POLISOMNOGRAFÍ

A DINAMICA NO
DISE.
CLUB DE REVISTAS
JULIÁN DAVID CÁCERES O.
OTORRINOLARINGOLOGÍA
 Las pruebas de sueño que utilizan dispositivos portátiles de nivel 3
pueden acelerar el diagnóstico y reducir los costos asociados con la
polisomnografía en laboratorio de nivel 1. Intentamos evaluar la
precisión diagnóstica de las pruebas de nivel 3 en comparación con las
pruebas de nivel 1 e identificar la población de pacientes adecuada para
cada prueba.
PACIENTES
 Edad media de 50,8 años.
 Puntuación media de 11,6 en la escala de Epworth Sleepines
 IMC medio de 30,4.
 Proporción de pacientes masculinos y femeninos fue de 2,9 a 1.
 Se notificaron 1382 comorbilidades:
 Enfermedades cardiovasculares las más comunes (1080 pacientes, 78,1% de las comorbilidades
totales).
 Hipertension arterial (574 pacientes)
 Enfermedad cardíaca crónica estable (142 pacientes)
 Enfermedad arterial coronaria (113 pacientes).
 1 Paciente con asma y 9 pacientes con enfermedad pulmonar obstructiva crónica (0,7% de las
comorbilidades totales).
Technical failures affected 0.44% of patients who underwent level 1 tests,
1.30% of patients who underwent in-laboratory level 3 tests and 10.25%
of patients who underwent level 3 tests at home.
CONCLUSIONES

 Our findings confirm that level 3 devices are useful in the diagnosis of obstructive sleep apnea in patients with a
high pretest likelihood of having moderate to severe forms of the condition.
 The American Academy of Sleep Medicine and Canadian Sleep Society/Canadian Thoracic Society guidelines
recommend that portable sleep studies be provided under the direction of health professionals with accreditation in
sleep medicine and as part of a comprehensive assessment.
 The US Centers for Medicare & Medicaid Services has determined that portable devices (with a minimum of 3
channels) are acceptable for diagnosing obstructive sleep apnea in patients with clinical signs or symptoms
suggestive of the condition.
 Obstructive sleep apnea (OSA) affects 1-5% of
pediatric patients. Laborator polysomnography is
expensive, not always available, and is inconvenient
for patients. Our study investigates the diagnostic
ability of an unattended ambulatory monitor for the
diagnosis of pediatric OSA.
METHODS

 This was a prospective study designed to investigate the use of unattended,

home portable monitoring in children.
 Subjects were identified both in the Otolaryngology clinic and the Sleep
Disorder Center clinic of the San Antonio Military Health System.
 Patients were required to be less than 18 years of age and exhibit the signs and
symptoms of pediatric obstructive sleep apnea. Exclusion criteria included
obesity, Down syndrome, craniofacial abnormalities, neuromuscular disorders,
sickle cell disease, and mucopolysaccharidoses. Otolaryngology-Head and
Neck Surgery previous tonsillectomy or adenoidectomy, or other airway
surgery.
METHODS

 Forty-five patients were enrolled in the study

 33 subjects completed simultaneous laboratory polysomnogram with portable monitoring.
 Twenty patients completed the home studies, with 16 completing 2 nights of monitoring.
 Among the in-lab portable monitor setups, 31 of 33 were technically acceptable, with 75%
(25 of 33) of studies having successful recordings (interpretable data in 3 channels for at least
360 min).
 For the studies done at home, 32 of 36 were technically acceptable, and 67% (24 of 36) were
successful recordings
 IAH
The range (0–17.5/hr) of values
obtained by the PSG is much
greater than that obtained by the
portable monitor. The comparisons
for PSG vs. In-Lab (p = 0.0026),
PSG vs. Home 1 (p = 0.033), and
PSG vs. Home 2 (p = 0.033)
support the graphical
interpretation.
LSAT

the PSG captured a wider

range of LSAT values,
including more cases of a value
less than 90%, than the
portable monitor. The portable
monitor in each circumstance
calculated total sleep time
 (TST) as higher than the PSG
(In-Lab p = 0.000022; Home 1
p = 0.00036; Home 2
p = 0.00048).
CONCLUSIONES

 Our results in a small population found that the portable device did not perform well
compared to the PSG in calculating the AHI and LSAT, or in accurately diagnosing OSA.
 However, we did find that the results from the home sleep test were reproducible over
multiple nights of use.
 The results compared significantly better in children age 6 and over, suggesting that older
children may be better suited for home sleep apnea testing.
 Additional studies on larger numbers of patients will be needed prior to widespread use of
home sleep apnea testing in children.
 Test the utility of an integrated clinical pathway for
obstructive sleep apnea (OSA) diagnosis and
continuous positive airway pressure (CPAP) treatment
using portable monitoring devices
 METHODS
 DESIGN: Randomized, open-label, parallel group, unblinded, multicenter clinical trial comparing home-based,
unattended portable monitoring for diagnosis and autotitrating CPAP (autoPAP) compared with in-laboratory
polysomnography (PSG) and CPAP titration.
 SETTING: Seven American Academy of Sleep Medicine (AASM) accredited sleep centers.
 PARTICIPANTS: Consecutive new referrals, age 18 yr or older with high probability of moderate to severe OSA
(apnea-hypopnea index [AHI] ≥ 15) identified by clinical algorithm and Epworth Sleepiness Scale (ESS) score ≥
12.
 INTERVENTIONS: Home-based level 3 testing followed by 1 wk of autoPAP with a fixed pressure CPAP
prescription based on the 90% pressure from autotitration of PAP therapy (autoPAP) device (HOME) compared
with attended, in-laboratory studies (LAB).
 MEASUREMENTS: CPAP acceptance, time to treatment, adherence at 1 and 3 mo; changes in ESS, and
functional outcomes.
Functional Outcomes of Sleep Questionnaire (FOSQ),7 Medical Outcomes Study 36-Item Short Form (SF36),8 Calgary
Sleep Apnea Quality of Life Index (SAQLI),9 European Health Status Questionnaire (EQ-5D) center for Epidemiologic
Studies Depression scale (CESD-10).
INCLUSION - EXCLUSION

 apnea-hypopnea index (AHI) of at least 15 events/hr by objective testing.

 “adjusted neck circumference” of at least 43 cm. This adjusted neck circumference was calculated as the measured neck
circumference (cm) plus an additional 3 cm if habitual snoring was present; 4 cm if hypertension was present; and 3 cm if
apnea, gasping, or choking was present on most nights.
 Epworth Sleepiness Scale (ESS) score ≥ 12 at the time of referral.
 Exclusion criteria: preexisting diagnosis of OSA or treatment (CPAP); significant comorbid pulmonary disease. awake
hypercapnia or hypoventilation syndrome; respiratory or heart failure or neuromuscular disease; concerns about unsafe
driving defined as report of an automobile accident due to falling asleep behind the wheel in the past year; chronic narcotic
use; alcohol abuse; uncontrolled psychiatric disturbance.
 Clinical features of other sleep disorders; for example, moderate to severe restless leg symptoms, chronic insomnia or other
conditions resulting in less than 4 hr of sleep per night, or history of cataplexy; to undergo home testing because of living
arrangements; anticipation of upper airway or gastric bypass surgery in the next 6 months
CONCLUSIONES

 La estrategia de diagnostico y tratamiento basado en medidas domesticas comparado

con polisomnografias convencionales no fueron inferiores en terminos de aceptacion,
adherencia tiempo de tratamiento y mejoria functional.
 Los costos son significativamente menores con estrategias domiciliarias, lleganfo a
haber reducciones de hasta el 70%