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Clinical Guidelines |

Diagnosis of Obstructive Sleep Apnea in Adults: A Clinical Practice Guideline From the American College of PhysiciansDiagnosis of Obstructive Sleep Apnea in Adults FREE

Amir Qaseem, MD, PhD, MHA; Paul Dallas, MD; Douglas K. Owens, MD, MS; Melissa Starkey, PhD; Jon-Erik C. Holty, MD, MS; Paul Shekelle, MD, PhD, for the Clinical Guidelines Committee of the American College of Physicians*
[+] Article and Author Information

* This paper, written by Amir Qaseem, MD, PhD, MHA; Paul Dallas, MD; Douglas K. Owens, MD, MS; Melissa Starkey, PhD; Jon-Erik C. Holty, MD, MS; and Paul Shekelle, MD, PhD, was developed for the Clinical Guidelines Committee of the American College of Physicians. Individuals who served on the Clinical Guidelines Committee from initiation of the project until its approval were Paul Shekelle, MD, PhD (Chair); Roger Chou, MD; Molly Cooke, MD; Paul Dallas, MD; Thomas D. Denberg, MD, PhD; Nick Fitterman, MD; Mary Ann Forciea, MD; Robert H. Hopkins Jr., MD; Linda L. Humphrey, MD, MPH; Tanveer P. Mir, MD; Holger J. Schünemann, MD, PhD; Donna E. Sweet, MD; David S. Weinberg, MD, MSc; and Timothy Wilt, MD, MPH. Approved by the ACP Board of Regents on 17 November 2012.


From the American College of Physicians, Philadelphia, Pennsylvania; Virginia Tech Carilion School of Medicine, Roanoke, Virginia; Veterans Affairs Palo Alto Health Care System, Palo Alto, California; Stanford University, Stanford, California; and West Los Angeles Veterans Affairs Medical Center, Los Angeles, California.

Note: Clinical practice guidelines are “guides” only and may not apply to all patients and clinical situations. Thus, they are not intended to override clinicians' judgment. All ACP clinical practice guidelines are considered automatically withdrawn or invalid 5 years after publication or once an update has been issued.

Disclaimer: The authors of this article are responsible for its contents, including any clinical or treatment recommendations. No statement in this article should be construed as an official position of the U.S. Department of Veterans Affairs.

Financial Support: Financial support for the development of this guideline comes exclusively from the ACP operating budget.

Disclosures: Dr. Shekelle reports a grant from the Agency for Healthcare Research and Quality during the conduct of the study; personal fees from ECRI Institute and the U.S. Department of Veterans Affairs outside the submitted work; grants from the Agency for Healthcare Research and Quality, U.S. Department of Veterans Affairs, Centers for Medicare & Medicaid Services, and Office of the National Coordinator outside the submitted work; and a patent with royalties paid to UpToDate. Authors not named here have disclosed no conflicts of interest. Authors followed the policy regarding conflicts of interest described at www.annals.org/article.aspx?articleid=745942. Disclosures can also be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M12-3187. A record of conflicts of interest is kept for each Clinical Guidelines Committee meeting and conference call and can be viewed at www.acponline.org/clinical_information/guidelines/guidelines/conflicts_cgc.htm.

Requests for Single Reprints: Amir Qaseem, MD, PhD, MHA, American College of Physicians, 190 N. Independence Mall West, Philadelphia, PA 19106; e-mail, aqaseem@acponline.org.

Current Author Addresses: Drs. Qaseem and Starkey: American College of Physicians, 190 N. Independence Mall West, Philadelphia, PA 19106.

Dr. Dallas: Virginia Tech Carilion School of Medicine, 1906 Belleview Avenue, Roanoke, VA 24014.

Drs. Owens and Holty: Stanford University, 117 Encina Commons, Stanford, CA 94305.

Dr. Shekelle: West Los Angeles Veterans Affairs Medical Center, 11301 Wilshire Boulevard, Los Angeles, CA 90073.

Author Contributions: Conception and design: A. Qaseem, D.K. Owens, J.E.C. Holty, P. Shekelle.

Analysis and interpretation of the data: A. Qaseem, P. Dallas, D.K. Owens, M. Starkey, J.E.C. Holty.

Drafting of the article: A. Qaseem, M. Starkey.

Critical revision of the article for important intellectual content: A. Qaseem, P. Dallas, D.K. Owens, M. Starkey, J.E.C. Holty, P. Shekelle.

Final approval of the article: A. Qaseem, P. Dallas, D.K. Owens, J.E.C. Holty, P. Shekelle.

Statistical expertise: A. Qaseem.

Administrative, technical, or logistic support: A. Qaseem, M. Starkey.

Collection and assembly of data: A. Qaseem, D.K. Owens, M. Starkey, J.E.C. Holty.


Ann Intern Med. 2014;161(3):210-220. doi:10.7326/M12-3187
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Description: The American College of Physicians (ACP) developed this guideline to present the evidence and provide clinical recommendations on the diagnosis of obstructive sleep apnea in adults.

Methods: This guideline is based on published literature on this topic that was identified by using MEDLINE (1966 through May 2013), the Cochrane Central Register of Controlled Trials, and the Cochrane Database of Systematic Reviews. Searches were limited to English-language publications. The clinical outcomes evaluated for this guideline included all-cause mortality, cardiovascular mortality, nonfatal cardiovascular disease, stroke, hypertension, type 2 diabetes, postsurgical outcomes, and quality of life. Sensitivities, specificities, and likelihood ratios were also assessed as outcomes of diagnostic tests. This guideline grades the evidence and recommendations by using ACP's clinical practice guidelines grading system.

Recommendation 1: ACP recommends a sleep study for patients with unexplained daytime sleepiness. (Grade: weak recommendation, low-quality evidence)

Recommendation 2: ACP recommends polysomnography for diagnostic testing in patients suspected of obstructive sleep apnea. ACP recommends portable sleep monitors in patients without serious comorbidities as an alternative to polysomnography when polysomnography is not available for diagnostic testing. (Grade: weak recommendation, moderate-quality evidence)


Obstructive sleep apnea (OSA) is caused by repetitive obstruction of the upper airway during sleep, resulting in hypopnea (reduced airflow during sleep) or apnea (complete airflow cessation during sleep). Persons with OSA may experience loud snoring, oxygen desaturation, frequent arousals, and disruption of sleep. Disrupted sleep can result in hypersomnolence and impaired concentration during the day (1), increased probability of motor vehicle and other accidents (23), and decreased quality of life (4). Although evidence establishing a causal relationship is not currently available, OSA is associated with adverse clinical outcomes, including cardiovascular disease (58); hypertension (911); cognitive impairment and metabolic abnormalities, such as type 2 diabetes (6, 1215); and an increased risk for postoperative cardiac and respiratory complications (1618). The exact prevalence of OSA is unknown. Estimates range from 10% to 17% of the U.S. population, with the variation due in part to variable criteria used to define disease (for example, the number of apneic episodes per hour or whether individuals are required to have specific accompanying signs or symptoms) (1920). Prevalence of OSA increases with age, particularly in adults older than 60 years (2125). The growing rate of obesity also contributes to increasing OSA prevalence (26).

Considerable controversy surrounds the type and level of respiratory abnormality, the presence and type of signs or symptoms, and the most appropriate sleep monitoring device for diagnosing OSA. Questionnaires are used to prescreen patients for further testing, the most common of which is the Epworth Sleepiness Scale (ESS) (27). Polysomnography (PSG), which must be performed in a sleep laboratory setting, is considered the reference standard for diagnosing OSA, but it is expensive and requires specialized resources. Type I monitors are facility-based PSG. Type II monitors are portable, measure most of the same channels (physiologic parameters) as type I monitors (including ≥2 respiratory channels), and can differentiate between sleep and awake states. Type III monitors also measure at least 2 respiratory channels but cannot reliably distinguish between sleep and awake states. Type IV monitors are those that do not fit into type III classification and can vary in the number of channels that they record. Table 1 summarizes the types of monitors.

Table Jump PlaceholderTable 1. Types of Monitors for Diagnosis of Obstructive Sleep Apnea* 

Polysomnography and portable monitors measure or estimate the apnea–hypopnea index (AHI), a measure of the number of apnea or hypopnea events per hour during sleep (Table 1). The AHI is used to diagnose and assess the severity of OSA. The American Academy of Sleep Medicine (AASM) sets a threshold of 15 events per hour with or without symptoms or 5 events per hour with symptoms for OSA diagnosis (2930). The Centers for Medicare & Medicaid Services reimburses for OSA treatment with continuous positive airway pressure (CPAP) devices for patients with an AHI score of at least 15 events per hour or those with at least 5 events per hour and symptoms, such as daytime somnolence, fatigue, insomnia, mood disorders, and cognitive impairment, or cardiovascular comorbid conditions, such as hypertension, ischemic heart disease, or prior stroke (31).

The purpose of this American College of Physicians (ACP) guideline is to address the screening and diagnosis of OSA by presenting a comparison of the effectiveness of the available diagnostic methods. The target audience for this guideline includes all clinicians, and the target patient population includes all adults with suspected OSA. This guideline is based on the comparative effectiveness review sponsored by the Agency for Healthcare Research and Quality (AHRQ) (28), the 2007 Technology Assessment of Home Diagnosis of Obstructive Sleep Apnea-Hypopnea Syndrome (32), and an updated literature review through May 2013. The recently published ACP guideline on the management of OSA in adults (33) provides guidance on treatment of OSA.

This guideline addresses the following key questions related to the screening and diagnosis of OSA:

1. How do different available tests compare in their ability to diagnose sleep apnea in adults with symptoms suggestive of disordered sleep? How do these tests compare in different subgroups of patients based on race, sex, body mass index, existing type 2 diabetes mellitus, existing cardiovascular disease, existing hypertension, clinical symptoms, previous stroke, or airway characteristics?

2. How does phased testing (screening tests or battery followed by full test) compare with full testing alone?

3. What is the effect of preoperative screening for sleep apnea on surgical outcomes?

4. In adults being screened for OSA, what is the relationship between the AHI and other patient characteristics with respect to long-term clinical and functional outcomes?

The literature search for the systematic review (28) was conducted using MEDLINE (1966 to September 2010), the Cochrane Central Register of Controlled Trials, and the Cochrane Database of Systematic Reviews and included peer-reviewed studies published in English. The evidence review was updated through 30 May 2013 by identifying literature in MEDLINE with the same search strategy and inclusion and exclusion criteria as the 2010 report (Supplement). The included studies reported minimum AHI thresholds for OSA diagnosis ranging from 5 to 20 events per hour (28). Further details about the methods and inclusion and exclusion criteria applied in the evidence review are available in the AHRQ report (28) and the Supplement.

This guideline rates the evidence and recommendations by using ACP's guideline grading system (Table 2). Details of the guideline development process can be found in ACP's methods paper (34).

Table Jump PlaceholderTable 2. The American College of Physicians' Guideline Grading System* 
Type II Monitors Versus PSG

Moderate-quality evidence from 9 studies showed that type II monitors may predict AHI scores suggestive of OSA (31, 3542). The sensitivities and specificities for type II monitors to predict AHI scores greater than 5, 15, and 30 events per hour are summarized in Table 3.

Table Jump PlaceholderTable 3. Accuracy of Portable Monitors and Questionnaires for Diagnosis of Obstructive Sleep Apnea 
Type III Monitors Versus PSG

Moderate-quality evidence from 34 studies (4376) showed that type III monitors have the ability to predict AHI scores suggestive of OSA. The sensitivities and specificities for type III monitors to predict AHI scores greater than 5, 15, and 30 events per hour are summarized in Table 3. Type III monitors showed a wide range of difference in AHI estimates compared with PSG (28).

Type IV Monitors Versus PSG

Moderate-quality evidence from 37 studies (32, 77113) showed that type IV monitors can predict AHI scores suggestive of OSA. The sensitivities and specificities for type IV monitors to predict AHI scores greater than 5, 15, and 30 events per hour are summarized in Table 3. Type IV monitors showed a wide range of difference in AHI estimates compared with PSG (28). Direct comparison between type III and type IV monitors was not possible, but indirect evidence from studies comparing each monitor with PSG suggested that type III monitors performed better than type IV monitors in predicting AHI scores suggestive of OSA.

Questionnaires Versus PSG

A total of 47 studies compared questionnaires and PSG (72, 102, 106, 114156). The sensitivities and specificities of selected tests are summarized in Table 3. Low-quality evidence from 18 studies (72, 115116, 118133) showed that the Berlin Questionnaire may be helpful in predicting risk for OSA. However, the sensitivity and specificity of the questionnaire had a wide range depending on the AHI cutoff level (Table 3). Low-quality evidence from 22 studies describing the ESS (72, 121123, 128, 130, 134149), 3 describing the Multivariate Apnea Prediction Index (102, 147, 150), 3 describing the Pittsburgh Sleep Quality Index (139, 141, 151), and 5 describing the STOP-BANG Questionnaire (135, 148, 152154) showed that these questionnaires had low accuracy for diagnosis. Evidence was insufficient to determine the diagnostic accuracy of the other questionnaires.

Clinical Prediction Rules Versus PSG

Thirteen studies (102, 144, 157167) assessed a total of 16 internally validated clinical prediction rules (refer to the AHRQ report [28] and the Supplement for descriptions of each of these tools). Most of the rules used information that was available through clinical history and examination, and all were compared with facility-based PSG. Studies were highly heterogeneous with respect to populations assessed, type of reference test used, and OSA definitions, and only 1 study was identified for each prediction rule. Overall, low-quality evidence suggested that some clinical prediction rules can be used to effectively predict OSA diagnosis. However, the applicability of these rules to the general population cannot be determined from the existing literature. In addition, none of the studies examined the potential clinical utility of applying these rules to clinical practice.

Comparison of Phased Testing Versus Full Testing

Phased testing involves a series of tests that may be done depending on the results of initial tests, whereas full testing involves overnight PSG. Evidence was insufficient to determine the utility of phased testing for diagnosing OSA; 1 low-quality prospective study was subject to verification bias (168), and another reported a positive likelihood ratio of at least 3.9 and a negative likelihood ratio of 0.06 (102).

Fourteen studies met the inclusion criteria for predictors of long-term clinical outcomes, such as mortality, stroke, hypertension, and cardiovascular disease (5, 10, 1920, 169178). Results were inconclusive to establish a causal relationship and are summarized in Table 4.

Table Jump PlaceholderTable 4. The AHI as a Predictor of Clinical Outcomes 

Polysomnography performed in a sleep laboratory has been the standard method to diagnose OSA; however, it requires specialized facilities, is resource-intensive and expensive, and requires patients to spend the night under observation in a foreign environment. In addition to PSG, portable monitors (types II, III, and IV) can be used to diagnose OSA, although the measured AHI score can differ substantially from that measured with PSG. Low-quality evidence showed that type II monitors may identify AHI scores suggestive of OSA. No study directly compared different portable monitors with each other, although current evidence supports greater diagnostic accuracy with type III monitors than type IV monitors (28). The utility of portable monitors for diagnosing OSA in patients with comorbid conditions, including chronic lung disease, congestive heart failure, or neurologic disorders, is uncertain because most studies excluded these patients. Also, compared with PSG, type II, III, and IV monitors had a wide range of difference in AHI estimates (28).

A significant limitation of type IV monitors is that they cannot differentiate between obstructive and central apneas. In contrast to OSA, where airflow is disrupted because of airway obstruction, central sleep apnea results from a temporary failure of the brain to send signals to breathe. Because CPAP may be contraindicated in patients with central sleep apnea, an accurate diagnosis is important. Patients with cardiac, respiratory, or neurologic disease may be at the greatest risk for central sleep apnea, and the AASM does not recommend the use of portable monitors for diagnosis in these patients (179).

