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Portable Testing for Sleep Disorders

Pittsburgh Mind Body Center, Core D “The Pittsburgh Sleep Group (PSG)”. Portable Testing for Sleep Disorders. How to do it When to use it. Sleep Testing Possibilities. Questionnaires Actigraphy Full PSG Other. Portable Testing. What we will cover in this session Rationale

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Portable Testing for Sleep Disorders

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  1. Pittsburgh Mind Body Center, Core D “The Pittsburgh Sleep Group (PSG)” Portable Testing for Sleep Disorders How to do it When to use it

  2. Sleep Testing Possibilities • Questionnaires • Actigraphy • Full PSG • Other

  3. Portable Testing What we will cover in this session • Rationale • Types of equipment • Pros and cons of different systems • Costs • Examples of usage; some hands on “play” • Questions/Answers

  4. Portable Sleep Apnea Monitoring

  5. Current State of non-Sleep Laboratory Diagnosis of OSA • Clinical suspicion • Probably accurate in obvious cases but cannot be routinely relied upon • Lacks sensitivity and specificity • Questionnaires • Validate clinical suspicion • None sufficiently sensitive or specific as a stand alone diagnostic method • Are useful as an adjunct to clinical decision-making, triage – MAP, Berlin are reasonable to consider

  6. Cardiovascular Consequences of Sleep-Disordered Breathing Report of a Workshop From the National Center on Sleep Disorders Research and the National Heart, Lung, and Blood Institute Basic Science Clinical Epidemiology Develop new tools for population screening Cellular / molecular studies Sleep Disordered Breathing & Cardiovascular Disease Prospective cohort studies Mouse models Incorporation of SDB / Sleep Deprivation in ongoing CV cohort studies Pathway studies for humans Clinical Therapeutic Studies • High – risk patient subsets • Development of new • treatment approaches Circulation 2004 109:951-957

  7. What is needed? Expand awareness among health care professionals through education and training. Develop and validate new and existing diagnostic and therapeutic technologies. Institute of Medicine Report2006

  8. Ability of type III monitors in the home setting to identify AHI suggestive of OSAHS in laboratory-based polysomnography Neg LR < 0.1 Pos LR >10 From Trikalinos et al, AHRQ, 07

  9. Current State of non-Sleep Laboratory Diagnosis of OSA • Diagnostic equipment • Terminology: Portable, ambulatory, out-of-sleep lab, HST, etc • Types of equipment • Type 2 • Type 3 • Type 4

  10. 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 2 Monitors: Mini-PSG

  11. 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 3 Monitors: Cardio-pulmonary Studies

  12. 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 Type 4 Monitors: Oximetry +

  13. 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?

  14. 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

  15. 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

  16. 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

  17. Type 3 monitor

  18. Type 3 monitor

  19. Stardust Report

  20. 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

  21. Example of moderate sleep apnea on Apnea Link

  22. 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

  23. WatchPAT Example

  24. Apnea Risk Evaluation System (ARES) New unit Cardiopulmonary monitor Moderately expensive Some local experience with it Tech time minimal Other devices

  25. 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

  26. Bodymedia, Inc Wearable devices that sense activity – more akin to actigraphy Evolving more into a obesity management solution than a sleep rhythm detector Bodymedia -Sensewear

  27. 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

  28. 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?

  29. 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

  30. Scenario 2, continued • How would you screen for sleep apnea? • What are the pros and cons? • What else do you need to know?

  31. 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).

  32. Scenario 3, continued • What would your approach be? • How might you combine approaches?

  33. http://www.cms.hhs.gov/mcd/viewtechassess.asp?from2=viewtechassess.asp&where=index&tid=48&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 Further reading

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