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Editorials |

Improving Access to Diagnosis and Treatment of Sleep-Disordered Breathing

Barbara Phillips, MD, MSPH, FCCP
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University of Kentucky College of Medicine, Lexington, KY

Correspondence to: Barbara Phillips, MD, MSPH, FCCP, University of Kentucky College of Medicine, 119 Sycamore Rd, Lexington, KY 40502; e-mail: Bphil95@aol.com



Chest. 2007;132(5):1418-1420. doi:10.1378/chest.07-1793
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This issue of CHEST includes “Topics in Practice Management” articles addressing split-night polysomnography and portable monitoring.12 Both reviews are well written, current, and immediately relevant to the practice of sleep medicine, but they don’t help us with many daily management conundrums, nor do they address serious deficiencies in our current approach to the diagnosis of sleep apnea. For example, the review of split-night polysomnography fails to address such practical questions as, “What do we do when we fail to accomplish an excellent continuous positive airway pressure (CPAP) titration, achieving rapid eye movement sleep, supine, for adequate time?” As of this writing, the infamous “2-h rule” (the Centers for Medicare and Medicaid Services [CMS] requires 2 h of sleep prior to CPAP initiation in a split-night study) makes it quite difficult to accomplish everything that needs to be done in an adequate CPAP titration in a single night, or even a full night. Then what? Options include trying to get the patient to return for another study, using the last pressure reached in the attempted titration, using autotitrating CPAP, or simply guessing what pressure to apply. Fortunately, that usually turns out okay; multiple studies35 of classical obstructive sleep apnea patients have established that in-laboratory CPAP titration does not improve outcomes compared with autotitrating, algorithm-derived, or empiric CPAP titration. The approach of Hukins et al4 is particularly pragmatic. This group showed that basing CPAP pressure on the patient’s body mass index resulted in outcomes similar use of laboratory-titrated pressures. Indeed, most people wind up receiving CPAP at 10 ± 2 cm H2O. In my view, the main value of in-laboratory titration is that it gives the patient a chance to experience and be educated about CPAP by a competent health-care professional. Of course, this might be better done during the daytime when everyone is awake!

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