Although the evidence was insufficient to determine the utility of most questionnaires compared with PSG for OSA screening, low-quality evidence indicated that the Berlin Questionnaire may be used to screen for OSA. However, questionnaires may not be applicable to the general population because they include subjective questions about sleepiness and not all patients, even those with severe OSA, report sleepiness. For example, the Wisconsin Sleep Cohort Study found that only 37% of patients with severe OSA (AHI score ≥30 events/h) reported daytime sleepiness and that mortality associated with long-term OSA was independent of subjective sleepiness (20).

Evidence was insufficient to determine the effectiveness of phased testing for the diagnosis of OSA or the utility of preoperative screening for OSA to improve postsurgical outcomes.

Evidence was mixed to correlate OSA with predictors of long-term clinical outcomes, and no causal relationships have been established. High-quality evidence showed an association between an AHI score greater than 30 events per hour and greater all-cause mortality. Low-quality evidence showed an association between higher AHI score and incident diabetes, although obesity was probably a confounding variable in these studies. However, a randomized trial showed that CPAP treatment did not reduce mortality or coronary heart disease events in patients with OSA who did not have daytime sleepiness. Although CPAP seems to reduce blood pressure in patients with symptomatic OSA who adhere to it, its effect on blood pressure in adults with OSA who do not have daytime sleepiness is less well-established (180). The short-term effect of CPAP on blood pressure in patients with moderate to severe OSA with or without daytime sleepiness and resistant hypertension is small (3 mm Hg) and of unknown clinical benefit (42).

Recommendation 1: ACP recommends a sleep study for patients with unexplained daytime sleepiness. (Grade: weak recommendation, low-quality evidence)

Clinicians should target their assessment of OSA to individuals with unexplained daytime sleepiness. This assessment should include evaluation of the risk factors and common presenting symptoms for OSA. The best-documented risk factor for OSA is obesity. Clinical symptoms for OSA include unintentional sleep episodes during wakefulness, daytime sleepiness, unrefreshing sleep, fatigue, insomnia, and snoring. If other causes have been ruled out (for example, thyroid disease, gastroesophageal reflux disease, or other respiratory diseases), further evaluation for OSA may be warranted in patients with daytime sleepiness, which is the clinically relevant OSA symptom most responsive to treatment. Evidence is lacking on the effect of CPAP on improving other outcomes, including hypertension, diabetes, coronary heart disease events, and mortality, especially among individuals without daytime sleepiness. For guidance on treatment, clinicians should refer to the ACP guideline on management of OSA (33). Sleepiness questionnaires, such as the ESS, help in assessing the symptom severity of OSA but cannot assess the AHI (a necessary but not sufficient component of OSA) and lack sufficient sensitivity and specificity to replace a sleep study in diagnosing OSA.

Recommendation 2: ACP recommends polysomnography for diagnostic testing in patients suspected of obstructive sleep apnea. ACP recommends portable sleep monitors in patients without serious comorbidities as an alternative to polysomnography when polysomnography is not available for diagnostic testing. (Grade: weak recommendation, moderate-quality evidence)

Full-night, attended, in-laboratory PSG is considered the reference standard diagnostic test and is recommended in patients with suspected OSA. However, in the absence of PSG, portable monitors may be used as an alternative diagnostic test in such patients. Both the AASM and the Centers for Medicare & Medicaid Services consider an AHI score of at least 15 events per hour or at least 5 events per hour with symptoms (such as daytime somnolence and fatigue) as criteria for OSA diagnosis. Evidence shows that compared with PSG, type II, III, and IV monitors have a wide range of difference in AHI estimates. These monitors have a high positive likelihood ratio and low negative likelihood ratio for various AHI cutoff levels to predict OSA. Monitors with more channels perform better than those with fewer channels, and type IV monitors have an important limitation in that they are unable to distinguish obstructive from central sleep apnea. There is no direct evidence from head-to-head comparisons of type III and IV monitors, but indirect evidence from studies comparing each monitor with PSG suggested that type III monitors performed better than type IV monitors in predicting AHI scores suggestive of OSA. Although portable monitors may be useful, data loss of 3% to 20% has been reported for type III and IV monitors (181). Furthermore, inadequate data resulting in limited interpretation of results from the use of type III monitors has been reported for 13% to 20% of the evaluations (182). The utility of portable monitors for patients with serious comorbid conditions, including chronic lung disease, congestive heart failure, or neurologic disorders, has not been verified.

Evidence from studies comparing one monitor with another is lacking. The Figure summarizes the recommendations and clinical considerations.

Grahic Jump Location
Figure.

Summary of the American College of Physicians guideline on diagnosis of OSA in adults.

AHI = apnea–hypopnea index; CHD = coronary heart disease; CPAP = continuous positive airway pressure; OSA = obstructive sleep apnea; PSG = polysomnography.

Grahic Jump Location
Preoperative Screening for OSA

Detection of OSA in patients having surgery is an area of considerable interest. However, the current evidence does not provide enough information on the effect of preoperative screening for sleep apnea on surgical outcomes. Four low-quality studies provided inconclusive evidence (115, 183185). Hence, at this point, ACP's Clinical Guidelines Committee cannot determine the benefits and harms of preoperative screening for OSA.

Phased Testing for OSA

The current evidence from 1 low-quality study was insufficient to draw conclusions about phased testing compared with full PSG testing for diagnosis of OSA.

Assessment in Patients With Comorbid Conditions

The utility of portable monitors for diagnosing OSA in patients with comorbid conditions, such as chronic lung disease, congestive heart failure, or neurologic disorders, is unknown because few studies included these patients.

Evidence shows that before diagnosis, patients with OSA have higher rates of health care use, more frequent and longer hospital stays, and greater health care costs than after diagnosis (18, 186). Clinicians should target evaluation of OSA to patients with unexplained daytime sleepiness. This assessment should include evaluation of the risk factors and common presenting symptoms for OSA. The best-documented risk factor is obesity. Clinical symptoms include unintentional sleep episodes during wakefulness, daytime sleepiness, unrefreshing sleep, fatigue, insomnia, and snoring. Assessment of OSA in the absence of daytime sleepiness or treatment of persons with low AHI scores is low-value care because evidence to date indicates that neither improves clinical outcomes.

Victor LD. Obstructive sleep apnea. Am Fam Physician. 1999; 60:2279-86.
PubMed
 
Howard ME, Desai AV, Grunstein RR, Hukins C, Armstrong JG, Joffe D, et al. Sleepiness, sleep-disordered breathing, and accident risk factors in commercial vehicle drivers. Am J Respir Crit Care Med. 2004; 170:1014-21.
PubMed
CrossRef
 
Terán-Santos J, Jiménez-Gómez A, Cordero-Guevara J. The association between sleep apnea and the risk of traffic accidents. Cooperative Group Burgos-Santander. N Engl J Med. 1999; 340:847-51.
PubMed
CrossRef
 
Young T, Palta M, Dempsey J, Skatrud J, Weber S, Badr S. The occurrence of sleep-disordered breathing among middle-aged adults. N Engl J Med. 1993; 328:1230-5.
PubMed
CrossRef
 
Marin JM, Carrizo SJ, Vicente E, Agusti AG. Long-term cardiovascular outcomes in men with obstructive sleep apnoea-hypopnoea with or without treatment with continuous positive airway pressure: an observational study. Lancet. 2005; 365:1046-53.
PubMed
CrossRef
 
Punjabi NM. The epidemiology of adult obstructive sleep apnea. Proc Am Thorac Soc. 2008; 5:136-43.
PubMed
CrossRef
 
Shahar E, Whitney CW, Redline S, Lee ET, Newman AB, Nieto FJ, et al. Sleep-disordered breathing and cardiovascular disease: cross-sectional results of the Sleep Heart Health Study. Am J Respir Crit Care Med. 2001; 163:19-25.
PubMed
CrossRef
 
Yaggi HK, Concato J, Kernan WN, Lichtman JH, Brass LM, Mohsenin V. Obstructive sleep apnea as a risk factor for stroke and death. N Engl J Med. 2005; 353:2034-41.
PubMed
CrossRef
 
Nieto FJ, Young TB, Lind BK, Shahar E, Samet JM, Redline S, et al. Association of sleep-disordered breathing, sleep apnea, and hypertension in a large community-based study. Sleep Heart Health Study. JAMA. 2000; 283:1829-36.
PubMed
CrossRef
 
Peppard PE, Young T, Palta M, Skatrud J. Prospective study of the association between sleep-disordered breathing and hypertension. N Engl J Med. 2000; 342:1378-84.
PubMed
CrossRef
 
Young T, Peppard P, Palta M, Hla KM, Finn L, Morgan B, et al. Population-based study of sleep-disordered breathing as a risk factor for hypertension. Arch Intern Med. 1997; 157:1746-52.
PubMed
CrossRef
 
Babu AR, Herdegen J, Fogelfeld L, Shott S, Mazzone T. Type 2 diabetes, glycemic control, and continuous positive airway pressure in obstructive sleep apnea. Arch Intern Med. 2005; 165:447-52.
PubMed
CrossRef
 
Caples SM, Gami AS, Somers VK. Obstructive sleep apnea. Ann Intern Med. 2005; 142:187-97.
CrossRef
 
Gruber A, Horwood F, Sithole J, Ali NJ, Idris I. Obstructive sleep apnoea is independently associated with the metabolic syndrome but not insulin resistance state. Cardiovasc Diabetol. 2006; 5:22.
PubMed
CrossRef
 
Young T, Peppard PE, Gottlieb DJ. Epidemiology of obstructive sleep apnea: a population health perspective. Am J Respir Crit Care Med. 2002; 165:1217-39.
PubMed
CrossRef
 
Chung SA, Yuan H, Chung F. A systemic review of obstructive sleep apnea and its implications for anesthesiologists. Anesth Analg. 2008; 107:1543-63.
PubMed
CrossRef
 
Finkel KJ, Searleman AC, Tymkew H, Tanaka CY, Saager L, Safer-Zadeh E, et al. Prevalence of undiagnosed obstructive sleep apnea among adult surgical patients in an academic medical center. Sleep Med. 2009; 10:753-8.
PubMed
CrossRef
 
Gupta RM, Parvizi J, Hanssen AD, Gay PC. Postoperative complications in patients with obstructive sleep apnea syndrome undergoing hip or knee replacement: a case-control study. Mayo Clin Proc. 2001; 76:897-905.
PubMed
CrossRef
 
Punjabi NM, Caffo BS, Goodwin JL, Gottlieb DJ, Newman AB, O'Connor GT, et al. Sleep-disordered breathing and mortality: a prospective cohort study. PLoS Med. 2009; 6:e1000132.
PubMed
CrossRef
 
Young T, Finn L, Peppard PE, Szklo-Coxe M, Austin D, Nieto FJ, et al. Sleep disordered breathing and mortality: eighteen-year follow-up of the Wisconsin Sleep Cohort. Sleep. 2008; 31:1071-8.
PubMed
 
Ancoli-Israel S, Kripke DF, Klauber MR, Mason WJ, Fell R, Kaplan O. Sleep-disordered breathing in community-dwelling elderly. Sleep. 1991; 14:486-95.
PubMed
 
Bixler EO, Vgontzas AN, Lin HM, Ten Have T, Rein J, Vela-Bueno A, et al. Prevalence of sleep-disordered breathing in women: effects of gender. Am J Respir Crit Care Med. 2001; 163:608-13.
PubMed
CrossRef
 
Bixler EO, Vgontzas AN, Ten Have T, Tyson K, Kales A. Effects of age on sleep apnea in men: I. Prevalence and severity. Am J Respir Crit Care Med. 1998; 157:144-8.
PubMed
CrossRef
 
Durán J, Esnaola S, Rubio R, Iztueta A. Obstructive sleep apnea-hypopnea and related clinical features in a population-based sample of subjects aged 30 to 70 yr. Am J Respir Crit Care Med. 2001; 163:685-9.
PubMed
CrossRef
 
Young T, Shahar E, Nieto FJ, Redline S, Newman AB, Gottlieb DJ, et al, Sleep Heart Health Study Research Group. Predictors of sleep-disordered breathing in community-dwelling adults: the Sleep Heart Health Study. Arch Intern Med. 2002; 162:893-900.
PubMed
CrossRef
 
Young T, Peppard PE, Taheri S. Excess weight and sleep-disordered breathing. J Appl Physiol (1985). 2005; 99:1592-9.
PubMed
CrossRef
 
Johns MW. A new method for measuring daytime sleepiness: the Epworth Sleepiness Scale. Sleep. 1991; 14:540-5.
PubMed
 
Balk EM, Moorthy D, Obadan NO, Patel K, Ip S, Chung M, et al. Diagnosis and treatment of obstructive sleep apnea in adults. Comparative effectiveness review no. 32. AHRQ publication no. 11-EHC052-EF. (Prepared by Tufts Evidence-based Practice Center under contract 290-2007-100551.). Rockville, MD: Agency for Healthcare Research and Quality; 2011.
 
American Academy of Sleep Medicine. The International Classification of Sleep Disorders, 2nd Edition: Diagnostic and Coding Manual. Westchester, IL: American Academy of Sleep Medicine; 2005.
 
Epstein LJ, Kristo D, Strollo PJ Jr, Friedman N, Malhotra A, Patil SP, et al, Adult Obstructive Sleep Apnea Task Force of the American Academy of Sleep Medicine. Clinical guideline for the evaluation, management and long-term care of obstructive sleep apnea in adults. J Clin Sleep Med. 2009; 5:263-76.
PubMed
 
Centers for Medicare & Medicaid Services.  National Coverage Determination (NCD) for Continuous Positive Airway Pressure (CPAP) Therapy For Obstructive Sleep Apnea (OSA) (240.4). Baltimore: Centers for Medicare & Medicaid Services; 2008. Accessed at www.cms.gov/medicare-coverage-database/details/ncd-details.aspx?NCDId=226&ncdver=3&NCAId=204&NcaName=Continuous±Positive±Airway±Pressure±%28CPAP%29±Therapy±for±Obstructive±Sleep±Apnea±%28OSA%29&IsPopup=y&bc=AAAAAAAAIAAA& on 2 April 2014.
 
Tufts-New England Medical Center EPC.  Home diagnosis of obstructive sleep apnea-hypopnea syndrome. Rockville, MD: Agency for Healthcare Research and Quality; 2007. Accessed at www.cms.gov/Medicare/Coverage/DeterminationProcess/downloads/id48TA.pdf on 19 March 2013.
 
Qaseem A, Holty JE, Owens DK, Dallas P, Starkey M, Shekelle P, for the Clinical Guidelines Committee of the American College of Physicians. Management of obstructive sleep apnea in adults: a clinical practice guideline from the American College of Physicians. Ann Intern Med. 2013; 159:471-83.
 
