portable testing for sleep disorders how to do it when to use it pittsburgh mind body center, core d...
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Portable Testing for Sleep Disorders
How to do it
When to use it
Pittsburgh Mind Body Center, Core D“The Pittsburgh Sleep Group (PSG)”
Sleep Testing Possibilities
Questionnaires Actigraphy Full PSG Other
Portable Testing
What we will cover in this sessionRationaleTypes of equipmentPros and cons of different systemsCostsExamples of usage; some hands on “play”Questions/Answers
Portable Sleep Apnea Monitoring
Current State of non-Sleep Laboratory Diagnosis of OSA
Clinical suspicionProbably accurate in obvious cases but cannot be
routinely relied uponLacks sensitivity and specificity
QuestionnairesValidate clinical suspicionNone sufficiently sensitive or specific as a stand alone
diagnostic methodAre useful as an adjunct to clinical decision-making,
triage – MAP, Berlin are reasonable to consider
Cardiovascular Consequences of Sleep-Disordered BreathingReport of a Workshop From the National Center on Sleep Disorders
Research and the National Heart, Lung, and Blood Institute
Circulation 2004109:951-957
Basic Science Clinical Epidemiology
Clinical Therapeutic Studies
SleepDisordered Breathing
&Cardiovascular
Disease
Cellular / molecularstudies
Mouse models
Pathway studiesfor humans
• High – risk patient subsets• Development of new treatment approaches
Develop new tools for
population screening
Prospective cohort studies
Incorporation of SDB / Sleep Deprivationin ongoing CV cohort studies
Institute of Medicine Report2006
What is needed? Expand awareness
among health care professionals through education and training.
Develop and validate new and existing diagnostic and therapeutic technologies.
Ability of type III monitors in the home setting to identify AHI suggestive of OSAHS in laboratory-based
polysomnography
Pos LR >10
Neg LR < 0.1
From Trikalinos et al, AHRQ, 07
Current State of non-Sleep Laboratory Diagnosis of OSA
Diagnostic equipment • Terminology: Portable, ambulatory, out-
of-sleep lab, HST, etc
• Types of equipmentType 2Type 3Type 4
Type 2 Monitors: Mini-PSG
Advantage• Multiple channels• Flexibility of signal
type• Comprehensive• Use standard software
of a base system• Portability• Extensive track-record
in research applications
Disadvantage• Tech hook up • Expensive• Probably no
reimbursement for home PSG
• Loss of signal – no way to easily correct problem
Type 3 Monitors: Cardio-pulmonary Studies
Advantage• Easy to set up: easily
done by most patients; technician not required
• Inexpensive (<$10K)• Very portable• Reduced number of
signals
Disadvantage• Reduced number of
signals• No reimbursement• Signal loss at home;
not way to correct• Requires scoring or at
least overview of scoring by tech; takes longer than you think
Type 4 Monitors: Oximetry +
Advantage• Most portable• Inexpensive• Easy to set up• Core signals:
oxygenation and airflow
• Now may include PAT signal
Disadvantage• No reimbursement• Minimal number of
signals – may not capture important aspects of some OSA
• Signal loss
Current Uncertainties: Type 3 & 4 Devices
How many signals are needed? Which signals add the most value? Are there clinical populations that this
does not work in? How can technology be combined with
clinical decision making to optimize OSA diagnosis outside the sleep lab?
More uncertainties…
New technologies – how do they fit in to the existing PSAT device classification?• WatchPAT-100• PTT• ARES• New systems on the horizon will have
capabilities to be a level 2-4 by adding or taking away modules
Stardust
Made by Respironics, Inc Level 3 device Measures: airflow, resp. effort, oximetry,
heart rate, body position Well validated Moderately expensive, ~$7000 but
subsequent units are cheaper Moderate tech time for scoring
Embletta
Somnologica/Medcare Level 3 Measures: Airflow, respiratory effort,
oximetry, body position Well-validated, widely used Moderately expensive, similar to Stardust Moderate tech time for scoring
Type 3 monitor
Type 3 monitor
Stardust Report
Apnea link
Resmed, Inc. Level 4 Measures: airflow +/- oximetry Some validation; generally shows that it’s
accurate in detecting more severe OSA Relatively inexpensive; consumables less
than $15 for earlier models Limited tech time
Example of moderate sleep apnea on Apnea Link
WatchPAT
Works on principle of changes in peripheral arterial tonometry
Indirect measure of ANS activity PAT is a surrogate marker for apnea,
hypoxia Moderately expensive to purchase;
individual probes are recurring cost Minimal to no tech time for scoring
WatchPAT Example
Other devices
Apnea Risk Evaluation System (ARES)• New unit• Cardiopulmonary
monitor• Moderately expensive• Some local experience
with it• Tech time minimal
Night Cap
Developed by Dr. Allan Hobson Head cap that can measure NREM vs.
REM sleep Limited validation studies Not used much anymore as best as I can
tell ?Commercial availability
Bodymedia -Sensewear
Bodymedia, Inc Wearable devices
that sense activity – more akin to actigraphy
Evolving more into a obesity management solution than a sleep rhythm detector
Scenario 1
Your objective is to measure psychological “well-being” in a cohort of Iraq war veterans over a 3 year span beginning with the end of military service
You are concerned that sleep disorders will be a mediator of psychological health
Your are also concerned that sleep disorders will confound the sleep measure
Scenario 1, continued
Your budget is very limited How can you assess for sleep apnea in a
cost efficient way? How can other sleep disorders be
assessed? What tools would you use and why?
Scenario 2
Your objective is to screen a population of factory workers for sleep apnea as part of a wellness program you are consulted about
You have 2500 middle-aged men and women to screen
Your budget total budget for sleep screening is $20 per person but you can get some equipment through a different grant
Scenario 2, continued
How would you screen for sleep apnea? What are the pros and cons? What else do you need to know?
Scenario 3
Your objective is to measure sleep and rule out sleep apnea in a study of obese individuals contemplating bariatric surgery and stress
This is a pilot study and you have essentially no budget but you have friend who will help with the sleep part for free (within reason).
Scenario 3, continued
What would your approach be? How might you combine approaches?
Further reading
http://www.cms.hhs.gov/mcd/viewtechassess.asp?from2=viewtechassess.asp&where=index&tid=48&
Or, go to www.ahrq.gov and search for completed technology assesments in 2007