Portable Polysomnography and

Positive Airway Pressure Titration

Home Sleep Home?

Lee Dresser, M.D.Medical Director

St. Francis Hospital Sleep Center

• Mental fatigue, poor decision-making, impaired learning, increased seizures and migraines occur when we are sleep deprived.

• Why does normal brain function deteriorate with prolonged waking and require (Good) sleep to be restored?

• Recent study showed waste products of brain metabolism are removed from brain of mice during sleep.

• Sleep therefore maybe required to clear potentially toxic metabolites from the brain. This may lead to feeling of refreshment.

Sleep Drives Metabolite Clearance from the Adult Brain

Lulu Xie1,*Maiken Nedergaard1,†

SCIENCE; October 2013

The conservation of sleep across all animal species suggests that sleep serves a vital function. We here report that sleep has a critical function in ensuring metabolic homeostasis. Using real-time assessments of tetramethylammonium diffusion and two-photon imaging in live mice, we show that natural sleep or anesthesia are associated with a 60% increase in the interstitial space, resulting in a striking increase in convective exchange of cerebrospinal fluid with interstitial fluid. In turn, convective fluxes of interstitial fluid increased the rate of β-amyloid clearance during sleep. Thus, the restorative function of sleep may be a consequence of the enhanced removal of potentially neurotoxic waste products that accumulate in the awake central nervous system.

SLEEP 2008;31(8):1071-1078.

Up to 17% Adults in US may Have Some Form

Sleep Disordered Breathing (SDB)

Up to 6% Have Moderate to Severe Apnea

Up to 75% of SDBPatients are Undiagnosed

Many Studies Link SDB to:

• Hypertension• Heart Disease• Stroke• Depression• Motor Vehicle Accidents• Cognitive Impairment• Decreased Quality of Life

Daytime Impairment Due to OSA May Decrease Motivation to Maintain Healthy Lifestyle and Diminish Compliance with Therapy for Comorbid Conditions

Obstructive Sleep Apnea defined as reduction of airflow by 90% or more

for at least 10 seconds.

Obstructive Hypopnea defined as either decrease in airflow by at

least 50% with reduction of oxygen saturation by 3%

orDecrease in airflow with reduction

of oxygen saturation by 4%

Sleep Disordered Breathing

Mild SDB: AHI > 5 < 15

Moderate SDB: AHI > 15 < 30

Severe SDB: AHI > 30

Severe Sleep Disordered BreathingWas Associated with Increased Mortality, Even in Non-sleepy

Patients

Association of SDB with DeathMuch Stronger After

Excluding PatientsUsing CPAP

Thus, CPAP Appears toPrevent Death in Patients

With Severe SDB

Conclusion:

Good Quality Sleep is Good For the Body, Brain

and Long Life

Reasons for Home Sleep Studies:

• Decrease Wait Time

• Patient Unable, Unwilling to go to Lab

• $$ More Attractive to patients with High Deductibles and to Insurance Companies

CMS Payments for PSGs

2001: $62 Million

2011: $565 Million

PSG HSTMedicare: $598 $186

Highmark: $1306 $226BC/BS

Centers for Medicare and Medicaid (CMS)Guidelines for Home Sleep Tests

Will pay for Types I, II, III and IV Studies

* Note CMS Type I-IV studies are different from AASM Type I-IV studies

Type I Studies• Attended• EEG• EOG• Heart Rate• Chin EMG• Limb EMG• Respiratory Effort at Thorax and Abdomen• Air Flow • Pulse Oximetry

Type IIUnattended with minimum 7

ChannelsMust Include:

• EEG• EOG• Heart rate• EMG• Airflow• Respiratory Effort• Oxygen Saturation

Type IIIUnattended with minimum 4

ChannelsMust Include:

• 2 Respiratory/Flow• Heart rate• Oxygen Saturation

Type IVUnattended with minimum 3 Channels

Must include channels that allowdirect calculation of AHI or RDI through

measurement of Thoracoabdominal Movement of Airflow

CMS will also allow studies done with PAT (Peripheral Arterial Tone) device

Most HST Devices Rely Upon

3 Signals to Diagnose OSA

• Nasal/Oral Airflow• Respiratory Effort• Oximetry

Other Channels Commonly Added:

Pulse, Position, TST

•Important That Patient Be Well Educated How to Use HST Device

•Must be Able to Review Raw Data

•Must Be Interpreted by Well Trained Sleep Specialist in Context Comprehensive Sleep Evaluation

Home Sleep Test Advantages:

• Patient can sleep at home

• Good for immobile, reluctant patients

• Financially attractive to patients and insurers

Home Sleep Test Disadvantages:

• May Underestimate OSA Severity•3-18% Failure rate. Artifact• Not suitable for central apnea, significant CHF or COPD, morbid obesity• Miss PLMs, RBD, Seizures

What is Evidence Regarding Home Sleep

Studies?