Qaseem A, Snow V, Owens DK, Shekelle P, Clinical Guidelines Committee of the American College of Physicians. The development of clinical practice guidelines and guidance statements of the American College of Physicians: summary of methods. Ann Intern Med. 2010; 153:194-9.
CrossRef
 
Iber C, Redline S, Kaplan Gilpin AM, Quan SF, Zhang L, Gottlieb DJ, et al. Polysomnography performed in the unattended home versus the attended laboratory setting—Sleep Heart Health Study methodology. Sleep. 2004; 27:536-40.
PubMed
 
Mykytyn IJ, Sajkov D, Neill AM, McEvoy RD. Portable computerized polysomnography in attended and unattended settings. Chest. 1999; 115:114-22.
PubMed
CrossRef
 
Orr WC, Eiken T, Pegram V, Jones R, Rundell OH. A laboratory validation study of a portable system for remote recording of sleep-related respiratory disorders. Chest. 1994; 105:160-2.
PubMed
CrossRef
 
Portier F, Portmann A, Czernichow P, Vascaut L, Devin E, Benhamou D, et al. Evaluation of home versus laboratory polysomnography in the diagnosis of sleep apnea syndrome. Am J Respir Crit Care Med. 2000; 162:814-8.
PubMed
CrossRef
 
Gagnadoux F, Pelletier-Fleury N, Philippe C, Rakotonanahary D, Fleury B. Home unattended vs hospital telemonitored polysomnography in suspected obstructive sleep apnea syndrome: a randomized crossover trial. Chest. 2002; 121:753-8.
PubMed
CrossRef
 
Ferré A, Sampol G, Jurado MJ, Cambrodi R, Lloberes P, Romero O. Neurophysiological two-channel polysomnographic device in the diagnosis of sleep apnea. J Clin Sleep Med. 2012; 8:163-8.
PubMed
 
Oliveira MG, Nery LE, Santos-Silva R, Sartori DE, Alonso FF, Togeiro SM, et al. Is portable monitoring accurate in the diagnosis of obstructive sleep apnea syndrome in chronic pulmonary obstructive disease? Sleep Med. 2012; 13:1033-8.
PubMed
CrossRef
 
Martínez-García MA, Capote F, Campos-Rodríguez F, Lloberes P, Díaz de Atauri MJ, Somoza M, et al, Spanish Sleep Network. Effect of CPAP on blood pressure in patients with obstructive sleep apnea and resistant hypertension: the HIPARCO randomized clinical trial. JAMA. 2013; 310:2407-15.
PubMed
 
Amir O, Barak-Shinar D, Amos Y, MacDonald M, Pittman S, White DP. An automated sleep-analysis system operated through a standard hospital monitor. J Clin Sleep Med. 2010; 6:59-63.
PubMed
 
García-Díaz E, Quintana-Gallego E, Ruiz A, Carmona-Bernal C, Sánchez-Armengol A, Botebol-Benhamou G, et al. Respiratory polygraphy with actigraphy in the diagnosis of sleep apnea-hypopnea syndrome. Chest. 2007; 131:725-32.
PubMed
CrossRef
 
Ng SS, Chan TO, To KW, Ngai J, Tung A, Ko FW, et al. Validation of Embletta portable diagnostic system for identifying patients with suspected obstructive sleep apnoea syndrome (OSAS). Respirology. 2010; 15:336-42.
PubMed
CrossRef
 
Planès C, Leroy M, Bouach Khalil N, El Mahmoud R, Digne F, de Roquefeuil F, et al. Home diagnosis of obstructive sleep apnoea in coronary patients: validity of a simplified device automated analysis. Sleep Breath. 2010; 14:25-32.
PubMed
CrossRef
 
Santos-Silva R, Sartori DE, Truksinas V, Truksinas E, Alonso FF, Tufik S, et al. Validation of a portable monitoring system for the diagnosis of obstructive sleep apnea syndrome. Sleep. 2009; 32:629-36.
PubMed
 
To KW, Chan WC, Chan TO, Tung A, Ngai J, Ng S, et al. Validation study of a portable monitoring device for identifying OSA in a symptomatic patient population. Respirology. 2009; 14:270-5.
PubMed
CrossRef
 
Tonelli de Oliveira AC, Martinez D, Vasconcelos LF, Gonçalves SC, Lenz MC, Fuchs SC, et al. Diagnosis of obstructive sleep apnea syndrome and its outcomes with home portable monitoring. Chest. 2009; 135:330-6.
PubMed
CrossRef
 
Redline S, Tosteson T, Boucher MA, Millman RP. Measurement of sleep-related breathing disturbances in epidemiologic studies. Assessment of the validity and reproducibility of a portable monitoring device. Chest. 1991; 100:1281-6.
PubMed
CrossRef
 
Reichert JA, Bloch DA, Cundiff E, Votteri BA. Comparison of the NovaSom QSG, a new sleep apnea home-diagnostic system, and polysomnography. Sleep Med. 2003; 4:213-8.
PubMed
CrossRef
 
White DP, Gibb TJ, Wall JM, Westbrook PR. Assessment of accuracy and analysis time of a novel device to monitor sleep and breathing in the home. Sleep. 1995; 18:115-26.
PubMed
 
Calleja JM, Esnaola S, Rubio R, Durán J. Comparison of a cardiorespiratory device versus polysomnography for diagnosis of sleep apnoea. Eur Respir J. 2002; 20:1505-10.
PubMed
CrossRef
 
Carrasco O, Montserrat JM, Lloberes P, Ascasco C, Ballester E, Fornas C, et al. Visual and different automatic scoring profiles of respiratory variables in the diagnosis of sleep apnoea-hypopnoea syndrome. Eur Respir J. 1996; 9:125-30.
PubMed
CrossRef
 
Dingli K, Coleman EL, Vennelle M, Finch SP, Wraith PK, Mackay TW, et al. Evaluation of a portable device for diagnosing the sleep apnoea/hypopnoea syndrome. Eur Respir J. 2003; 21:253-9.
PubMed
CrossRef
 
Ficker JH, Wiest GH, Wilpert J, Fuchs FS, Hahn EG. Evaluation of a portable recording device (Somnocheck) for use in patients with suspected obstructive sleep apnoea. Respiration. 2001; 68:307-12.
PubMed
CrossRef
 
Fietze I, Glos M, Röttig J, Witt C. Automated analysis of data is inferior to visual analysis of ambulatory sleep apnea monitoring. Respiration. 2002; 69:235-41.
PubMed
CrossRef
 
Zucconi M, Ferini-Strambi L, Castronovo V, Oldani A, Smirne S. An unattended device for sleep-related breathing disorders: validation study in suspected obstructive sleep apnoea syndrome. Eur Respir J. 1996; 9:1251-6.
PubMed
CrossRef
 
Yin M, Miyazaki S, Ishikawa K. Evaluation of type 3 portable monitoring in unattended home setting for suspected sleep apnea: factors that may affect its accuracy. Otolaryngol Head Neck Surg. 2006; 134:204-9.
PubMed
CrossRef
 
Claman D, Murr A, Trotter K. Clinical validation of the Bedbugg in detection of obstructive sleep apnea. Otolaryngol Head Neck Surg. 2001; 125:227-30.
PubMed
CrossRef
 
Ancoli-Israel S, Mason W, Coy TV, Stepnowsky C, Clausen JL, Dimsdale J. Evaluation of sleep disordered breathing with unattended recording: the Nightwatch System. J Med Eng Technol. 1997; 21:10-4.
PubMed
CrossRef
 
Ballester E, Solans M, Vila X, Hernandez L, Quintó L, Bolivar I, et al. Evaluation of a portable respiratory recording device for detecting apnoeas and hypopnoeas in subjects from a general population. Eur Respir J. 2000; 16:123-7.
PubMed
CrossRef
 
Emsellem HA, Corson WA, Rappaport BA, Hackett S, Smith LG, Hausfeld JN. Verification of sleep apnea using a portable sleep apnea screening device. South Med J. 1990; 83:748-52.
PubMed
CrossRef
 
Lloberes P, Montserrat JM, Ascaso A, Parra O, Granados A, Alonso P, et al. Comparison of partially attended night time respiratory recordings and full polysomnography in patients with suspected sleep apnoea/hypopnoea syndrome. Thorax. 1996; 51:1043-7.
PubMed
CrossRef
 
Man GC, Kang BV. Validation of a portable sleep apnea monitoring device. Chest. 1995; 108:388-93.
PubMed
CrossRef
 
Marrone O, Salvaggio A, Insalaco G, Bonsignore MR, Bonsignore G. Evaluation of the POLYMESAM system in the diagnosis of obstructive sleep apnea syndrome. Monaldi Arch Chest Dis. 2001; 56:486-90.
PubMed
 
Parra O, García-Esclasans N, Montserrat JM, García Eroles L, Ruíz J, López JA, et al. Should patients with sleep apnoea/hypopnoea syndrome be diagnosed and managed on the basis of home sleep studies? Eur Respir J. 1997; 10:1720-4.
PubMed
CrossRef
 
Quintana-Gallego E, Villa-Gil M, Carmona-Bernal C, Botebol-Benhamou G, Martínez-Martínez A, Sánchez-Armengol A, et al. Home respiratory polygraphy for diagnosis of sleep-disordered breathing in heart failure. Eur Respir J. 2004; 24:443-8.
PubMed
CrossRef
 
Su S, Baroody FM, Kohrman M, Suskind D. A comparison of polysomnography and a portable home sleep study in the diagnosis of obstructive sleep apnea syndrome. Otolaryngol Head Neck Surg. 2004; 131:844-50.
PubMed
CrossRef
 
Verse T, Pirsig W, Junge-Hülsing B, Kroker B. Validation of the POLY-MESAM seven-channel ambulatory recording unit. Chest. 2000; 117:1613-8.
PubMed
CrossRef
 
Whittle AT, Finch SP, Mortimore IL, MacKay TW, Douglas NJ. Use of home sleep studies for diagnosis of the sleep apnoea/hypopnoea syndrome. Thorax. 1997; 52:1068-73.
PubMed
CrossRef
 
Danzi-Soares NJ, Genta PR, Nerbass FB, Pedrosa RP, Soares FS, César LA, et al. Obstructive sleep apnea is common among patients referred for coronary artery bypass grafting and can be diagnosed by portable monitoring. Coron Artery Dis. 2012; 23:31-8.
PubMed
CrossRef
 
Cheliout-Heraut F, Senny F, Djouadi F, Ouayoun M, Bour F. Obstructive sleep apnoea syndrome: comparison between polysomnography and portable sleep monitoring based on jaw recordings. Neurophysiol Clin. 2011; 41:191-8.
PubMed
CrossRef
 
Driver HS, Pereira EJ, Bjerring K, Toop F, Stewart SC, Munt PW, et al. Validation of the MediByte® type 3 portable monitor compared with polysomnography for screening of obstructive sleep apnea. Can Respir J. 2011; 18:137-43.
PubMed
 
Gjevre JA, Taylor-Gjevre RM, Skomro R, Reid J, Fenton M, Cotton D. Comparison of polysomnographic and portable home monitoring assessments of obstructive sleep apnea in Saskatchewan women. Can Respir J. 2011; 18:271-4.
PubMed
 
Masa JF, Corral J, Pereira R, Duran-Cantolla J, Cabello M, Hernández-Blasco L, et al. Effectiveness of home respiratory polygraphy for the diagnosis of sleep apnoea and hypopnoea syndrome. Thorax. 2011; 66:567-73.
PubMed
CrossRef
 
Abraham WT, Trupp RJ, Phillilps B, Bourge RC, Bailey B, Harding SM, et al. Validation and clinical utility of a simple in-home testing tool for sleep-disordered breathing and arrhythmias in heart failure: results of the Sleep Events, Arrhythmias, and Respiratory Analysis in Congestive Heart Failure (SEARCH) study. Congest Heart Fail. 2006; 12:241-7.
PubMed
CrossRef
 
Agatsuma T, Fujimoto K, Komatsu Y, Urushihata K, Honda T, Tsukahara T, et al. A novel device (SD-101) with high accuracy for screening sleep apnoea-hypopnoea syndrome. Respirology. 2009; 14:1143-50.
PubMed
CrossRef
 
Ayappa I, Norman RG, Seelall V, Rapoport DM. Validation of a self-applied unattended monitor for sleep disordered breathing. J Clin Sleep Med. 2008; 4:26-37.
PubMed
 
Chen H, Lowe AA, Bai Y, Hamilton P, Fleetham JA, Almeida FR. Evaluation of a portable recording device (ApneaLink) for case selection of obstructive sleep apnea. Sleep Breath. 2009; 13:213-9.
PubMed
CrossRef
 
Clark AL, Crabbe S, Aziz A, Reddy P, Greenstone M. Use of a screening tool for detection of sleep-disordered breathing. J Laryngol Otol. 2009; 123:746-9.
PubMed
CrossRef
 
de Almeida FR, Ayas NT, Otsuka R, Ueda H, Hamilton P, Ryan FC, et al. Nasal pressure recordings to detect obstructive sleep apnea. Sleep Breath. 2006; 10:62-9.
PubMed
CrossRef
 
Erman MK, Stewart D, Einhorn D, Gordon N, Casal E. Validation of the ApneaLink for the screening of sleep apnea: a novel and simple single-channel recording device. J Clin Sleep Med. 2007; 3:387-92.
PubMed
 
Goodrich S, Orr WC. An investigation of the validity of the Lifeshirt in comparison to standard polysomnography in the detection of obstructive sleep apnea. Sleep Med. 2009; 10:118-22.
PubMed
CrossRef
 
Heneghan C, Chua CP, Garvey JF, de Chazal P, Shouldice R, Boyle P, et al. A portable automated assessment tool for sleep apnea using a combined Holter-oximeter. Sleep. 2008; 31:1432-9.
PubMed
 
Heneghan C, de Chazal P, Ryan S, Chua CP, Doherty L, Boyle P, et al. Electrocardiogram recording as a screening tool for sleep disordered breathing. J Clin Sleep Med. 2008; 4:223-8.
PubMed
 
Nakano H, Tanigawa T, Ohnishi Y, Uemori H, Senzaki K, Furukawa T, et al. Validation of a single-channel airflow monitor for screening of sleep-disordered breathing. Eur Respir J. 2008; 32:1060-7.
PubMed
CrossRef
 
Ng SS, Chan TO, To KW, Ngai J, Tung A, Ko FW, et al. Validation of a portable recording device (ApneaLink) for identifying patients with suspected obstructive sleep apnoea syndrome. Intern Med J. 2009; 39:757-62.
PubMed
CrossRef
 
Nigro CA, Aimaretti S, Gonzalez S, Rhodius E. Validation of the WristOx 3100 oximeter for the diagnosis of sleep apnea/hypopnea syndrome. Sleep Breath. 2009; 13:127-36.
PubMed
CrossRef
 
Pang KP, Gourin CG, Terris DJ. A comparison of polysomnography and the WatchPAT in the diagnosis of obstructive sleep apnea. Otolaryngol Head Neck Surg. 2007; 137:665-8.
PubMed
CrossRef
 
Pépin JL, Defaye P, Vincent E, Christophle-Boulard S, Tamisier R, Lévy P. Sleep apnea diagnosis using an ECG Holter device including a nasal pressure (NP) recording: validation of visual and automatic analysis of nasal pressure versus full polysomnography. Sleep Med. 2009; 10:651-6.
PubMed
CrossRef
 
Ragette R, Wang Y, Weinreich G, Teschler H. Diagnostic performance of single airflow channel recording (ApneaLink) in home diagnosis of sleep apnea. Sleep Breath. 2010; 14:109-14.
PubMed
CrossRef
 
Reda M, Gibson GJ, Wilson JA. Pharyngoesophageal pressure monitoring in sleep apnea syndrome. Otolaryngol Head Neck Surg. 2001; 125:324-31.
PubMed
CrossRef
 
Schäfer H, Ewig S, Hasper E, Lüderitz B. Predictive diagnostic value of clinical assessment and nonlaboratory monitoring system recordings in patients with symptoms suggestive of obstructive sleep apnea syndrome. Respiration. 1997; 64:194-9.
PubMed
CrossRef
 
Smith LA, Chong DW, Vennelle M, Denvir MA, Newby DE, Douglas NJ. Diagnosis of sleep-disordered breathing in patients with chronic heart failure: evaluation of a portable limited sleep study system. J Sleep Res. 2007; 16:428-35.
PubMed
CrossRef
 
Szyszko A, Franceschini C, Gonzalez-Zuelgaray J. Reliability of a Holter-based methodology for evaluation of sleep apnoea syndrome. Europace. 2009; 11:94-9.
PubMed
CrossRef
 
Watkins MR, Talmage JB, Thiese MS, Hudson TB, Hegmann KT. Correlation between screening for obstructive sleep apnea using a portable device versus polysomnography testing in a commercial driving population. J Occup Environ Med. 2009; 51:1145-50.
PubMed
CrossRef
 
White JE, Smithson AJ, Close PR, Drinnan MJ, Prichard AJ, Gibson GJ. The use of sound recording and oxygen saturation in screening snorers for obstructive sleep apnoea. Clin Otolaryngol Allied Sci. 1994; 19:218-21.
PubMed
CrossRef
 
