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Correspondence |

Diagnosing Obstructive Sleep Apnea in the Setting of Comorbid Pulmonary Disease FREE TO VIEW

Sanjay R. Patel, MD, MS, FCCP; Reena Mehra, MD, MS, FCCP
Author and Funding Information

Case Western Reserve University Cleveland, OH

Correspondence to: Sanjay R. Patel, MD, MS, FCCP, 11400 Euclid Ave, Room 290-D, Cleveland, OH 44106; e-mail: srp20@case.edu


The authors have 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.

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (www.chestjournal.org/site/misc/reprints.xhtml).


© 2009 American College of Chest Physicians


Chest. 2009;136(3):948. doi:10.1378/chest.08-2997
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To the Editor:

In a recent “Postgraduate Education Corner” report in CHEST (December 2008), Benson and Schwarz1 reported on a young woman with recurrent hemoptysis resulting from pauciimmune pulmonary capillaritis exacerbated by negative-pressure pulmonary hemorrhage secondary to presumed coexisting obstructive sleep apnea (OSA). The authors described a detailed evaluation regarding the patient's pulmonary capillaritis that serves as a worthy example for pulmonologists in training.

In contrast, the approach taken regarding the patient's tentative diagnosis of OSA was markedly flawed, and it is concerning that this could misinform trainees regarding the appropriate evaluation, diagnosis, and treatment of OSA. Although the authors presumed a high probability of OSA based on the patient's physical examination, they did not report that they obtained a sleep history, which should be standard in the evaluation of OSA. The diagnostic test used in this patient, who had a waking oxygen saturation of 89% while breathing 8 L/min supplemental oxygen, was overnight oximetry. There is no description provided of the oximetry results. This may be because there has been no validation of this testing and no consensus on how to interpret overnight oximetry for the purpose of evaluating OSA in otherwise healthy individuals.2 In patients such as the one whose case was described, the utility of oximetry is even more problematic, because the false-positive rate increases with underlying pulmonary disease and the false-negative rate increases with the administration of supplemental oxygen.

An evidence-based practice parameter guideline3 issued by the American Academy of Sleep Medicine has strongly recommended against the use of even multichannel unattended monitoring for OSA diagnosis in patients with underlying pulmonary disease. Similarly, recent practice parameter guidelines4 state that, as a standard of care, autotitrating positive airway pressure should not be used to determine continuous positive airway pressure (CPAP) levels in patients with underlying lung disease. In addition, in the case of the patient described by Benson and Schwarz,1 the use of hydrocodone predisposed her to increased risk for central apneas, which would also be a contraindication for autotitration. While the treatment of acutely ill patients who are too sick to undergo formal polysomnography is challenging, and the risks of empiric CPAP use in the short term are relatively low, it is clear that once this patient's clinical status improved, an appropriate evaluation should have been performed to verify the diagnosis of OSA, given the burden imposed by lifetime CPAP therapy.

Benson A, Schwarz M. A 26-year-old woman with recurrent hemoptysis and a sleep disturbance. Chest. 2008;134:1325-1331. [PubMed] [CrossRef]
 
Ramsey R, Mehra R, Strohl KP. Variations in physician interpretation of overnight pulse oximetry monitoring. Chest. 2007;132:852-859. [PubMed]
 
Collop NA, Anderson WM, Boehlecke B, et al. Clinical guidelines for the use of unattended portable monitors in the diagnosis of obstructive sleep apnea in adult patients: Portable Monitoring Task Force of the American Academy of Sleep Medicine. J Clin Sleep Med. 2007;3:737-747. [PubMed]
 
Morgenthaler TI, Aurora RN, Brown T, et al. Practice parameters for the use of autotitrating continuous positive airway pressure devices for titrating pressures and treating adult patients with obstructive sleep apnea syndrome: an update for 2007; an American Academy of Sleep Medicine report. Sleep. 2008;31:141-147. [PubMed]
 

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References

Benson A, Schwarz M. A 26-year-old woman with recurrent hemoptysis and a sleep disturbance. Chest. 2008;134:1325-1331. [PubMed] [CrossRef]
 
Ramsey R, Mehra R, Strohl KP. Variations in physician interpretation of overnight pulse oximetry monitoring. Chest. 2007;132:852-859. [PubMed]
 
Collop NA, Anderson WM, Boehlecke B, et al. Clinical guidelines for the use of unattended portable monitors in the diagnosis of obstructive sleep apnea in adult patients: Portable Monitoring Task Force of the American Academy of Sleep Medicine. J Clin Sleep Med. 2007;3:737-747. [PubMed]
 
Morgenthaler TI, Aurora RN, Brown T, et al. Practice parameters for the use of autotitrating continuous positive airway pressure devices for titrating pressures and treating adult patients with obstructive sleep apnea syndrome: an update for 2007; an American Academy of Sleep Medicine report. Sleep. 2008;31:141-147. [PubMed]
 
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