart, D. Einhorn, N. Gordon, and E. Casal, “Validation of the ApneaLink for the screening of sleep apnea: a novel and simple single-channel recording device,” Journal of Clinical Sleep Medicine, vol. 3, no. 4, pp. 387–392, 2007.
[13]
H. Chen, A. A. Lowe, Y. Bai, P. Hamilton, J. A. Fleetham, and F. R. Almeida, “Evaluation of a portable recording device (ApneaLink) for case selection of obstructive sleep apnea,” Sleep and Breathing, vol. 13, no. 3, pp. 213–219, 2009.
[14]
R. Ragette, Y. Wang, G. Weinreich, and H. Teschler, “Diagnostic performance of single airflow channel recording (ApneaLink) in home diagnosis of sleep apnea,” Sleep and Breathing, vol. 14, no. 2, pp. 109–114, 2010.
[15]
G. Weinreich, J. Armitstead, V. T？pfer, Y. M. Wang, Y. Wang, and H. Teschler, “Validation of apnealink as screening device for cheyne-stokes respiration,” Sleep, vol. 32, no. 4, pp. 553–557, 2009.
[16]
C. A. Nigro, E. Dibur, S. Aimaretti, S. González, and E. Rhodius, “Comparison of the automatic analysis versus the manual scoring from ApneaLink device for the diagnosis of obstructive sleep apnoea syndrome,” Sleep and Breathing, vol. 15, pp. 679–686, 2011.
[17]
H. L. Chica-Urzola, F. Escobar-Córdoba, and J. Eslava-Schmalbach, “Validating the Epworth sleepiness scale,” Revista de Salud Publica, vol. 9, no. 4, pp. 558–567, 2007.
[18]
“Consenso Nacional sobre el Síndrome Apneas-Hipopneas del Sue？o del Grupo Espa？ol de Sue？o. Tratamiento del SAHS con CPAP,” Archivos de Bronconeumología, vol. 41, Extraordinario 4, pp. 51–66, 2005.
[19]
C. A. Kushida, M. R. Littner, T. Morgenthaler et al., “Practice parameters for the indications for polysomnography and related procedures: an update for 2005,” Sleep, vol. 38, no. 4, pp. 499–521, 2005.
[20]
A. Rechtschafen and A. Kales, A Manual of Standarized Technology, Techniques and Scoring System for Sleep Stages of Human Subjects, Brain Information Service, Brain Information Institute, University of California, Los Angeles, Calif, USA, 1968.
[21]
M. Bonnet, D. Carley, M. Carskadon et al., “EEG arousals: scoring rules and examples. A preliminary report from the Sleep Disorders Atlas Task Force of the American Sleep Disorder Association,” Sleep, vol. 15, no. 2, pp. 173–184, 1992.
[22]
“Consenso Nacional sobre el Síndrome Apneas-Hipopneas del Sue？o del Grupo Espa？ol de Sue？o. Definición y concepto, fisiopatología, clínica y exploración del SAHS,” Archivos de Bronconeumología, vol. 41, Extraordinario 4, pp. 12–29, 2005.
[23]
I. Ayappa, R. G. Norman, A. C. Krieger, A. Rosen, R. L. O'Malley, and D. M. Rapoport, “Non-invasive detection of respiratory effort-related arousals (RERAs) by a nasal cannula/pressure transducer system,” Sleep, vol. 23, no. 6, pp. 763–771, 2000.
[24]
C. Guilleminault and A. Bassiri, “Clinical features and evaluation of obstructive sleep apnea-hypopnea syndrome and upper airway resistance syndrome,” in Principles and Practice of Sleep Medicine, M. H. Kryger, T. Roth, and W. C. Dement, Eds., pp. 1043–1052, Elservier, Philadelphia, Pa, USA, 4th edition, 2005.
[25]
H. Sala, C. Nigro, C. Rabec, A. S. Guardia, and M. Smurra, “Argentine consensus on sleep-related breathing disorders,” Medicina, vol. 61, no. 3, pp. 351–363, 2001.
[26]
R. Farré, J. Rigau, J. M. Montserrat, E. Ballester, and D. Navajas, “Relevance of linearizing nasal prongs for assessing hypopneas and flow limitation during sleep,” American Journal of Respiratory and Critical Care Medicine, vol. 163, no. 2, pp. 494–497, 2001.
[27]
J. W. Winkelman, “The evoked heart rate response to periodic leg movements of sleep,” Sleep, vol. 22, no. 5, pp. 575–580, 1999.
[28]
V. K. Somers and S. Javaheri, “Cardiovascular effects of sleep related breathing disorders,” in Principles and Practice of Sleep Medicine, M. H. Kryger, T. Roth, and W. C. Dement, Eds., pp. 1180–1191, Elservier, Philadelphia, Pa, USA, 4th edition, 2005.
[29]
A. T. Mulgrew, N. Fox, N. T. Ayas, and C. F. Ryan, “Diagnosis and initial management of obstructive sleep apnea without polysomnography: a randomized validation study,” Annals of Internal Medicine, vol. 146, no. 3, pp. 157–166, 2007.
[30]
U. Anttalainen, K. Liippo, and T. Saaresranta, “Diagnosis and initiation of nasal continuous positive airway pressure therapy for OSAS without a preceding sleep study?” Sleep and Breathing, vol. 15, pp. 791–797, 2011.
[31]
R. P. Skomro, J. Gjevre, J. Reid et al., “Outcomes of home-based diagnosis and treatment of obstructive sleep apnea,” Chest, vol. 138, no. 2, pp. 257–263, 2010.
[32]
S. T. Kuna, I. Gurubhagavatula, G. Maislin et al., “Noninferiority of functional outcome in ambulatory management of obstructive sleep apnea,” American Journal of Respiratory and Critical Care Medicine, vol. 183, no. 9, pp. 1238–1244, 2011.
[33]
R. B. Berry, G. Hill, L. Thompson, and V. McLaurin, “Portable monitoring and autotitration versus polysomnography for the diagnosis and treatment of sleep apnea,” Sleep, vol. 31, no. 10, pp. 1423–1431, 2008.
[34]
N. A. Antic, C. Buchan, A. Esterman et al., “A randomized controlled trial of nurse-led care for symptomatic moderate-severe obstructive sleep apnea,” American Journal of Respiratory and Critical Care Medicine, vol. 179, no. 6, pp. 501–508, 2009.
[35]
C. A. Nigro, E. Dibur, and E. Rhodius, “Accuracy of the clinical parameters and oximetry to initiate CPAP in patients with suspected obstructive sleep apnea,” Sleep and Breathing. In press.