Wong KK, Jankelson D, Reid A, Unger G, Dungan G, Hedner JA, et al. Diagnostic test evaluation of a nasal flow monitor for obstructive sleep apnea detection in sleep apnea research. Behav Res Methods. 2008; 40:360-6.
PubMed
CrossRef
 
Yagi H, Nakata S, Tsuge H, Yasuma F, Noda A, Morinaga M, et al. Significance of a screening device (Apnomonitor 5) for sleep apnea syndrome. Auris Nasus Larynx. 2009; 36:176-80.
PubMed
CrossRef
 
Nigro CA, Dibur E, Malnis S, Grandval S, Nogueira F. Validation of ApneaLink Ox for the diagnosis of obstructive sleep apnea. Sleep Breath. 2013; 17:259-66.
PubMed
CrossRef
 
Morales CR, Hurley S, Wick LC, Staley B, Pack FM, Gooneratne NS, et al. In-home, self-assembled sleep studies are useful in diagnosing sleep apnea in the elderly. Sleep. 2012; 35:1491-501.
PubMed
 
O'Brien LM, Bullough AS, Shelgikar AV, Chames MC, Armitage R, Chervin RD. Validation of Watch-PAT-200 against polysomnography during pregnancy. J Clin Sleep Med. 2012; 8:287-94.
PubMed
 
Onder NS, Akpinar ME, Yigit O, Gor AP. Watch peripheral arterial tonometry in the diagnosis of obstructive sleep apnea: influence of aging. Laryngoscope. 2012; 122:1409-14.
PubMed
CrossRef
 
BaHammam AS, Sharif M, Gacuan DE, George S. Evaluation of the accuracy of manual and automatic scoring of a single airflow channel in patients with a high probability of obstructive sleep apnea. Med Sci Monit. 2011; 17:MT13-9.
PubMed
CrossRef
 
Chai-Coetzer CL, Antic NA, Rowland LS, Catcheside PG, Esterman A, Reed RL, et al. A simplified model of screening questionnaire and home monitoring for obstructive sleep apnoea in primary care. Thorax. 2011; 66:213-9.
PubMed
CrossRef
 
Chouchou F, Sforza E, Celle S, Pichot V, Maudoux D, Garcin A, et al, PROOF Study Group. Pulse transit time in screening sleep disordered breathing in an elderly population: the PROOF-SYNAPSE study. Sleep. 2011; 34:1051-9.
PubMed
 
Hedner J, White DP, Malhotra A, Herscovici S, Pittman SD, Zou D, et al. Sleep staging based on autonomic signals: a multi-center validation study. J Clin Sleep Med. 2011; 7:301-6.
PubMed
 
Nigro CA, Dibur E, Aimaretti S, González S, Rhodius E. Comparison of the automatic analysis versus the manual scoring from ApneaLink device for the diagnosis of obstructive sleep apnoea syndrome. Sleep Breath. 2011; 15:679-86.
PubMed
CrossRef
 
Yang GG, Yang MC, Chung CY, Chen YT, Chang ET. Respiratory-inductive-plethysmography-derived flow can be a useful clinical tool to detect patients with obstructive sleep apnea syndrome. J Formos Med Assoc. 2011; 110:642-5.
PubMed
CrossRef
 
Alvarez D, Gutierrez GC, Marcos JV, Del Campo F, Hornero R. Spectral analysis of single-channel airflow and oxygen saturation recordings in obstructive sleep apnea detection. Conf Proc IEEE Eng Med Biol Soc. 2010; 2010:847-50.
PubMed
 
Nigro CA, Serrano F, Aimaretti S, González S, Codinardo C, Rhodius E. Utility of ApneaLink for the diagnosis of sleep apnea-hypopnea syndrome. Medicina (B Aires). 2010; 70:53-9.
PubMed
 
Yadollahi A, Giannouli E, Moussavi Z. Sleep apnea monitoring and diagnosis based on pulse oximetry and tracheal sound signals. Med Biol Eng Comput. 2010; 48:1087-97.
PubMed
CrossRef
 
Chung F, Yegneswaran B, Liao P, Chung SA, Vairavanathan S, Islam S, et al. STOP questionnaire: a tool to screen patients for obstructive sleep apnea. Anesthesiology. 2008; 108:812-21.
PubMed
CrossRef
 
Chung F, Yegneswaran B, Liao P, Chung SA, Vairavanathan S, Islam S, et al. Validation of the Berlin Questionnaire and American Society of Anesthesiologists checklist as screening tools for obstructive sleep apnea in surgical patients. Anesthesiology. 2008; 108:822-30.
PubMed
CrossRef
 
Drager LF, Genta PR, Pedrosa RP, Nerbass FB, Gonzaga CC, Krieger EM, et al. Characteristics and predictors of obstructive sleep apnea in patients with systemic hypertension. Am J Cardiol. 2010; 105:1135-9.
PubMed
CrossRef
 
Kapuniai LE, Andrew DJ, Crowell DH, Pearce JW. Identifying sleep apnea from self-reports. Sleep. 1988; 11:430-6.
PubMed
 
Netzer NC, Stoohs RA, Netzer CM, Clark K, Strohl KP. Using the Berlin Questionnaire to identify patients at risk for the sleep apnea syndrome. Ann Intern Med. 1999; 131:485-91.
CrossRef
 
Sharma SK, Vasudev C, Sinha S, Banga A, Pandey RM, Handa KK. Validation of the modified Berlin Questionnaire to identify patients at risk for the obstructive sleep apnoea syndrome. Indian J Med Res. 2006; 124:281-90.
PubMed
 
Geiger-Brown J, Rogers VE, Han K, Trinkoff A, Bausell RB, Scharf SM. Occupational screening for sleep disorders in 12-h shift nurses using the Berlin Questionnaire. Sleep Breath. 2013; 17:381-8.
PubMed
CrossRef
 
Facco FL, Ouyang DW, Zee PC, Grobman WA. Development of a pregnancy-specific screening tool for sleep apnea. J Clin Sleep Med. 2012; 8:389-94.
PubMed
 
Gjevre JA, Taylor-Gjevre RM, Nair BV, Lim HJ. Do sleepy rheumatoid arthritis patients have a sleep disorder? Musculoskeletal Care. 2012; 10:187-95.
PubMed
CrossRef
 
Koyama RG, Esteves AM, Oliveira e Silva L, Lira FS, Bittencourt LR, Tufik S, et al. Prevalence of and risk factors for obstructive sleep apnea syndrome in Brazilian railroad workers. Sleep Med. 2012; 13:1028-32.
PubMed
CrossRef
 
Laporta R, Anandam A, El-Solh AA. Screening for obstructive sleep apnea in veterans with ischemic heart disease using a computer-based clinical decision-support system. Clin Res Cardiol. 2012; 101:737-44.
PubMed
CrossRef
 
Martinez D, da Silva RP, Klein C, Fiori CZ, Massierer D, Cassol CM, et al. High risk for sleep apnea in the Berlin Questionnaire and coronary artery disease. Sleep Breath. 2012; 16:89-94.
PubMed
CrossRef
 
Enciso R, Clark GT. Comparing the Berlin and the ARES questionnaire to identify patients with obstructive sleep apnea in a dental setting. Sleep Breath. 2011; 15:83-9.
PubMed
CrossRef
 
Hrubos-Strøm H, Randby A, Namtvedt SK, Kristiansen HA, Einvik G, Benth J, et al. A Norwegian population-based study on the risk and prevalence of obstructive sleep apnea. The Akershus Sleep Apnea Project (ASAP). J Sleep Res. 2011; 20:162-70.
PubMed
CrossRef
 
Sert Kuniyoshi FH, Zellmer MR, Calvin AD, Lopez-Jimenez F, Albuquerque FN, van der Walt C, et al. Diagnostic accuracy of the Berlin Questionnaire in detecting sleep-disordered breathing in patients with a recent myocardial infarction. Chest. 2011; 140:1192-7.
PubMed
CrossRef
 
Sforza E, Chouchou F, Pichot V, Herrmann F, Barthélémy JC, Roche F. Is the Berlin Questionnaire a useful tool to diagnose obstructive sleep apnea in the elderly? Sleep Med. 2011; 12:142-6.
PubMed
CrossRef
 
Subramanian S, Hesselbacher SE, Aguilar R, Surani SR. The NAMES assessment: a novel combined-modality screening tool for obstructive sleep apnea. Sleep Breath. 2011; 15:819-26.
PubMed
CrossRef
 
Thurtell MJ, Bruce BB, Rye DB, Newman NJ, Biousse V. The Berlin Questionnaire screens for obstructive sleep apnea in idiopathic intracranial hypertension. J Neuroophthalmol. 2011; 31:316-9.
PubMed
CrossRef
 
Vaz AP, Drummond M, Mota PC, Severo M, Almeida J, Winck JC. Translation of Berlin Questionnaire to Portuguese language and its application in OSA identification in a sleep disordered breathing clinic. Rev Port Pneumol. 2011; 17:59-65.
PubMed
CrossRef
 
Patt BT, Jarjoura D, Lambert L, Roy S, Gordillo G, Schlanger R, et al. Prevalence of obstructive sleep apnea in patients with chronic wounds. J Clin Sleep Med. 2010; 6:541-4.
PubMed
 
Sharkey KM, Orff HJ, Tosi C, Harrington D, Roye GD, Millman RP. Subjective sleepiness and daytime functioning in bariatric patients with obstructive sleep apnea. Sleep Breath. 2013; 17:267-74.
PubMed
CrossRef
 
Vana KD, Silva GE, Goldberg R. Predictive abilities of the STOP-Bang and Epworth Sleepiness Scale in identifying sleep clinic patients at high risk for obstructive sleep apnea. Res Nurs Health. 2013; 36:84-94.
PubMed
CrossRef
 
Albuquerque FN, Calvin AD, Sert Kuniyoshi FH, Konecny T, Lopez-Jimenez F, Pressman GS, et al. Sleep-disordered breathing and excessive daytime sleepiness in patients with atrial fibrillation. Chest. 2012; 141:967-73.
PubMed
CrossRef
 
Asha'ari ZA, Hasmoni MH, Ab Rahman J, Yusof RA, Ahmad RA. The association between sleep apnea and young adults with hypertension. Laryngoscope. 2012; 122:2337-42.
PubMed
CrossRef
 
Feng J, He QY, Zhang XL, Chen BY, Sleep Breath Disorder Group, Society of Respiratory Medicine. Epworth Sleepiness Scale may be an indicator for blood pressure profile and prevalence of coronary artery disease and cerebrovascular disease in patients with obstructive sleep apnea. Sleep Breath. 2012; 16:31-40.
PubMed
CrossRef
 
Knutson KL, Zhao X, Mattingly M, Galli G, Cizza G. Predictors of sleep-disordered breathing in obese adults who are chronic short sleepers. Sleep Med. 2012; 13:484-9.
PubMed
CrossRef
 
Morrell MJ, Finn L, McMillan A, Peppard PE. The impact of ageing and sex on the association between sleepiness and sleep disordered breathing. Eur Respir J. 2012; 40:386-93.
PubMed
CrossRef
 
Nicholl DD, Ahmed SB, Loewen AH, Hemmelgarn BR, Sola DY, Beecroft JM, et al. Clinical presentation of obstructive sleep apnea in patients with chronic kidney disease. J Clin Sleep Med. 2012; 8:381-7.
PubMed
 
Ravesloot MJ, van Maanen JP, Hilgevoord AA, van Wagensveld BA, de Vries N. Obstructive sleep apnea is underrecognized and underdiagnosed in patients undergoing bariatric surgery. Eur Arch Otorhinolaryngol. 2012; 269:1865-71.
PubMed
CrossRef
 
Gasa M, Salord N, Fortuna AM, Mayos M, Vilarrasa N, Dorca J, et al. Obstructive sleep apnoea and metabolic impairment in severe obesity. Eur Respir J. 2011; 38:1089-97.
PubMed
CrossRef
 
Khoo SM, Poh HK, Chan YH, Ngerng WJ, Shi DX, Lim TK. Diagnostic characteristics of clinical prediction models for obstructive sleep apnea in different clinic populations. Sleep Breath. 2011; 15:431-7.
PubMed
CrossRef
 
Kopitovic I, Trajanovic N, Prodic S, Drvenica MJ, Ilic M, Kuruc V, et al. The Serbian version of the Epworth Sleepiness Scale. Sleep Breath. 2011; 15:775-80.
PubMed
CrossRef
 
Martinez D, Breitenbach TC, Lumertz MS, Alcântara DL, da Rocha NS, Cassol CM, et al. Repeating administration of Epworth Sleepiness Scale is clinically useful. Sleep Breath. 2011; 15:763-73.
PubMed
CrossRef
 
Sareli AE, Cantor CR, Williams NN, Korus G, Raper SE, Pien G, et al. Obstructive sleep apnea in patients undergoing bariatric surgery—a tertiary center experience. Obes Surg. 2011; 21:316-27.
PubMed
CrossRef
 
Silva GE, Vana KD, Goodwin JL, Sherrill DL, Quan SF. Identification of patients with sleep disordered breathing: comparing the four-variable screening tool, STOP, STOP-Bang, and Epworth Sleepiness Scales. J Clin Sleep Med. 2011; 7:467-72.
PubMed
 
Tanaka S, Shima M. Assessment of screening tests for sleep apnea syndrome in the workplace. J Occup Health. 2010; 52:99-105.
PubMed
CrossRef
 
Sharwood LN, Elkington J, Stevenson M, Grunstein RR, Meuleners L, Ivers RQ, et al. Assessing sleepiness and sleep disorders in Australian long-distance commercial vehicle drivers: self-report versus an “at home” monitoring device. Sleep. 2012; 35:469-75.
PubMed
 
Bertolazi AN, Fagondes SC, Hoff LS, Dartora EG, Miozzo IC, de Barba ME, et al. Validation of the Brazilian Portuguese version of the Pittsburgh Sleep Quality Index. Sleep Med. 2011; 12:70-5.
PubMed
CrossRef
 
Chung F, Subramanyam R, Liao P, Sasaki E, Shapiro C, Sun Y. High STOP-Bang score indicates a high probability of obstructive sleep apnoea. Br J Anaesth. 2012; 108:768-75.
PubMed
CrossRef
 
Farney RJ, Walker BS, Farney RM, Snow GL, Walker JM. The STOP-Bang equivalent model and prediction of severity of obstructive sleep apnea: relation to polysomnographic measurements of the apnea/hypopnea index. J Clin Sleep Med. 2011; 7:459-65B.
PubMed
 
Ong TH, Raudha S, Fook-Chong S, Lew N, Hsu AA. Simplifying STOP-BANG: use of a simple questionnaire to screen for OSA in an Asian population. Sleep Breath. 2010; 14:371-6.
PubMed
CrossRef
 
Senchak MA, Frey WC, O'Connor PD. Use of portable sleep monitors to diagnose sleep apnea during predeployment assessment. Mil Med. 2012; 177:1196-201.
PubMed
CrossRef
 
Rodrigues MM, Dibbern RS, Goulart CW, Palma RA. Correlation between the Friedman classification and the Apnea-Hypopnea Index in a population with OSAHS. Braz J Otorhinolaryngol. 2010; 76:557-60.
PubMed
CrossRef
 
Crocker BD, Olson LG, Saunders NA, Hensley MJ, McKeon JL, Allen KM, et al. Estimation of the probability of disturbed breathing during sleep before a sleep study. Am Rev Respir Dis. 1990; 142:14-8.
PubMed
CrossRef
 
Gurubhagavatula I, Maislin G, Pack AI. An algorithm to stratify sleep apnea risk in a sleep disorders clinic population. Am J Respir Crit Care Med. 2001; 164:1904-9.
PubMed
CrossRef
 
Kushida CA, Efron B, Guilleminault C. A predictive morphometric model for the obstructive sleep apnea syndrome. Ann Intern Med. 1997; 127:581-7.
CrossRef
 
Onen SH, Dubray C, Decullier E, Moreau T, Chapuis F, Onen F. Observation-based nocturnal sleep inventory: screening tool for sleep apnea in elderly people. J Am Geriatr Soc. 2008; 56:1920-5.
PubMed
CrossRef
 
