0
Correspondence |

Diagnosis of Obstructive Sleep Apnea : Alternatives to Polysomnography FREE TO VIEW

Robert Thurnheer, MD, FCCP
Author and Funding Information

Affiliations: Kantonsspital, Münsterlingen, Switzerland,  Johns Hopkins University, Baltimore, MD

Correspondence to: Robert Thurnheer, MD, FCCP, Kantonsspital, Pulmonary Medicine, Münsterlingen, Thurgau 8596, Switzerland; e-mail: robert.thurnheer@stgag.ch



Chest. 2006;130(5):1625-1626. doi:10.1378/chest.130.5.1625
Text Size: A A A
Published online

To the Editor:

In her editorial comment (January 2006),1Collop raised concern about a provocative study from Senn et al (January 2006).2 Patients with a history suggesting obstructive sleep apnea were treated empirically without diagnostic polysomnography. The clinical outcome was taken as indirect proof or exclusion of the diagnosis.

Most physicians treating patients with sleep apnea would agree that making a diagnosis before starting a potentially lifelong treatment is desirable. Demonstrating an elevated apnea-hypopnea index score helps patients to understand their condition and allows documentation of the effect of continuous positive airway pressure on respiratory disturbance. But, do we have good evidence that polysomnography is the best or only way to decide who will profit from treatment and who will not? It has been shown3 that apnea and arousal indexes correlate only weakly with sleepiness and daytime performance. Thus, the question remains as to how much polysomnography adds to our treatment decision compared to pure clinical judgment or less expensive tools such as cardiorespiratory monitoring. Improvement of daytime symptoms is more relevant to patients than a reduction of scores on apnea-hypopnea and arousal indexes. The study by Senn et al2 was the first to compare clinical judgment to polysomnography in the prediction of daytime symptoms. In a most recent trial,4 cardiorespiratory monitoring was performed as well as polysomnography to select patients who would profit from nasal continuous positive airway pressure therapy, challenging polysomnography as the only possible way to diagnose obstructive sleep apnea.

It may be difficult to justify the significantly higher expense of polysomnography, although unexpected findings on polysomnography are certainly valuable, as advocated in Collop’s editorial comment.1 For a long time, authorities in sleep medicine have critically appraised diagnostic approaches that are simpler than polysomnography but without proving their superiority; however, further research has been strongly encouraged.56 Because an apparent “demand-capacity chasm” for the availability of polysomnography has been recognized by American and European experts,7 the position of polysomnography in the diagnosis of patients with high pretest probability for obstructive sleep apnea should be debated.

The author of this letter is a former coworker of Professor K. E. Bloch, senior author of the study being discussed. The author has no significant conflicts of interest with any company whose products are discussed in this article.

The author has reported to the ACCP that no significant conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.

Collop, NA (2006) Blue light special on CPAP, aisle 11.Chest129,6-7. [CrossRef]
 
Senn, O, Brack, T, Russi, EW, et al A continuous positive airway pressure trial as a novel approach to the diagnosis of the obstructive sleep apnea syndrome.Chest2006;129,67-75. [CrossRef]
 
Kingshott, RN, Engleman, HM, Deary, IJ, et al Does arousal frequency predict daytime function?Eur Respir J1998;12,1264-1270. [CrossRef]
 
Whitelaw, WA, Brant, RF, Flemons, WW Clinical usefulness of home oximetry compared with polysomnography for assessment of sleep apnea.Am J Respir Crit Care Med2005;171,188-193. [CrossRef]
 
American Academy of Sleep Medicine.. Sleep-related breathing disorders in adults: recommendations for syndrome definition and measurement techniques in clinical research; the report of an American Academy of Sleep Medicine task force.Sleep1999;22,667-689
 
Flemons, WW, Littner, MR, Rowley, JA, et al Home diagnosis of sleep apnea: a systematic review of the literature: an evidence review cosponsored by the American Academy of Sleep Medicine, the American College of Chest Physicians, and the American Thoracic Society.Chest2003;124,1543-1579. [CrossRef]
 
Flemons, WW, Douglas, NJ, Kuna, ST, et al Access to diagnosis and treatment of patients with suspected sleep apnea.Am J Respir Crit Care Med2004;169,668-672. [CrossRef]
 
To the Editor:

I agree with many points that Dr. Thurnheer made in his letter-to-the-editor. There are undoubtedly many patients who do not require a full overnight polysomnography to diagnose their obstructive sleep apnea, and, indeed, the use of a limited channel cardiorespiratory monitor would suffice. However, such devices need to be used with a well-devised diagnostic and treatment algorithm so as to not abandon patients with a “negative study” but continued complaints with no answers or therapies, or those patients with “false-positive” results who do not respond well to therapy with continuous positive airway pressure, perhaps because they have central sleep apnea or a hypoventilation syndrome. Only until such algorithms using cardiorespiratory monitors are developed and tested will patients with sleep complaints be best served with the use of such devices.


Figures

Tables

References

Collop, NA (2006) Blue light special on CPAP, aisle 11.Chest129,6-7. [CrossRef]
 
Senn, O, Brack, T, Russi, EW, et al A continuous positive airway pressure trial as a novel approach to the diagnosis of the obstructive sleep apnea syndrome.Chest2006;129,67-75. [CrossRef]
 
Kingshott, RN, Engleman, HM, Deary, IJ, et al Does arousal frequency predict daytime function?Eur Respir J1998;12,1264-1270. [CrossRef]
 
Whitelaw, WA, Brant, RF, Flemons, WW Clinical usefulness of home oximetry compared with polysomnography for assessment of sleep apnea.Am J Respir Crit Care Med2005;171,188-193. [CrossRef]
 
American Academy of Sleep Medicine.. Sleep-related breathing disorders in adults: recommendations for syndrome definition and measurement techniques in clinical research; the report of an American Academy of Sleep Medicine task force.Sleep1999;22,667-689
 
Flemons, WW, Littner, MR, Rowley, JA, et al Home diagnosis of sleep apnea: a systematic review of the literature: an evidence review cosponsored by the American Academy of Sleep Medicine, the American College of Chest Physicians, and the American Thoracic Society.Chest2003;124,1543-1579. [CrossRef]
 
Flemons, WW, Douglas, NJ, Kuna, ST, et al Access to diagnosis and treatment of patients with suspected sleep apnea.Am J Respir Crit Care Med2004;169,668-672. [CrossRef]
 
NOTE:
Citing articles are presented as examples only. In non-demo SCM6 implementation, integration with CrossRef’s "Cited By" API will populate this tab (http://www.crossref.org/citedby.html).

Some tools below are only available to our subscribers or users with an online account.

Related Content

Customize your page view by dragging & repositioning the boxes below.

CHEST Journal Articles
PubMed Articles
Guidelines
  • CHEST Journal
    Print ISSN: 0012-3692
    Online ISSN: 1931-3543