Polysomnography for Obstructive Sleep Apnea Should Include Arousal-Based Scoring: An American Academy of Sleep Medicine Position Statement.

ABSTRACT: The diagnostic criteria for obstructive sleep apnea (OSA) in adults, as defined in the International Classification of Sleep Disorders, Third Edition, requires an increased frequency of obstructive respiratory events demonstrated by in-laboratory, attended polysomnography (PSG) or a home sleep apnea test (HSAT). However, there are currently two hypopnea scoring criteria in The AASM Manual for the Scoring of Sleep and Associated Events: Rules, Terminology and Technical Specifications (AASM Scoring Manual). This dichotomy results in differences among laboratory reports, patient treatments and payer policies. Confusion occurs regarding recognizing and scoring "arousal-based respiratory events" during OSA testing. "Arousal-based scoring" recognizes hypopneas associated with electroencephalography-based arousals, with or without significant oxygen desaturation, when calculating an apnea-hypopnea index (AHI), or it includes respiratory effort-related arousals (RERAs), in addition to hypopneas and apneas, when calculating a respiratory disturbance index (RDI). Respiratory events associated with arousals, even without oxygen desaturation, cause significant, and potentially dangerous, sleep apnea symptoms. During PSG, arousal-based respiratory scoring should be performed in the clinical evaluation of patients with suspected OSA, especially in those patients with symptoms of excessive daytime sleepiness, fatigue, insomnia, or other neurocognitive symptoms. Therefore, it is the position of the AASM that the RECOMMENDED AASM Scoring Manual scoring criteria for hypopneas, which includes diminished airflow accompanied by either an arousal or ≥ 3% oxygen desaturation, should be used to calculate the AHI. If the ACCEPTABLE AASM Scoring Manual criteria for scoring hypopneas, which includes only diminished airflow plus ≥ 4% oxygen desaturation (and does not allow for arousal-based scoring alone), must be utilized due to payer policy requirements, then hypopneas as defined by the RECOMMENDED AASM Scoring Manual criteria should also be scored. Alternatively, the AASM Scoring Manual includes an option to report an RDI which also provides an assessment of the sleep-disordered breathing that results in arousal from sleep. Furthermore, given the inability of most HSAT devices to capture arousals, a PSG should be performed in any patient with an increased risk for OSA whose HSAT is negative. If the PSG yields an AHI of 5 or more events/h, or if the RDI is greater than or equal to 5 events/h, then treatment of symptomatic patients is recommended to improve quality of life, limit neurocognitive symptoms, and reduce accident risk.

Quality Measure for Screening for Adult Obstructive Sleep Apnea by Primary Care Physicians.

ABSTRACT: Obstructive sleep apnea (OSA) is a highly prevalent condition which remains under-diagnosed and under-treated. Untreated OSA is associated with several chronic medical conditions, a reduction in quality of life and increases in health care costs. Therefore, early identification of undiagnosed cases is important. Implementation of a screening measure in a primary care environment for populations at high-risk for OSA could improve patient outcomes and reduce the health care burden of untreated OSA.

Computer-Assisted Automated Scoring of Polysomnograms Using the Somnolyzer System.

STUDY OBJECTIVES: Manual scoring of polysomnograms is a time-consuming and tedious process. To expedite the scoring of polysomnograms, several computerized algorithms for automated scoring have been developed. The overarching goal of this study was to determine the validity of the Somnolyzer system, an automated system for scoring polysomnograms. DESIGN: The analysis sample comprised of 97 sleep studies. Each polysomnogram was manually scored by certified technologists from four sleep laboratories and concurrently subjected to automated scoring by the Somnolyzer system. Agreement between manual and automated scoring was examined. Sleep staging and scoring of disordered breathing events was conducted using the 2007 American Academy of Sleep Medicine criteria. SETTING: Clinical sleep laboratories. MEASUREMENTS AND RESULTS: A high degree of agreement was noted between manual and automated scoring of the apnea-hypopnea index (AHI). The average correlation between the manually scored AHI across the four clinical sites was 0.92 (95% confidence interval: 0.90-0.93). Similarly, the average correlation between the manual and Somnolyzer-scored AHI values was 0.93 (95% confidence interval: 0.91-0.96). Thus, interscorer correlation between the manually scored results was no different than that derived from manual and automated scoring. Substantial concordance in the arousal index, total sleep time, and sleep efficiency between manual and automated scoring was also observed. In contrast, differences were noted between manually and automated scored percentages of sleep stages N1, N2, and N3. CONCLUSION: Automated analysis of polysomnograms using the Somnolyzer system provides results that are comparable to manual scoring for commonly used metrics in sleep medicine. Although differences exist between manual versus automated scoring for specific sleep stages, the level of agreement between manual and automated scoring is not significantly different than that between any two human scorers. In light of the burden associated with manual scoring, automated scoring platforms provide a viable complement of tools in the diagnostic armamentarium of sleep medicine.

Snoring and obstructive sleep apnea among former World Trade Center rescue workers and volunteers.

BACKGROUND: Snoring is a common symptom among workers with adverse health effects from their World Trade Center (WTC) occupational exposures. Rhinitis and upper airway disease are highly prevalent among these workers. Rhinitis has been associated with snoring and, in some studies, with obstructive sleep apnea (OSA). We examined the association of WTC exposure and findings on nocturnal polysomnogram, as well as known predictors of OSA in this patient population. METHODS: One hundred participants with snoring underwent a polysomnogram to exclude OSA. Comorbidities had been previously evaluated and treated. The apnea-hypopnea index (AHI) defined and categorized the severity of OSA. Age, sex, body mass index (BMI), and WTC exposure variables were examined in bivariate and multiple regression analyses. RESULTS: Our study sample had a similar prevalence of five major disease categories, as we previously reported. OSA was diagnosed in 62% of the patients and was not associated with any of those disease categories. A trend toward increasing AHI with increasing WTC exposure duration failed to reach the statistical significance (P = 0.14) in multiple regression analysis. An elevated AHI was associated with BMI (P = 0.003) and male sex (P < 0.001). CONCLUSIONS: OSA was associated with BMI and male sex but not with occupational WTC exposure indicators in this patient population.