Rodsutti J, Hensley M, Thakkinstian A, D'Este C, Attia J. A clinical decision rule to prioritize polysomnography in patients with suspected sleep apnea. Sleep. 2004; 27:694-9.
PubMed
 
Rowley JA, Aboussouan LS, Badr MS. The use of clinical prediction formulas in the evaluation of obstructive sleep apnea. Sleep. 2000; 23:929-38.
PubMed
 
Zerah-Lancner F, Lofaso F, d'Ortho MP, Delclaux C, Goldenberg F, Coste A, et al. Predictive value of pulmonary function parameters for sleep apnea syndrome. Am J Respir Crit Care Med. 2000; 162:2208-12.
PubMed
CrossRef
 
Jauhar S, Orchardson R, Banham SW, Livingston E, Sherriff A, Lyons MF. The Kushida Index as a screening tool for obstructive sleep apnoea-hypopnoea syndrome. Br Dent J. 2012; 212:E2.
PubMed
CrossRef
 
Su CT, Chen KH, Chen LF, Wang PC, Hsiao YH. Prediagnosis of obstructive sleep apnea via multiclass MTS. Comput Math Methods Med. 2012; 2012:212498.
PubMed
CrossRef
 
Kolotkin RL, LaMonte MJ, Walker JM, Cloward TV, Davidson LE, Crosby RD. Predicting sleep apnea in bariatric surgery patients. Surg Obes Relat Dis. 2011; 7:605-10.
PubMed
CrossRef
 
Sun LM, Chiu HW, Chuang CY, Liu L. A prediction model based on an artificial intelligence system for moderate to severe obstructive sleep apnea. Sleep Breath. 2011; 15:317-23.
PubMed
CrossRef
 
Gurubhagavatula I, Maislin G, Nkwuo JE, Pack AI. Occupational screening for obstructive sleep apnea in commercial drivers. Am J Respir Crit Care Med. 2004; 170:371-6.
PubMed
CrossRef
 
Arzt M, Young T, Finn L, Skatrud JB, Bradley TD. Association of sleep-disordered breathing and the occurrence of stroke. Am J Respir Crit Care Med. 2005; 172:1447-51.
PubMed
CrossRef
 
Botros N, Concato J, Mohsenin V, Selim B, Doctor K, Yaggi HK. Obstructive sleep apnea as a risk factor for type 2 diabetes. Am J Med. 2009; 122:1122-7.
PubMed
CrossRef
 
Lavie P, Herer P, Peled R, Berger I, Yoffe N, Zomer J, et al. Mortality in sleep apnea patients: a multivariate analysis of risk factors. Sleep. 1995; 18:149-57.
PubMed
 
Lavie P, Lavie L, Herer P. All-cause mortality in males with sleep apnoea syndrome: declining mortality rates with age. Eur Respir J. 2005; 25:514-20.
PubMed
CrossRef
 
O'Connor GT, Caffo B, Newman AB, Quan SF, Rapoport DM, Redline S, et al. Prospective study of sleep-disordered breathing and hypertension: the Sleep Heart Health Study. Am J Respir Crit Care Med. 2009; 179:1159-64.
PubMed
CrossRef
 
Reichmuth KJ, Austin D, Skatrud JB, Young T. Association of sleep apnea and type II diabetes: a population-based study. Am J Respir Crit Care Med. 2005; 172:1590-5.
PubMed
CrossRef
 
Silva GE, An MW, Goodwin JL, Shahar E, Redline S, Resnick H, et al. Longitudinal evaluation of sleep-disordered breathing and sleep symptoms with change in quality of life: the Sleep Heart Health Study (SHHS). Sleep. 2009; 32:1049-57.
PubMed
 
Ensrud KE, Blackwell TL, Ancoli-Israel S, Redline S, Cawthon PM, Paudel ML, et al. Sleep disturbances and risk of frailty and mortality in older men. Sleep Med. 2012; 13:1217-25.
PubMed
CrossRef
 
Chami HA, Resnick HE, Quan SF, Gottlieb DJ. Association of incident cardiovascular disease with progression of sleep-disordered breathing. Circulation. 2011; 123:1280-6.
PubMed
CrossRef
 
Fung MM, Peters K, Redline S, Ziegler MG, Ancoli-Israel S, Barrett-Connor E, et al, Osteoporotic Fractures in Men Research Group. Decreased slow wave sleep increases risk of developing hypertension in elderly men. Hypertension. 2011; 58:596-603.
PubMed
CrossRef
 
Collop NA, Anderson WM, Boehlecke B, Claman D, Goldberg R, Gottlieb DJ, et al, Portable Monitoring Task Force of the American Academy of Sleep Medicine. Clinical guidelines for the use of unattended portable monitors in the diagnosis of obstructive sleep apnea in adult patients. Portable Monitoring Task Force of the American Academy of Sleep Medicine. J Clin Sleep Med. 2007; 3:737-47.
PubMed
 
Robinson GV, Smith DM, Langford BA, Davies RJ, Stradling JR. Continuous positive airway pressure does not reduce blood pressure in nonsleepy hypertensive OSA patients. Eur Respir J. 2006; 27:1229-35.
PubMed
CrossRef
 
Mitler MM, Gujavarty KS, Browman CP. Maintenance of wakefulness test: a polysomnographic technique for evaluation treatment efficacy in patients with excessive somnolence. Electroencephalogr Clin Neurophysiol. 1982; 53:658-61.
PubMed
CrossRef
 
RTI International.  Effectiveness of portable monitoring devices for diagnosing obstructive sleep apnea: update of a systematic review. Rockville, MD: Agency for Healthcare Research and Quality; 2004. Accessed at www.cms.gov/Medicare/Coverage/DeterminationProcess/downloads/id24TA.pdf on 1 June 2012.
 
Hallowell PT, Stellato TA, Petrozzi MC, Schuster M, Graf K, Robinson A, et al. Eliminating respiratory intensive care unit stay after gastric bypass surgery. Surgery. 2007; 142:608-12.
PubMed
CrossRef
 
Singh M, Liao P, Kobah S, Wijeysundera DN, Shapiro C, Chung F. Proportion of surgical patients with undiagnosed obstructive sleep apnoea. Br J Anaesth. 2013; 110:629-36.
PubMed
CrossRef
 
Kim GH, Lee JJ, Choi SJ, Shin BS, Lee AR, Lee SH, et al. Clinical predictors of apnoea-hypopnoea during propofol sedation in patients undergoing spinal anaesthesia. Anaesthesia. 2012; 67:755-9.
PubMed
CrossRef
 
Practice parameters for the indications for polysomnography and related procedures. Polysomnography Task Force, American Sleep Disorders Association Standards of Practice Committee. Sleep. 1997; 20:406-22.
PubMed
 

Figures

Grahic Jump Location
Figure.

Summary of the American College of Physicians guideline on diagnosis of OSA in adults.

AHI = apnea–hypopnea index; CHD = coronary heart disease; CPAP = continuous positive airway pressure; OSA = obstructive sleep apnea; PSG = polysomnography.

Grahic Jump Location

Tables

Table Jump PlaceholderTable 1. Types of Monitors for Diagnosis of Obstructive Sleep Apnea* 
Table Jump PlaceholderTable 2. The American College of Physicians' Guideline Grading System* 
Table Jump PlaceholderTable 3. Accuracy of Portable Monitors and Questionnaires for Diagnosis of Obstructive Sleep Apnea 
Table Jump PlaceholderTable 4. The AHI as a Predictor of Clinical Outcomes 

Videos

Video News Release - ACP's Diagnosing Obstructive Sleep Apnea in Adults Guideline

References

Victor LD. Obstructive sleep apnea. Am Fam Physician. 1999; 60:2279-86.
PubMed
 
Howard ME, Desai AV, Grunstein RR, Hukins C, Armstrong JG, Joffe D, et al. Sleepiness, sleep-disordered breathing, and accident risk factors in commercial vehicle drivers. Am J Respir Crit Care Med. 2004; 170:1014-21.
PubMed
CrossRef
 
Terán-Santos J, Jiménez-Gómez A, Cordero-Guevara J. The association between sleep apnea and the risk of traffic accidents. Cooperative Group Burgos-Santander. N Engl J Med. 1999; 340:847-51.
PubMed
CrossRef
 
Young T, Palta M, Dempsey J, Skatrud J, Weber S, Badr S. The occurrence of sleep-disordered breathing among middle-aged adults. N Engl J Med. 1993; 328:1230-5.
PubMed
CrossRef
 
Marin JM, Carrizo SJ, Vicente E, Agusti AG. Long-term cardiovascular outcomes in men with obstructive sleep apnoea-hypopnoea with or without treatment with continuous positive airway pressure: an observational study. Lancet. 2005; 365:1046-53.
PubMed
CrossRef
 
Punjabi NM. The epidemiology of adult obstructive sleep apnea. Proc Am Thorac Soc. 2008; 5:136-43.
PubMed
CrossRef
 
Shahar E, Whitney CW, Redline S, Lee ET, Newman AB, Nieto FJ, et al. Sleep-disordered breathing and cardiovascular disease: cross-sectional results of the Sleep Heart Health Study. Am J Respir Crit Care Med. 2001; 163:19-25.
PubMed
CrossRef
 
Yaggi HK, Concato J, Kernan WN, Lichtman JH, Brass LM, Mohsenin V. Obstructive sleep apnea as a risk factor for stroke and death. N Engl J Med. 2005; 353:2034-41.
PubMed
CrossRef
 
Nieto FJ, Young TB, Lind BK, Shahar E, Samet JM, Redline S, et al. Association of sleep-disordered breathing, sleep apnea, and hypertension in a large community-based study. Sleep Heart Health Study. JAMA. 2000; 283:1829-36.
PubMed
CrossRef
 
Peppard PE, Young T, Palta M, Skatrud J. Prospective study of the association between sleep-disordered breathing and hypertension. N Engl J Med. 2000; 342:1378-84.
PubMed
CrossRef
 
Young T, Peppard P, Palta M, Hla KM, Finn L, Morgan B, et al. Population-based study of sleep-disordered breathing as a risk factor for hypertension. Arch Intern Med. 1997; 157:1746-52.
PubMed
CrossRef
 
Babu AR, Herdegen J, Fogelfeld L, Shott S, Mazzone T. Type 2 diabetes, glycemic control, and continuous positive airway pressure in obstructive sleep apnea. Arch Intern Med. 2005; 165:447-52.
PubMed
CrossRef
 
Caples SM, Gami AS, Somers VK. Obstructive sleep apnea. Ann Intern Med. 2005; 142:187-97.
CrossRef
 
Gruber A, Horwood F, Sithole J, Ali NJ, Idris I. Obstructive sleep apnoea is independently associated with the metabolic syndrome but not insulin resistance state. Cardiovasc Diabetol. 2006; 5:22.
PubMed
CrossRef
 
Young T, Peppard PE, Gottlieb DJ. Epidemiology of obstructive sleep apnea: a population health perspective. Am J Respir Crit Care Med. 2002; 165:1217-39.
PubMed
CrossRef
 
Chung SA, Yuan H, Chung F. A systemic review of obstructive sleep apnea and its implications for anesthesiologists. Anesth Analg. 2008; 107:1543-63.
PubMed
CrossRef
 
Finkel KJ, Searleman AC, Tymkew H, Tanaka CY, Saager L, Safer-Zadeh E, et al. Prevalence of undiagnosed obstructive sleep apnea among adult surgical patients in an academic medical center. Sleep Med. 2009; 10:753-8.
PubMed
CrossRef
 
Gupta RM, Parvizi J, Hanssen AD, Gay PC. Postoperative complications in patients with obstructive sleep apnea syndrome undergoing hip or knee replacement: a case-control study. Mayo Clin Proc. 2001; 76:897-905.
PubMed
CrossRef
 
Punjabi NM, Caffo BS, Goodwin JL, Gottlieb DJ, Newman AB, O'Connor GT, et al. Sleep-disordered breathing and mortality: a prospective cohort study. PLoS Med. 2009; 6:e1000132.
PubMed
CrossRef
 
Young T, Finn L, Peppard PE, Szklo-Coxe M, Austin D, Nieto FJ, et al. Sleep disordered breathing and mortality: eighteen-year follow-up of the Wisconsin Sleep Cohort. Sleep. 2008; 31:1071-8.
PubMed
 
Ancoli-Israel S, Kripke DF, Klauber MR, Mason WJ, Fell R, Kaplan O. Sleep-disordered breathing in community-dwelling elderly. Sleep. 1991; 14:486-95.
PubMed
 
Bixler EO, Vgontzas AN, Lin HM, Ten Have T, Rein J, Vela-Bueno A, et al. Prevalence of sleep-disordered breathing in women: effects of gender. Am J Respir Crit Care Med. 2001; 163:608-13.
PubMed
CrossRef
 
Bixler EO, Vgontzas AN, Ten Have T, Tyson K, Kales A. Effects of age on sleep apnea in men: I. Prevalence and severity. Am J Respir Crit Care Med. 1998; 157:144-8.
PubMed
CrossRef
 
Durán J, Esnaola S, Rubio R, Iztueta A. Obstructive sleep apnea-hypopnea and related clinical features in a population-based sample of subjects aged 30 to 70 yr. Am J Respir Crit Care Med. 2001; 163:685-9.
PubMed
CrossRef
 
Young T, Shahar E, Nieto FJ, Redline S, Newman AB, Gottlieb DJ, et al, Sleep Heart Health Study Research Group. Predictors of sleep-disordered breathing in community-dwelling adults: the Sleep Heart Health Study. Arch Intern Med. 2002; 162:893-900.
PubMed
CrossRef
 
Young T, Peppard PE, Taheri S. Excess weight and sleep-disordered breathing. J Appl Physiol (1985). 2005; 99:1592-9.
PubMed
CrossRef
 
Johns MW. A new method for measuring daytime sleepiness: the Epworth Sleepiness Scale. Sleep. 1991; 14:540-5.
PubMed
 
Balk EM, Moorthy D, Obadan NO, Patel K, Ip S, Chung M, et al. Diagnosis and treatment of obstructive sleep apnea in adults. Comparative effectiveness review no. 32. AHRQ publication no. 11-EHC052-EF. (Prepared by Tufts Evidence-based Practice Center under contract 290-2007-100551.). Rockville, MD: Agency for Healthcare Research and Quality; 2011.
 
American Academy of Sleep Medicine. The International Classification of Sleep Disorders, 2nd Edition: Diagnostic and Coding Manual. Westchester, IL: American Academy of Sleep Medicine; 2005.
 
Epstein LJ, Kristo D, Strollo PJ Jr, Friedman N, Malhotra A, Patil SP, et al, Adult Obstructive Sleep Apnea Task Force of the American Academy of Sleep Medicine. Clinical guideline for the evaluation, management and long-term care of obstructive sleep apnea in adults. J Clin Sleep Med. 2009; 5:263-76.
PubMed
 
Centers for Medicare & Medicaid Services.  National Coverage Determination (NCD) for Continuous Positive Airway Pressure (CPAP) Therapy For Obstructive Sleep Apnea (OSA) (240.4). Baltimore: Centers for Medicare & Medicaid Services; 2008. Accessed at www.cms.gov/medicare-coverage-database/details/ncd-details.aspx?NCDId=226&ncdver=3&NCAId=204&NcaName=Continuous±Positive±Airway±Pressure±%28CPAP%29±Therapy±for±Obstructive±Sleep±Apnea±%28OSA%29&IsPopup=y&bc=AAAAAAAAIAAA& on 2 April 2014.
 
Tufts-New England Medical Center EPC.  Home diagnosis of obstructive sleep apnea-hypopnea syndrome. Rockville, MD: Agency for Healthcare Research and Quality; 2007. Accessed at www.cms.gov/Medicare/Coverage/DeterminationProcess/downloads/id48TA.pdf on 19 March 2013.
 
