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Correspondence |

Usefulness of Elbow Sign for Screening OSA OnlyElbow Sign in OSA Screening FREE TO VIEW

Mahadevappa Hunasikatti, MD, DPM, FCCP
Author and Funding Information

From the Division of Internal Medicine, Department of Pulmonary Medicine, Critical Care Medicine and Sleep Medicine, Inova Fairfax Hospital; and the US Food and Drug Administration.

CORRESPONDENCE TO: Mahadevappa Hunasikatti, MD, DPM, FCCP, Inova Fairfax Hospital, 2826 Old Lee Hwy, #250, Fairfax, VA 22031; e-mail: drhunasikatti@gmail.com


FINANCIAL/NONFINANCIAL DISCLOSURES: The author has reported to CHEST that no potential 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. See online for more details.


Chest. 2014;146(3):e113. doi:10.1378/chest.14-0641
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Published online
To the Editor:

I read with interest the article on the utility of the elbow sign in the diagnosis of OSA by Fenton et al1 in a recent issue of CHEST (March 2014). The authors infer that the elbow sign could be used as an alternative to polysomnography (PSG) to establish the diagnosis of OSA. I disagree. It is analogous to treat a patient who complains of palpitation with ablation therapy for supposed atrial fibrillation. Although cost control is the goal, it may increase the cost to the health-care system. Many people without sleep apnea may start using it, but inadequate treatment of many patients may cause a delay in definitive treatment.

As Fenton et al1 mention, untreated sleep apnea is associated with hypertension, cardiovascular disease, increased number of motor vehicle accidents, increased health-care costs, and decreased productivity in the workplace.2 Sleep apnea is not a homogeneous disorder. The treatment is not autotitrating positive airway pressure for everyone. That is oversimplification. What happens when the patient has central sleep apnea, and how do we know that the patient does not have it? Should we wait until the condition worsens and leads to the medical consequences of inadequate therapy?

The empirical CPAP trial for suspected OSA reported earlier actually showed that 40% of those patients were treated with suboptimal pressures. Eventually, they all had a PSG/CPAP titration sleep study.3

There are significant wait times in many places in Canada, as the authors point out. That can be managed with judicious use of home sleep testing4 rather than with using the elbow sign to replace PSG. That is actually doing a disservice to our patients. The elbow sign could be useful in the screening of the patients but not as a diagnostic test.

Acknowledgments

Other contributions: The opinion presented here represents the personal views of the author, not that of the Food and Drug Administration.

Fenton ME, Heathcote K, Bryce R, et al. The utility of the elbow sign in the diagnosis of OSA. Chest. 2014;145(3):518-524. [CrossRef] [PubMed]
 
Teng AY, Won C. Implications of OSA on work and work disability including drivers. Clin Chest Med. 2012;33(4):731-744. [CrossRef] [PubMed]
 
Skomro RP, Cotton DJ, Gjevre JA, et al. An empirical continuous positive airway pressure trial for suspected obstructive sleep apnea. Can Respir J. 2007;14(3):159-163. [PubMed]
 
Collop NA, Anderson WM, Boehlecke B, et al; Portable Monitoring Task Force of the American Academy of Sleep Medicine. 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(7):737-747. [PubMed]
 

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References

Fenton ME, Heathcote K, Bryce R, et al. The utility of the elbow sign in the diagnosis of OSA. Chest. 2014;145(3):518-524. [CrossRef] [PubMed]
 
Teng AY, Won C. Implications of OSA on work and work disability including drivers. Clin Chest Med. 2012;33(4):731-744. [CrossRef] [PubMed]
 
Skomro RP, Cotton DJ, Gjevre JA, et al. An empirical continuous positive airway pressure trial for suspected obstructive sleep apnea. Can Respir J. 2007;14(3):159-163. [PubMed]
 
Collop NA, Anderson WM, Boehlecke B, et al; Portable Monitoring Task Force of the American Academy of Sleep Medicine. 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(7):737-747. [PubMed]
 
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