Noninferiority of Functional Outcome in Ambulatory Management of Sleep ApneaSamuel T. Kuna, et al.Am J. Respir. Crit. Care Med.; 183, 1238-1244, 2011

• Compared HST and Auto-PAP to In Lab PSG and CPAP Titration

• Randomized, Controlled Trial 296 Patients

• VA Study, 95% Male

• 15% Failure Auto-PAP

• Compared Productivity, Vigilance, Activity Level, Intimacy and Sexual Relationships, Compliance with CPAP between Two Groups

Noninferiority of Functional Outcome in Ambulatory Management of Sleep ApneaSamuel T. Kuna, et al.Am J. Respir. Crit. Care Med.; 183, 1238-1244, 2011

RESULTS:

• Functional Outcomes Improved Equally in Both Groups

• CPAP Compliance the same in Both Groups at 3 Months

SLEEP 2012;35(6):757-767

• Selected patients with moderate to severe OSA

• Used “Adjusted Neck Circumference” >/= 43 cm

• To Neck Circumference Add:

Habitual Snoring: 3 cmHTN: 4 cmWitnessed Apnea, Gasping Most Nights: 3 cm

To Be Included in Study Needed Adjusted Neck Circumference >/= 43 cm AND ESS >/= 12

• Used Embletta HST. Measured Airflow, Chest and Abdominal Movements, Pulsox, ECG and Body Position

• Adjusted Neck Circumference Gave 50% Pretest Probability of AHI > 15

HST and Auto-PAP were Equivalent to In Lab Studies In:

• Tolerance of CPAP• Time to Beginning Therapy• Reduction in Hypersomnolence• Adherence at 3 Months Better in HST Patients

• 23/74 Patients with Home AHI < 15 Had In Lab AHI > 15

• Despite Rigorous Education, Acclimatization, Ongoing Support only 30% Lab and 40% Home Groups were Compliant with CPAP at One Month According to Medicare Guidelines

Physician Credentials for Interpretation HST

and Ordering PAP Devices

• Board Certified By ABSM or Member ofAmerican Board of Medical Specialties; or

• Completed Sleep Fellowship; or

• Active Staff Member AASM or Joint Commission Accredited Sleep Center

Automatic Titrating CPAP

Most Studies Excluded Patients with CHF, COPD and Central Apnea

Designed to Increase Pressure toMaintain Airway Patency and

Decrease Pressure if No Events Detected in Certain Period of Time

Automatic Titrating CPAP

Auto-PAP Devices Measure Different Variables:

• Snoring• Apnea, Hypopnea• Airflow Limitation• Or Combination

Automatic Titrating CPAP

Advantages:• Increase Patient Compliance by IncreasingPressure only as Needed, i.e. in REM and when Supine

• Adjust if patient gains/loses weight

Automatic Titrating CPAP

Can Keep Patient on APAP or Determine P90 or P95 and

Set CPAP at That Pressure

Automatic Titrating CPAP

•Many Studies Show Reduction of AHI < 5 with Auto-PAP

•One Review of 30 Studies on Auto-PAPShowed No Clear Increase Acceptance or Compliance with Auto-PAP vs CPAP

Conclusions• HSTs are Accurate at Diagnosing

OSA,Especially if Patients Well Screened

to Have Moderate to Severe Disease

• Certain Patient Populations Require

In Lab Studies (Demented Patients, Morbidly Obese, With Severe Coexistent Medical Problems,

Suspect PLMs or RBD

Conclusions

• Must Have Proper Equipment and Must be Properly Utilized

•Studies Must be Interpreted by Experienced Clinicians

•Auto-PAP Effective for Titrating,Delivering Therapy for OSA

to Certain Patient Populations