Qaseem A, Holty JE, Owens DK, Dallas P, Starkey M, Shekelle P, for the Clinical Guidelines Committee of the American College of Physicians. Management of obstructive sleep apnea in adults: a clinical practice guideline from the American College of Physicians. Ann Intern Med. 2013; 159:471-83.
 
Qaseem A, Snow V, Owens DK, Shekelle P, Clinical Guidelines Committee of the American College of Physicians. The development of clinical practice guidelines and guidance statements of the American College of Physicians: summary of methods. Ann Intern Med. 2010; 153:194-9.
CrossRef
 
Iber C, Redline S, Kaplan Gilpin AM, Quan SF, Zhang L, Gottlieb DJ, et al. Polysomnography performed in the unattended home versus the attended laboratory setting—Sleep Heart Health Study methodology. Sleep. 2004; 27:536-40.
PubMed
 
Mykytyn IJ, Sajkov D, Neill AM, McEvoy RD. Portable computerized polysomnography in attended and unattended settings. Chest. 1999; 115:114-22.
PubMed
CrossRef
 
Orr WC, Eiken T, Pegram V, Jones R, Rundell OH. A laboratory validation study of a portable system for remote recording of sleep-related respiratory disorders. Chest. 1994; 105:160-2.
PubMed
CrossRef
 
Portier F, Portmann A, Czernichow P, Vascaut L, Devin E, Benhamou D, et al. Evaluation of home versus laboratory polysomnography in the diagnosis of sleep apnea syndrome. Am J Respir Crit Care Med. 2000; 162:814-8.
PubMed
CrossRef
 
Gagnadoux F, Pelletier-Fleury N, Philippe C, Rakotonanahary D, Fleury B. Home unattended vs hospital telemonitored polysomnography in suspected obstructive sleep apnea syndrome: a randomized crossover trial. Chest. 2002; 121:753-8.
PubMed
CrossRef
 
Ferré A, Sampol G, Jurado MJ, Cambrodi R, Lloberes P, Romero O. Neurophysiological two-channel polysomnographic device in the diagnosis of sleep apnea. J Clin Sleep Med. 2012; 8:163-8.
PubMed
 
Oliveira MG, Nery LE, Santos-Silva R, Sartori DE, Alonso FF, Togeiro SM, et al. Is portable monitoring accurate in the diagnosis of obstructive sleep apnea syndrome in chronic pulmonary obstructive disease? Sleep Med. 2012; 13:1033-8.
PubMed
CrossRef
 
Martínez-García MA, Capote F, Campos-Rodríguez F, Lloberes P, Díaz de Atauri MJ, Somoza M, et al, Spanish Sleep Network. Effect of CPAP on blood pressure in patients with obstructive sleep apnea and resistant hypertension: the HIPARCO randomized clinical trial. JAMA. 2013; 310:2407-15.
PubMed
 
Amir O, Barak-Shinar D, Amos Y, MacDonald M, Pittman S, White DP. An automated sleep-analysis system operated through a standard hospital monitor. J Clin Sleep Med. 2010; 6:59-63.
PubMed
 
García-Díaz E, Quintana-Gallego E, Ruiz A, Carmona-Bernal C, Sánchez-Armengol A, Botebol-Benhamou G, et al. Respiratory polygraphy with actigraphy in the diagnosis of sleep apnea-hypopnea syndrome. Chest. 2007; 131:725-32.
PubMed
CrossRef
 
Ng SS, Chan TO, To KW, Ngai J, Tung A, Ko FW, et al. Validation of Embletta portable diagnostic system for identifying patients with suspected obstructive sleep apnoea syndrome (OSAS). Respirology. 2010; 15:336-42.
PubMed
CrossRef
 
Planès C, Leroy M, Bouach Khalil N, El Mahmoud R, Digne F, de Roquefeuil F, et al. Home diagnosis of obstructive sleep apnoea in coronary patients: validity of a simplified device automated analysis. Sleep Breath. 2010; 14:25-32.
PubMed
CrossRef
 
Santos-Silva R, Sartori DE, Truksinas V, Truksinas E, Alonso FF, Tufik S, et al. Validation of a portable monitoring system for the diagnosis of obstructive sleep apnea syndrome. Sleep. 2009; 32:629-36.
PubMed
 
To KW, Chan WC, Chan TO, Tung A, Ngai J, Ng S, et al. Validation study of a portable monitoring device for identifying OSA in a symptomatic patient population. Respirology. 2009; 14:270-5.
PubMed
CrossRef
 
Tonelli de Oliveira AC, Martinez D, Vasconcelos LF, Gonçalves SC, Lenz MC, Fuchs SC, et al. Diagnosis of obstructive sleep apnea syndrome and its outcomes with home portable monitoring. Chest. 2009; 135:330-6.
PubMed
CrossRef
 
Redline S, Tosteson T, Boucher MA, Millman RP. Measurement of sleep-related breathing disturbances in epidemiologic studies. Assessment of the validity and reproducibility of a portable monitoring device. Chest. 1991; 100:1281-6.
PubMed
CrossRef
 
Reichert JA, Bloch DA, Cundiff E, Votteri BA. Comparison of the NovaSom QSG, a new sleep apnea home-diagnostic system, and polysomnography. Sleep Med. 2003; 4:213-8.
PubMed
CrossRef
 
White DP, Gibb TJ, Wall JM, Westbrook PR. Assessment of accuracy and analysis time of a novel device to monitor sleep and breathing in the home. Sleep. 1995; 18:115-26.
PubMed
 
Calleja JM, Esnaola S, Rubio R, Durán J. Comparison of a cardiorespiratory device versus polysomnography for diagnosis of sleep apnoea. Eur Respir J. 2002; 20:1505-10.
PubMed
CrossRef
 
Carrasco O, Montserrat JM, Lloberes P, Ascasco C, Ballester E, Fornas C, et al. Visual and different automatic scoring profiles of respiratory variables in the diagnosis of sleep apnoea-hypopnoea syndrome. Eur Respir J. 1996; 9:125-30.
PubMed
CrossRef
 
Dingli K, Coleman EL, Vennelle M, Finch SP, Wraith PK, Mackay TW, et al. Evaluation of a portable device for diagnosing the sleep apnoea/hypopnoea syndrome. Eur Respir J. 2003; 21:253-9.
PubMed
CrossRef
 
Ficker JH, Wiest GH, Wilpert J, Fuchs FS, Hahn EG. Evaluation of a portable recording device (Somnocheck) for use in patients with suspected obstructive sleep apnoea. Respiration. 2001; 68:307-12.
PubMed
CrossRef
 
Fietze I, Glos M, Röttig J, Witt C. Automated analysis of data is inferior to visual analysis of ambulatory sleep apnea monitoring. Respiration. 2002; 69:235-41.
PubMed
CrossRef
 
Zucconi M, Ferini-Strambi L, Castronovo V, Oldani A, Smirne S. An unattended device for sleep-related breathing disorders: validation study in suspected obstructive sleep apnoea syndrome. Eur Respir J. 1996; 9:1251-6.
PubMed
CrossRef
 
Yin M, Miyazaki S, Ishikawa K. Evaluation of type 3 portable monitoring in unattended home setting for suspected sleep apnea: factors that may affect its accuracy. Otolaryngol Head Neck Surg. 2006; 134:204-9.
PubMed
CrossRef
 
Claman D, Murr A, Trotter K. Clinical validation of the Bedbugg in detection of obstructive sleep apnea. Otolaryngol Head Neck Surg. 2001; 125:227-30.
PubMed
CrossRef
 
Ancoli-Israel S, Mason W, Coy TV, Stepnowsky C, Clausen JL, Dimsdale J. Evaluation of sleep disordered breathing with unattended recording: the Nightwatch System. J Med Eng Technol. 1997; 21:10-4.
PubMed
CrossRef
 
Ballester E, Solans M, Vila X, Hernandez L, Quintó L, Bolivar I, et al. Evaluation of a portable respiratory recording device for detecting apnoeas and hypopnoeas in subjects from a general population. Eur Respir J. 2000; 16:123-7.
PubMed
CrossRef
 
Emsellem HA, Corson WA, Rappaport BA, Hackett S, Smith LG, Hausfeld JN. Verification of sleep apnea using a portable sleep apnea screening device. South Med J. 1990; 83:748-52.
PubMed
CrossRef
 
Lloberes P, Montserrat JM, Ascaso A, Parra O, Granados A, Alonso P, et al. Comparison of partially attended night time respiratory recordings and full polysomnography in patients with suspected sleep apnoea/hypopnoea syndrome. Thorax. 1996; 51:1043-7.
PubMed
CrossRef
 
Man GC, Kang BV. Validation of a portable sleep apnea monitoring device. Chest. 1995; 108:388-93.
PubMed
CrossRef
 
Marrone O, Salvaggio A, Insalaco G, Bonsignore MR, Bonsignore G. Evaluation of the POLYMESAM system in the diagnosis of obstructive sleep apnea syndrome. Monaldi Arch Chest Dis. 2001; 56:486-90.
PubMed
 
Parra O, García-Esclasans N, Montserrat JM, García Eroles L, Ruíz J, López JA, et al. Should patients with sleep apnoea/hypopnoea syndrome be diagnosed and managed on the basis of home sleep studies? Eur Respir J. 1997; 10:1720-4.
PubMed
CrossRef
 
Quintana-Gallego E, Villa-Gil M, Carmona-Bernal C, Botebol-Benhamou G, Martínez-Martínez A, Sánchez-Armengol A, et al. Home respiratory polygraphy for diagnosis of sleep-disordered breathing in heart failure. Eur Respir J. 2004; 24:443-8.
PubMed
CrossRef
 
Su S, Baroody FM, Kohrman M, Suskind D. A comparison of polysomnography and a portable home sleep study in the diagnosis of obstructive sleep apnea syndrome. Otolaryngol Head Neck Surg. 2004; 131:844-50.
PubMed
CrossRef
 
Verse T, Pirsig W, Junge-Hülsing B, Kroker B. Validation of the POLY-MESAM seven-channel ambulatory recording unit. Chest. 2000; 117:1613-8.
PubMed
CrossRef
 
Whittle AT, Finch SP, Mortimore IL, MacKay TW, Douglas NJ. Use of home sleep studies for diagnosis of the sleep apnoea/hypopnoea syndrome. Thorax. 1997; 52:1068-73.
PubMed
CrossRef
 
Danzi-Soares NJ, Genta PR, Nerbass FB, Pedrosa RP, Soares FS, César LA, et al. Obstructive sleep apnea is common among patients referred for coronary artery bypass grafting and can be diagnosed by portable monitoring. Coron Artery Dis. 2012; 23:31-8.
PubMed
CrossRef
 
Cheliout-Heraut F, Senny F, Djouadi F, Ouayoun M, Bour F. Obstructive sleep apnoea syndrome: comparison between polysomnography and portable sleep monitoring based on jaw recordings. Neurophysiol Clin. 2011; 41:191-8.
PubMed
CrossRef
 
Driver HS, Pereira EJ, Bjerring K, Toop F, Stewart SC, Munt PW, et al. Validation of the MediByte® type 3 portable monitor compared with polysomnography for screening of obstructive sleep apnea. Can Respir J. 2011; 18:137-43.
PubMed
 
Gjevre JA, Taylor-Gjevre RM, Skomro R, Reid J, Fenton M, Cotton D. Comparison of polysomnographic and portable home monitoring assessments of obstructive sleep apnea in Saskatchewan women. Can Respir J. 2011; 18:271-4.
PubMed
 
Masa JF, Corral J, Pereira R, Duran-Cantolla J, Cabello M, Hernández-Blasco L, et al. Effectiveness of home respiratory polygraphy for the diagnosis of sleep apnoea and hypopnoea syndrome. Thorax. 2011; 66:567-73.
PubMed
CrossRef
 
Abraham WT, Trupp RJ, Phillilps B, Bourge RC, Bailey B, Harding SM, et al. Validation and clinical utility of a simple in-home testing tool for sleep-disordered breathing and arrhythmias in heart failure: results of the Sleep Events, Arrhythmias, and Respiratory Analysis in Congestive Heart Failure (SEARCH) study. Congest Heart Fail. 2006; 12:241-7.
PubMed
CrossRef
 
Agatsuma T, Fujimoto K, Komatsu Y, Urushihata K, Honda T, Tsukahara T, et al. A novel device (SD-101) with high accuracy for screening sleep apnoea-hypopnoea syndrome. Respirology. 2009; 14:1143-50.
PubMed
CrossRef
 
Ayappa I, Norman RG, Seelall V, Rapoport DM. Validation of a self-applied unattended monitor for sleep disordered breathing. J Clin Sleep Med. 2008; 4:26-37.
PubMed
 
Chen H, Lowe AA, Bai Y, Hamilton P, Fleetham JA, Almeida FR. Evaluation of a portable recording device (ApneaLink) for case selection of obstructive sleep apnea. Sleep Breath. 2009; 13:213-9.
PubMed
CrossRef
 
Clark AL, Crabbe S, Aziz A, Reddy P, Greenstone M. Use of a screening tool for detection of sleep-disordered breathing. J Laryngol Otol. 2009; 123:746-9.
PubMed
CrossRef
 
de Almeida FR, Ayas NT, Otsuka R, Ueda H, Hamilton P, Ryan FC, et al. Nasal pressure recordings to detect obstructive sleep apnea. Sleep Breath. 2006; 10:62-9.
PubMed
CrossRef
 
Erman MK, Stewart D, Einhorn D, Gordon N, Casal E. Validation of the ApneaLink for the screening of sleep apnea: a novel and simple single-channel recording device. J Clin Sleep Med. 2007; 3:387-92.
PubMed
 
Goodrich S, Orr WC. An investigation of the validity of the Lifeshirt in comparison to standard polysomnography in the detection of obstructive sleep apnea. Sleep Med. 2009; 10:118-22.
PubMed
CrossRef
 
Heneghan C, Chua CP, Garvey JF, de Chazal P, Shouldice R, Boyle P, et al. A portable automated assessment tool for sleep apnea using a combined Holter-oximeter. Sleep. 2008; 31:1432-9.
PubMed
 
Heneghan C, de Chazal P, Ryan S, Chua CP, Doherty L, Boyle P, et al. Electrocardiogram recording as a screening tool for sleep disordered breathing. J Clin Sleep Med. 2008; 4:223-8.
PubMed
 
Nakano H, Tanigawa T, Ohnishi Y, Uemori H, Senzaki K, Furukawa T, et al. Validation of a single-channel airflow monitor for screening of sleep-disordered breathing. Eur Respir J. 2008; 32:1060-7.
PubMed
CrossRef
 
Ng SS, Chan TO, To KW, Ngai J, Tung A, Ko FW, et al. Validation of a portable recording device (ApneaLink) for identifying patients with suspected obstructive sleep apnoea syndrome. Intern Med J. 2009; 39:757-62.
PubMed
CrossRef
 
Nigro CA, Aimaretti S, Gonzalez S, Rhodius E. Validation of the WristOx 3100 oximeter for the diagnosis of sleep apnea/hypopnea syndrome. Sleep Breath. 2009; 13:127-36.
PubMed
CrossRef
 
Pang KP, Gourin CG, Terris DJ. A comparison of polysomnography and the WatchPAT in the diagnosis of obstructive sleep apnea. Otolaryngol Head Neck Surg. 2007; 137:665-8.
PubMed
CrossRef
 
Pépin JL, Defaye P, Vincent E, Christophle-Boulard S, Tamisier R, Lévy P. Sleep apnea diagnosis using an ECG Holter device including a nasal pressure (NP) recording: validation of visual and automatic analysis of nasal pressure versus full polysomnography. Sleep Med. 2009; 10:651-6.
PubMed
CrossRef
 
Ragette R, Wang Y, Weinreich G, Teschler H. Diagnostic performance of single airflow channel recording (ApneaLink) in home diagnosis of sleep apnea. Sleep Breath. 2010; 14:109-14.
PubMed
CrossRef
 
