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Home Sleep Testing Clarified

With the emergence of home sleep testing, there has been some confusion regarding the indications for home sleep testing. This letter is an attempt to provide clarity on the use of home sleep testing. Patients should be prescreened for sleep apnea before using any home sleep testing program.

It is important to use a validated screening tool. The Berlin questionnaire is
the most validated screening tool, but unfortunately it is not easy to use or score.

Berlin Questionnaire for Sleep Issues

However, the Stop-Bang questionnaire is extremely simple!

The Stop Bang Questionnaire

If the patient answers yes to any 3 of the questions – they are at high risk for sleep apnea. Home sleep testing should only be used in patients who are at high risk for sleep apnea. Anyone who screens positive to the Stop-Bang questionnaire is high risk.

The Watermark Ares home testing device performs level 2 sleep studies. Level 2
studies measure indices of both sleep and breathing. These studies have proven to be
equivalent to laboratory testing for the assessment of sleep apnea.

Most home testing equipment performs level 3 sleep studies which only record indices of breathing. Level 3 studies are also appropriate for testing for sleep apnea. A positive level 3 study is sufficient for the diagnosis of sleep apnea.

However a negative level 3 study in a high risk patient does not rule out sleep apnea and necessitates a laboratory study. Home sleep testing is not appropriate for patients who are not at high risk for obstructive sleep apnea. It is also contraindicated in circumstances in which the accuracy of the testing equipment may be altered.

The most common scenario that will decrease the accuracy of a home sleep testing device is the use of nasal oxygen. This is because nasal airflow is usually measured by monitoring nasal pressure changes at the nose. The slightly positive pressure of nasal oxygen can alter the signal.

Continuous positive airway pressure (CPAP) is the preferred therapy for sleep apnea.
There are 2 big categories of CPAP: traditional fixed pressure CPAP machines and autotitrating CPAP machines. These have been shown to be equivalent in the treatment of obstructive sleep apnea in multiple clinical trials.

They are both recognized as an acceptable treatment for sleep apnea by the American Academy of Sleep Medicine

Fixed pressure CPAP machines require a study to determine the best pressure for treatment. Auto-titrating CPAP machines are equipped with a microprocessor that constantly monitors the patient’s breathing.

If an increase in airway resistance is noted, CPAP pressure is slowly increased. Therapy with an auto-titrating CPAP machine can be initiated in the home. Cost and convenience are the two areas that differ greatly between laboratory and home based testing and treatment. Home sleep testing is roughly one-seventh the cost of laboratory testing!

In summary, it is no longer necessary to send your routine sleep apnea patients to a sleep laboratory. The use of an auto-titrating CPAP machine can eliminate the need for a second sleep study. High quality, more cost effective care can be provided in the comfort and convenience of the home.

Please contact Aeroflow Healthcare at 888-345-1780 if we can be of assistance in managing your patients.

Additional Links,

Validation of a Self-Applied Unattended Monitor for Sleep Disordered Breathing

Clinical Guidelines for the Use of Unattended Portable Monitors

Practice Parameters for the Use of Autotitrating CPAP

Outcomes of Home-Based Diagnosis and Treatment of Obstructive Sleep Apnea

Re: What is a sleep doctor?

A sleep doc is a doc who is supposed to quide patients through the testing process so he or she can customize treatment for sleep problems, since the doc knows enough about PSGs to catch things most would miss and knows enough about PAP therapy to ensure patients get effective therapy.

But sometimes (and way too often, seems to me) it means a doc who likes being able to make a quick buck by scribbling a number on a pad after techs run and score tests so that RTs can be expected to coordinate treatment.

Did I just say that out loud?

Just a couple more things to consider. The doctor should be board cerfied in sleep medicine. Also, the lab should have AASM accreditation. The lab should be not just a sleep lab but a sleep center, the former simply deals with apnea the latter deals with all sleep disorders. The tech that performs the study should be an RT that is also an RPSGT. If the tech is only an RPSGT, then he/she should have been a tech for at least 5 years. These are just personal observations, but being in the field I can tell you that if a physician has gone through the trouble of all this they likely want to provide good care. One final thought, just because the lab is in a hospital does not mean you are getting good care. Hospitals often have agreements with outside companies to completely run the lab. These companies mostly only care about the bottom line. They are covered under the Joint Commission accreditation of the hospital (not necessarily AASM) which only really considers the emergency and sterilization procedures of the lab, not how sleep medicine is practiced. Another benefit of not using the hospital is that it is much cheaper. Nonetheless go where you can find reputable, verifiable providers/labs/techs.