Reda M, Gibson GJ, Wilson JA. Pharyngoesophageal pressure monitoring in sleep apnea syndrome. Otolaryngol Head Neck Surg. 2001; 125:324-31.
PubMed
CrossRef
 
Schäfer H, Ewig S, Hasper E, Lüderitz B. Predictive diagnostic value of clinical assessment and nonlaboratory monitoring system recordings in patients with symptoms suggestive of obstructive sleep apnea syndrome. Respiration. 1997; 64:194-9.
PubMed
CrossRef
 
Smith LA, Chong DW, Vennelle M, Denvir MA, Newby DE, Douglas NJ. Diagnosis of sleep-disordered breathing in patients with chronic heart failure: evaluation of a portable limited sleep study system. J Sleep Res. 2007; 16:428-35.
PubMed
CrossRef
 
Szyszko A, Franceschini C, Gonzalez-Zuelgaray J. Reliability of a Holter-based methodology for evaluation of sleep apnoea syndrome. Europace. 2009; 11:94-9.
PubMed
CrossRef
 
Watkins MR, Talmage JB, Thiese MS, Hudson TB, Hegmann KT. Correlation between screening for obstructive sleep apnea using a portable device versus polysomnography testing in a commercial driving population. J Occup Environ Med. 2009; 51:1145-50.
PubMed
CrossRef
 
White JE, Smithson AJ, Close PR, Drinnan MJ, Prichard AJ, Gibson GJ. The use of sound recording and oxygen saturation in screening snorers for obstructive sleep apnoea. Clin Otolaryngol Allied Sci. 1994; 19:218-21.
PubMed
CrossRef
 
Wong KK, Jankelson D, Reid A, Unger G, Dungan G, Hedner JA, et al. Diagnostic test evaluation of a nasal flow monitor for obstructive sleep apnea detection in sleep apnea research. Behav Res Methods. 2008; 40:360-6.
PubMed
CrossRef
 
Yagi H, Nakata S, Tsuge H, Yasuma F, Noda A, Morinaga M, et al. Significance of a screening device (Apnomonitor 5) for sleep apnea syndrome. Auris Nasus Larynx. 2009; 36:176-80.
PubMed
CrossRef
 
Nigro CA, Dibur E, Malnis S, Grandval S, Nogueira F. Validation of ApneaLink Ox for the diagnosis of obstructive sleep apnea. Sleep Breath. 2013; 17:259-66.
PubMed
CrossRef
 
Morales CR, Hurley S, Wick LC, Staley B, Pack FM, Gooneratne NS, et al. In-home, self-assembled sleep studies are useful in diagnosing sleep apnea in the elderly. Sleep. 2012; 35:1491-501.
PubMed
 
O'Brien LM, Bullough AS, Shelgikar AV, Chames MC, Armitage R, Chervin RD. Validation of Watch-PAT-200 against polysomnography during pregnancy. J Clin Sleep Med. 2012; 8:287-94.
PubMed
 
Onder NS, Akpinar ME, Yigit O, Gor AP. Watch peripheral arterial tonometry in the diagnosis of obstructive sleep apnea: influence of aging. Laryngoscope. 2012; 122:1409-14.
PubMed
CrossRef
 
BaHammam AS, Sharif M, Gacuan DE, George S. Evaluation of the accuracy of manual and automatic scoring of a single airflow channel in patients with a high probability of obstructive sleep apnea. Med Sci Monit. 2011; 17:MT13-9.
PubMed
CrossRef
 
Chai-Coetzer CL, Antic NA, Rowland LS, Catcheside PG, Esterman A, Reed RL, et al. A simplified model of screening questionnaire and home monitoring for obstructive sleep apnoea in primary care. Thorax. 2011; 66:213-9.
PubMed
CrossRef
 
Chouchou F, Sforza E, Celle S, Pichot V, Maudoux D, Garcin A, et al, PROOF Study Group. Pulse transit time in screening sleep disordered breathing in an elderly population: the PROOF-SYNAPSE study. Sleep. 2011; 34:1051-9.
PubMed
 
Hedner J, White DP, Malhotra A, Herscovici S, Pittman SD, Zou D, et al. Sleep staging based on autonomic signals: a multi-center validation study. J Clin Sleep Med. 2011; 7:301-6.
PubMed
 
Nigro CA, Dibur E, Aimaretti S, González S, Rhodius E. Comparison of the automatic analysis versus the manual scoring from ApneaLink device for the diagnosis of obstructive sleep apnoea syndrome. Sleep Breath. 2011; 15:679-86.
PubMed
CrossRef
 
Yang GG, Yang MC, Chung CY, Chen YT, Chang ET. Respiratory-inductive-plethysmography-derived flow can be a useful clinical tool to detect patients with obstructive sleep apnea syndrome. J Formos Med Assoc. 2011; 110:642-5.
PubMed
CrossRef
 
Alvarez D, Gutierrez GC, Marcos JV, Del Campo F, Hornero R. Spectral analysis of single-channel airflow and oxygen saturation recordings in obstructive sleep apnea detection. Conf Proc IEEE Eng Med Biol Soc. 2010; 2010:847-50.
PubMed
 
Nigro CA, Serrano F, Aimaretti S, González S, Codinardo C, Rhodius E. Utility of ApneaLink for the diagnosis of sleep apnea-hypopnea syndrome. Medicina (B Aires). 2010; 70:53-9.
PubMed
 
Yadollahi A, Giannouli E, Moussavi Z. Sleep apnea monitoring and diagnosis based on pulse oximetry and tracheal sound signals. Med Biol Eng Comput. 2010; 48:1087-97.
PubMed
CrossRef
 
Chung F, Yegneswaran B, Liao P, Chung SA, Vairavanathan S, Islam S, et al. STOP questionnaire: a tool to screen patients for obstructive sleep apnea. Anesthesiology. 2008; 108:812-21.
PubMed
CrossRef
 
Chung F, Yegneswaran B, Liao P, Chung SA, Vairavanathan S, Islam S, et al. Validation of the Berlin Questionnaire and American Society of Anesthesiologists checklist as screening tools for obstructive sleep apnea in surgical patients. Anesthesiology. 2008; 108:822-30.
PubMed
CrossRef
 
Drager LF, Genta PR, Pedrosa RP, Nerbass FB, Gonzaga CC, Krieger EM, et al. Characteristics and predictors of obstructive sleep apnea in patients with systemic hypertension. Am J Cardiol. 2010; 105:1135-9.
PubMed
CrossRef
 
Kapuniai LE, Andrew DJ, Crowell DH, Pearce JW. Identifying sleep apnea from self-reports. Sleep. 1988; 11:430-6.
PubMed
 
Netzer NC, Stoohs RA, Netzer CM, Clark K, Strohl KP. Using the Berlin Questionnaire to identify patients at risk for the sleep apnea syndrome. Ann Intern Med. 1999; 131:485-91.
CrossRef
 
Sharma SK, Vasudev C, Sinha S, Banga A, Pandey RM, Handa KK. Validation of the modified Berlin Questionnaire to identify patients at risk for the obstructive sleep apnoea syndrome. Indian J Med Res. 2006; 124:281-90.
PubMed
 
Geiger-Brown J, Rogers VE, Han K, Trinkoff A, Bausell RB, Scharf SM. Occupational screening for sleep disorders in 12-h shift nurses using the Berlin Questionnaire. Sleep Breath. 2013; 17:381-8.
PubMed
CrossRef
 
Facco FL, Ouyang DW, Zee PC, Grobman WA. Development of a pregnancy-specific screening tool for sleep apnea. J Clin Sleep Med. 2012; 8:389-94.
PubMed
 
Gjevre JA, Taylor-Gjevre RM, Nair BV, Lim HJ. Do sleepy rheumatoid arthritis patients have a sleep disorder? Musculoskeletal Care. 2012; 10:187-95.
PubMed
CrossRef
 
Koyama RG, Esteves AM, Oliveira e Silva L, Lira FS, Bittencourt LR, Tufik S, et al. Prevalence of and risk factors for obstructive sleep apnea syndrome in Brazilian railroad workers. Sleep Med. 2012; 13:1028-32.
PubMed
CrossRef
 
Laporta R, Anandam A, El-Solh AA. Screening for obstructive sleep apnea in veterans with ischemic heart disease using a computer-based clinical decision-support system. Clin Res Cardiol. 2012; 101:737-44.
PubMed
CrossRef
 
Martinez D, da Silva RP, Klein C, Fiori CZ, Massierer D, Cassol CM, et al. High risk for sleep apnea in the Berlin Questionnaire and coronary artery disease. Sleep Breath. 2012; 16:89-94.
PubMed
CrossRef
 
Enciso R, Clark GT. Comparing the Berlin and the ARES questionnaire to identify patients with obstructive sleep apnea in a dental setting. Sleep Breath. 2011; 15:83-9.
PubMed
CrossRef
 
Hrubos-Strøm H, Randby A, Namtvedt SK, Kristiansen HA, Einvik G, Benth J, et al. A Norwegian population-based study on the risk and prevalence of obstructive sleep apnea. The Akershus Sleep Apnea Project (ASAP). J Sleep Res. 2011; 20:162-70.
PubMed
CrossRef
 
Sert Kuniyoshi FH, Zellmer MR, Calvin AD, Lopez-Jimenez F, Albuquerque FN, van der Walt C, et al. Diagnostic accuracy of the Berlin Questionnaire in detecting sleep-disordered breathing in patients with a recent myocardial infarction. Chest. 2011; 140:1192-7.
PubMed
CrossRef
 
Sforza E, Chouchou F, Pichot V, Herrmann F, Barthélémy JC, Roche F. Is the Berlin Questionnaire a useful tool to diagnose obstructive sleep apnea in the elderly? Sleep Med. 2011; 12:142-6.
PubMed
CrossRef
 
Subramanian S, Hesselbacher SE, Aguilar R, Surani SR. The NAMES assessment: a novel combined-modality screening tool for obstructive sleep apnea. Sleep Breath. 2011; 15:819-26.
PubMed
CrossRef
 
Thurtell MJ, Bruce BB, Rye DB, Newman NJ, Biousse V. The Berlin Questionnaire screens for obstructive sleep apnea in idiopathic intracranial hypertension. J Neuroophthalmol. 2011; 31:316-9.
PubMed
CrossRef
 
Vaz AP, Drummond M, Mota PC, Severo M, Almeida J, Winck JC. Translation of Berlin Questionnaire to Portuguese language and its application in OSA identification in a sleep disordered breathing clinic. Rev Port Pneumol. 2011; 17:59-65.
PubMed
CrossRef
 
Patt BT, Jarjoura D, Lambert L, Roy S, Gordillo G, Schlanger R, et al. Prevalence of obstructive sleep apnea in patients with chronic wounds. J Clin Sleep Med. 2010; 6:541-4.
PubMed
 
Sharkey KM, Orff HJ, Tosi C, Harrington D, Roye GD, Millman RP. Subjective sleepiness and daytime functioning in bariatric patients with obstructive sleep apnea. Sleep Breath. 2013; 17:267-74.
PubMed
CrossRef
 
Vana KD, Silva GE, Goldberg R. Predictive abilities of the STOP-Bang and Epworth Sleepiness Scale in identifying sleep clinic patients at high risk for obstructive sleep apnea. Res Nurs Health. 2013; 36:84-94.
PubMed
CrossRef
 
Albuquerque FN, Calvin AD, Sert Kuniyoshi FH, Konecny T, Lopez-Jimenez F, Pressman GS, et al. Sleep-disordered breathing and excessive daytime sleepiness in patients with atrial fibrillation. Chest. 2012; 141:967-73.
PubMed
CrossRef
 
Asha'ari ZA, Hasmoni MH, Ab Rahman J, Yusof RA, Ahmad RA. The association between sleep apnea and young adults with hypertension. Laryngoscope. 2012; 122:2337-42.
PubMed
CrossRef
 
Feng J, He QY, Zhang XL, Chen BY, Sleep Breath Disorder Group, Society of Respiratory Medicine. Epworth Sleepiness Scale may be an indicator for blood pressure profile and prevalence of coronary artery disease and cerebrovascular disease in patients with obstructive sleep apnea. Sleep Breath. 2012; 16:31-40.
PubMed
CrossRef
 
Knutson KL, Zhao X, Mattingly M, Galli G, Cizza G. Predictors of sleep-disordered breathing in obese adults who are chronic short sleepers. Sleep Med. 2012; 13:484-9.
PubMed
CrossRef
 
Morrell MJ, Finn L, McMillan A, Peppard PE. The impact of ageing and sex on the association between sleepiness and sleep disordered breathing. Eur Respir J. 2012; 40:386-93.
PubMed
CrossRef
 
Nicholl DD, Ahmed SB, Loewen AH, Hemmelgarn BR, Sola DY, Beecroft JM, et al. Clinical presentation of obstructive sleep apnea in patients with chronic kidney disease. J Clin Sleep Med. 2012; 8:381-7.
PubMed
 
Ravesloot MJ, van Maanen JP, Hilgevoord AA, van Wagensveld BA, de Vries N. Obstructive sleep apnea is underrecognized and underdiagnosed in patients undergoing bariatric surgery. Eur Arch Otorhinolaryngol. 2012; 269:1865-71.
PubMed
CrossRef
 
Gasa M, Salord N, Fortuna AM, Mayos M, Vilarrasa N, Dorca J, et al. Obstructive sleep apnoea and metabolic impairment in severe obesity. Eur Respir J. 2011; 38:1089-97.
PubMed
CrossRef
 
Khoo SM, Poh HK, Chan YH, Ngerng WJ, Shi DX, Lim TK. Diagnostic characteristics of clinical prediction models for obstructive sleep apnea in different clinic populations. Sleep Breath. 2011; 15:431-7.
PubMed
CrossRef
 
Kopitovic I, Trajanovic N, Prodic S, Drvenica MJ, Ilic M, Kuruc V, et al. The Serbian version of the Epworth Sleepiness Scale. Sleep Breath. 2011; 15:775-80.
PubMed
CrossRef
 
Martinez D, Breitenbach TC, Lumertz MS, Alcântara DL, da Rocha NS, Cassol CM, et al. Repeating administration of Epworth Sleepiness Scale is clinically useful. Sleep Breath. 2011; 15:763-73.
PubMed
CrossRef
 
Sareli AE, Cantor CR, Williams NN, Korus G, Raper SE, Pien G, et al. Obstructive sleep apnea in patients undergoing bariatric surgery—a tertiary center experience. Obes Surg. 2011; 21:316-27.
PubMed
CrossRef
 
Silva GE, Vana KD, Goodwin JL, Sherrill DL, Quan SF. Identification of patients with sleep disordered breathing: comparing the four-variable screening tool, STOP, STOP-Bang, and Epworth Sleepiness Scales. J Clin Sleep Med. 2011; 7:467-72.
PubMed
 
Tanaka S, Shima M. Assessment of screening tests for sleep apnea syndrome in the workplace. J Occup Health. 2010; 52:99-105.
PubMed
CrossRef
 
Sharwood LN, Elkington J, Stevenson M, Grunstein RR, Meuleners L, Ivers RQ, et al. Assessing sleepiness and sleep disorders in Australian long-distance commercial vehicle drivers: self-report versus an “at home” monitoring device. Sleep. 2012; 35:469-75.
PubMed
 
Bertolazi AN, Fagondes SC, Hoff LS, Dartora EG, Miozzo IC, de Barba ME, et al. Validation of the Brazilian Portuguese version of the Pittsburgh Sleep Quality Index. Sleep Med. 2011; 12:70-5.
PubMed
CrossRef
 
Chung F, Subramanyam R, Liao P, Sasaki E, Shapiro C, Sun Y. High STOP-Bang score indicates a high probability of obstructive sleep apnoea. Br J Anaesth. 2012; 108:768-75.
PubMed
CrossRef
 
Farney RJ, Walker BS, Farney RM, Snow GL, Walker JM. The STOP-Bang equivalent model and prediction of severity of obstructive sleep apnea: relation to polysomnographic measurements of the apnea/hypopnea index. J Clin Sleep Med. 2011; 7:459-65B.
PubMed
 
Ong TH, Raudha S, Fook-Chong S, Lew N, Hsu AA. Simplifying STOP-BANG: use of a simple questionnaire to screen for OSA in an Asian population. Sleep Breath. 2010; 14:371-6.
PubMed
CrossRef
 
Senchak MA, Frey WC, O'Connor PD. Use of portable sleep monitors to diagnose sleep apnea during predeployment assessment. Mil Med. 2012; 177:1196-201.
PubMed
CrossRef
 
Rodrigues MM, Dibbern RS, Goulart CW, Palma RA. Correlation between the Friedman classification and the Apnea-Hypopnea Index in a population with OSAHS. Braz J Otorhinolaryngol. 2010; 76:557-60.
PubMed
CrossRef
 
Crocker BD, Olson LG, Saunders NA, Hensley MJ, McKeon JL, Allen KM, et al. Estimation of the probability of disturbed breathing during sleep before a sleep study. Am Rev Respir Dis. 1990; 142:14-8.
PubMed
CrossRef
 
Gurubhagavatula I, Maislin G, Pack AI. An algorithm to stratify sleep apnea risk in a sleep disorders clinic population. Am J Respir Crit Care Med. 2001; 164:1904-9.
PubMed
CrossRef
 
Kushida CA, Efron B, Guilleminault C. A predictive morphometric model for the obstructive sleep apnea syndrome. Ann Intern Med. 1997; 127:581-7.
CrossRef
 
Onen SH, Dubray C, Decullier E, Moreau T, Chapuis F, Onen F. Observation-based nocturnal sleep inventory: screening tool for sleep apnea in elderly people. J Am Geriatr Soc. 2008; 56:1920-5.
PubMed
CrossRef
 
Rodsutti J, Hensley M, Thakkinstian A, D'Este C, Attia J. A clinical decision rule to prioritize polysomnography in patients with suspected sleep apnea. Sleep. 2004; 27:694-9.
PubMed
 
Rowley JA, Aboussouan LS, Badr MS. The use of clinical prediction formulas in the evaluation of obstructive sleep apnea. Sleep. 2000; 23:929-38.
PubMed
 
Zerah-Lancner F, Lofaso F, d'Ortho MP, Delclaux C, Goldenberg F, Coste A, et al. Predictive value of pulmonary function parameters for sleep apnea syndrome. Am J Respir Crit Care Med. 2000; 162:2208-12.
PubMed
CrossRef
 
Jauhar S, Orchardson R, Banham SW, Livingston E, Sherriff A, Lyons MF. The Kushida Index as a screening tool for obstructive sleep apnoea-hypopnoea syndrome. Br Dent J. 2012; 212:E2.
PubMed
CrossRef
 
Su CT, Chen KH, Chen LF, Wang PC, Hsiao YH. Prediagnosis of obstructive sleep apnea via multiclass MTS. Comput Math Methods Med. 2012; 2012:212498.
PubMed
CrossRef
 
Kolotkin RL, LaMonte MJ, Walker JM, Cloward TV, Davidson LE, Crosby RD. Predicting sleep apnea in bariatric surgery patients. Surg Obes Relat Dis. 2011; 7:605-10.
PubMed
CrossRef
 
Sun LM, Chiu HW, Chuang CY, Liu L. A prediction model based on an artificial intelligence system for moderate to severe obstructive sleep apnea. Sleep Breath. 2011; 15:317-23.
PubMed
CrossRef
 
Gurubhagavatula I, Maislin G, Nkwuo JE, Pack AI. Occupational screening for obstructive sleep apnea in commercial drivers. Am J Respir Crit Care Med. 2004; 170:371-6.
PubMed
CrossRef
 
Arzt M, Young T, Finn L, Skatrud JB, Bradley TD. Association of sleep-disordered breathing and the occurrence of stroke. Am J Respir Crit Care Med. 2005; 172:1447-51.
PubMed
CrossRef
 
Botros N, Concato J, Mohsenin V, Selim B, Doctor K, Yaggi HK. Obstructive sleep apnea as a risk factor for type 2 diabetes. Am J Med. 2009; 122:1122-7.
PubMed
CrossRef
 
Lavie P, Herer P, Peled R, Berger I, Yoffe N, Zomer J, et al. Mortality in sleep apnea patients: a multivariate analysis of risk factors. Sleep. 1995; 18:149-57.
PubMed
 
Lavie P, Lavie L, Herer P. All-cause mortality in males with sleep apnoea syndrome: declining mortality rates with age. Eur Respir J. 2005; 25:514-20.
PubMed
CrossRef
 
O'Connor GT, Caffo B, Newman AB, Quan SF, Rapoport DM, Redline S, et al. Prospective study of sleep-disordered breathing and hypertension: the Sleep Heart Health Study. Am J Respir Crit Care Med. 2009; 179:1159-64.
PubMed
CrossRef
 
Reichmuth KJ, Austin D, Skatrud JB, Young T. Association of sleep apnea and type II diabetes: a population-based study. Am J Respir Crit Care Med. 2005; 172:1590-5.
PubMed
CrossRef
 
Silva GE, An MW, Goodwin JL, Shahar E, Redline S, Resnick H, et al. Longitudinal evaluation of sleep-disordered breathing and sleep symptoms with change in quality of life: the Sleep Heart Health Study (SHHS). Sleep. 2009; 32:1049-57.
PubMed
 
Ensrud KE, Blackwell TL, Ancoli-Israel S, Redline S, Cawthon PM, Paudel ML, et al. Sleep disturbances and risk of frailty and mortality in older men. Sleep Med. 2012; 13:1217-25.
PubMed
CrossRef
 
Chami HA, Resnick HE, Quan SF, Gottlieb DJ. Association of incident cardiovascular disease with progression of sleep-disordered breathing. Circulation. 2011; 123:1280-6.
PubMed
CrossRef
 
Fung MM, Peters K, Redline S, Ziegler MG, Ancoli-Israel S, Barrett-Connor E, et al, Osteoporotic Fractures in Men Research Group. Decreased slow wave sleep increases risk of developing hypertension in elderly men. Hypertension. 2011; 58:596-603.
PubMed
CrossRef
 
Collop NA, Anderson WM, Boehlecke B, Claman D, Goldberg R, Gottlieb DJ, et al, Portable Monitoring Task Force of the American Academy of Sleep Medicine. Clinical guidelines for the use of unattended portable monitors in the diagnosis of obstructive sleep apnea in adult patients. Portable Monitoring Task Force of the American Academy of Sleep Medicine. J Clin Sleep Med. 2007; 3:737-47.
PubMed
 
Robinson GV, Smith DM, Langford BA, Davies RJ, Stradling JR. Continuous positive airway pressure does not reduce blood pressure in nonsleepy hypertensive OSA patients. Eur Respir J. 2006; 27:1229-35.
PubMed
CrossRef
 
Mitler MM, Gujavarty KS, Browman CP. Maintenance of wakefulness test: a polysomnographic technique for evaluation treatment efficacy in patients with excessive somnolence. Electroencephalogr Clin Neurophysiol. 1982; 53:658-61.
PubMed
CrossRef
 
RTI International.  Effectiveness of portable monitoring devices for diagnosing obstructive sleep apnea: update of a systematic review. Rockville, MD: Agency for Healthcare Research and Quality; 2004. Accessed at www.cms.gov/Medicare/Coverage/DeterminationProcess/downloads/id24TA.pdf on 1 June 2012.
 
Hallowell PT, Stellato TA, Petrozzi MC, Schuster M, Graf K, Robinson A, et al. Eliminating respiratory intensive care unit stay after gastric bypass surgery. Surgery. 2007; 142:608-12.
PubMed
CrossRef
 
Singh M, Liao P, Kobah S, Wijeysundera DN, Shapiro C, Chung F. Proportion of surgical patients with undiagnosed obstructive sleep apnoea. Br J Anaesth. 2013; 110:629-36.
PubMed
CrossRef
 
Kim GH, Lee JJ, Choi SJ, Shin BS, Lee AR, Lee SH, et al. Clinical predictors of apnoea-hypopnoea during propofol sedation in patients undergoing spinal anaesthesia. Anaesthesia. 2012; 67:755-9.
PubMed
CrossRef
 
Practice parameters for the indications for polysomnography and related procedures. Polysomnography Task Force, American Sleep Disorders Association Standards of Practice Committee. Sleep. 1997; 20:406-22.
PubMed
 

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Diagnostic Testing for Obstructive Sleep Apnea; Almost Right
Posted on September 4, 2014
Timothy I. Morgenthaler
Mayo Clinic Center for Sleep Medicine, Mayo Clinic, Rochester, MN
Conflict of Interest: I serve as President of the American Academy of Sleep Medicine (AASM). The opinion expressed here reflects the positions and policies of the AASM as well as my own.
The American College of Physicians' (ACP) clinical practice guideline regarding the diagnosis of obstructive sleep apnea (OSA) in adults addresses a prevalent and serious medical illness that deserves the attention of internists.(1) Although there is some similarity between the clinical guidelines published by the ACP and the American Academy of Sleep Medicine (AASM), significant differences are of concern to the AASM.

The ACP’s recommendation to limit home sleep apnea testing to situations “when polysomnography is not available for diagnostic testing” is both overly restrictive and inconsistent with the AASM clinical guideline. Home sleep apnea testing interpreted by a sleep specialist, in conjunction with a comprehensive sleep evaluation, may be an equally viable diagnostic option in patients with a high pre-test probability for at least moderate to severe OSA who do not have comorbid cardiopulmonary or neuromuscular disorders, or in whom other sleep disorders are not a consideration.(2) Under these conditions a home sleep apnea test may be the most reasonable choice even when polysomnography is available. When these conditions are not met, yet sleep disordered breathing is a consideration, we agree that PSG is the test of choice at this time.

Furthermore, the ACP guideline places an inordinate emphasis on sleepiness as the main reason for evaluation with sleep testing. In the Wisconsin Sleep Cohort Study, only 37% of patients with severe OSA (AHI>=30) reported daytime sleepiness, which is one among many symptoms that might suggest that OSA be included in the differential diagnosis.(3) Other symptoms include witnessed apneas, snoring, nocturnal gasping or choking, nonrefreshing sleep, disturbed sleep, nocturia, morning headaches, impaired concentration, memory loss, and decreased libido.(4) Concurrent risk factors, such as obesity, retrognathia on exam, hypertension, or type 2 diabetes, should prompt consideration for sleep apnea testing; however, some of the other causes of sleepiness do not require sleep apnea testing and respond to specific interventions. A complaint of excessive sleepiness should prompt a comprehensive review of the patients sleep schedule, questioning for auxiliary symptoms of narcolepsy, and consideration for sleep specialist referral if the cause is not apparent.(5)

It is critical to advance high-value care of patients with a sleep illness such as OSA. Physicians should inquire for symptoms of sleep disturbances and specifically look for sleep apnea in patients belonging to high-risk populations, including those who do not complain of sleepiness. The AASM recognizes that internists have an important role to play in the management of patients with OSA, and we believe that collaborative relationships between sleep specialists and internists will undergird our efforts to improve public health by promoting healthy sleep.

1. Qaseem A, Dallas P, Owens DK, et al. Diagnosis of obstructive sleep apnea in adults: a clinical practice guideline from the american college of physicians. Ann Intern Med 2014;161:210-20.

2. Epstein LJ, Kristo D, Strollo Jr PJ, et al. Clinical guideline for the evaluation, management and long-term care of obstructive sleep apnea in adults. Journal of Clinical Sleep Medicine 2009;5:263-76.

3. Young T, Finn L, Peppard PE, et al. Sleep disordered breathing and mortality: eighteen-year follow-up of the Wisconsin sleep cohort. Sleep 2008;31:1071-8.

4. American Academy of Sleep Medicine. International Classification of Sleep Disorders. Diagnostic and Coding Manual. 3rd ed: American Academy of Sleep Medicine, 2014.

5. Kushida CA, Littner MR, Morgenthaler T, et al. Practice parameters for the indications for polysomnography and related procedures: an update for 2005. Sleep 2005;28:499-521.
“Weak recommendation, low-quality evidence: dangerous guideline”
Posted on September 8, 2014
Jordanna Hostler MD, David Hostler MD/MPH, Aaron Holley MD/FACP/FCCP/AASM Diplomate
Walter Reed NAtional Military Medical Center
Conflict of Interest: The views represented in this letter are those of the authors and not reflective of the policies of the DoD or the US Army.

There are no other conflicts of interest.
”My candle burns at both ends, it will not last the night.
But oh my friends and oh my foes it gives a lovely light.”
– Edna St. Vincent Millay

We read with concern the recent ACP clinical guideline regarding the diagnosis of obstructive sleep apnea (OSA).(1) This guideline offers polysomnography (PSG) as a solitary tool for sleep-related symptoms; the guideline’s broad application could result in unnecessary testing and treatment.
A PSG performed with current technologies and scored with current criteria will yield an AHI almost 3-fold higher than a study in an identical patient using the technologies and scoring criteria available at the time of the majority of the works cited by this guideline. Flow changes are currently graded using a pressure-transduced air flow monitor, which is far more sensitive than the thermistor utilized in prior studies.(2) In fact, a recent trial showed the prevalence of an AHI ≥5 utilizing the current criteria was 94.6% in a population with a “mild-moderate” pre-test probability of disease.(3) OSA exists on a spectrum and AHI cutoffs are largely arbitrary. Given the changes in diagnosis, are we measuring clinically meaningful disease? What are the costs of overdiagnosis?
Furthermore, the term “unexplained sleepiness” (which is pivotal in the guideline’s first recommendation) is only meaningful when clinicians have a thorough understanding of the causes of sleepiness. The average physician receives approximately 2 hours of formal medical education on the evaluation of sleep disorders.(4) This guideline fails to acknowledge that behaviorally-induced insufficient sleep, insomnia, mood disorders, restless legs syndrome and many other problems cannot be measured by PSG or treated with CPAP.
We know from survey data that the average American effectively “burns the candle at both ends”, obtaining 6 hours and 40 minutes of sleep on the average workday.(5)
Recommending PSG for every patient whose sleepiness is “unexplained” – without also recommending qualitative and quantitative assessment of sleep duration – is ill-advised. We suggest ACP develop a comprehensive sleep-symptom guideline encouraging a more holistic evaluation of the patient presenting with sleepiness and focusing more attention on the limitations of PSG.

References

1. Diagnosis of Obstructive Sleep Apnea in Adults: A Clinical Practice Guideline from the American College of Physicians. Ann Intern Med. 2014;161:210-220.
2. Ruehland W, Rochford R, O’Donoghue F, et al. The New AASM Criteria for Scoring Hypopneas: Impact on the Apena Hypopnea Index. Sleep Vol. 32, No. 2, 2009
3. Guerrero A, Embid C, Isetta V et al. Management of Sleep Apnea without High Pretest Probability or without Comorbidities by Three Nights of Portable Sleep Monitoring. Sleep. 2014;37(8):1363-73.
4. Rosen R, Mahowald M, Chesson A, et al. The Taskforce 2000 survey on medical education in sleep and sleep disorders. Sleep. 1998;21(3):235-254.
5. National Sleep Foundation. Sleep in America Poll 2008. http://sleepfoundation.org/sites/default/files/2008%20POLL%20SOF.PDF accessed 8 September 2014.
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Diagnosis of Obstructive Sleep Apnea in Adults: A Clinical Practice Guideline From the American College of Physicians

The full report is titled “Diagnosis of Obstructive Sleep Apnea in Adults: A Clinical Practice Guideline From the American College of Physicians.” It is in the 5 August 2014 issue of Annals of Internal Medicine (volume 161, pages 210-220). The authors are A. Qaseem, P. Dallas, D.K. Owens, M. Starkey, J.E.C. Holty, and P. Shekelle, for the Clinical Guidelines Committee of the American College of Physicians.

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