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

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

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

4. Portable Sleep Apnea Monitoring

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

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

7. Institute of Medicine Report 2006 What is needed?  Expand awareness among health care professionals through education and training.  Develop and validate new and existing diagnostic and therapeutic technologies.

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

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

10. Type 2 Monitors: Mini-PSG  Advantage Multiple channels Flexibility of signal type Comprehensive Use standard software of a base system Portability Extensive track-record in research applications  Disadvantage Tech hook up Expensive Probably no reimbursement for home PSG Loss of signal – no way to easily correct problem

11. Type 3 Monitors: Cardio-pulmonary Studies  Advantage Easy to set up: easily done by most patients; technician not required Inexpensive (<$10K) Very portable Reduced number of signals  Disadvantage Reduced number of signals No reimbursement Signal loss at home; not way to correct Requires scoring or at least overview of scoring by tech; takes longer than you think

12. Type 4 Monitors: Oximetry +  Advantage Most portable Inexpensive Easy to set up Core signals: oxygenation and airflow Now may include PAT signal  Disadvantage No reimbursement Minimal number of signals – may not capture important aspects of some OSA Signal loss

13. Current Uncertainties: Type 3 & 4 Devices  How many signals are needed?  Which signals add the most value?  Are there clinical populations that this does not work in?  How can technology be combined with clinical decision making to optimize OSA diagnosis outside the sleep lab?

14. More uncertainties…  New technologies – how do they fit in to the existing PSAT device classification? WatchPAT-100 PTT ARES New systems on the horizon will have capabilities to be a level 2-4 by adding or taking away modules

15. Stardust  Made by Respironics, Inc  Level 3 device  Measures: airflow, resp. effort, oximetry, heart rate, body position  Well validated  Moderately expensive, ~$7000 but subsequent units are cheaper  Moderate tech time for scoring

16. Embletta  Somnologica/Medcare  Level 3  Measures: Airflow, respiratory effort, oximetry, body position  Well-validated, widely used  Moderately expensive, similar to Stardust  Moderate tech time for scoring

17. Type 3 monitor

19. Stardust Report

20. Apnea link  Resmed, Inc.  Level 4  Measures: airflow +/- oximetry  Some validation; generally shows that it’s accurate in detecting more severe OSA  Relatively inexpensive; consumables less than $15 for earlier models  Limited tech time

21. Example of moderate sleep apnea on Apnea Link

22. WatchPAT  Works on principle of changes in peripheral arterial tonometry  Indirect measure of ANS activity  PAT is a surrogate marker for apnea, hypoxia  Moderately expensive to purchase; individual probes are recurring cost  Minimal to no tech time for scoring

23. WatchPAT Example

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

25. Night Cap  Developed by Dr. Allan Hobson  Head cap that can measure NREM vs. REM sleep  Limited validation studies  Not used much anymore as best as I can tell  ?Commercial availability

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

27. Scenario 1  Your objective is to measure psychological “well-being” in a cohort of Iraq war veterans over a 3 year span beginning with the end of military service  You are concerned that sleep disorders will be a mediator of psychological health  Your are also concerned that sleep disorders will confound the sleep measure

28. Scenario 1, continued  Your budget is very limited  How can you assess for sleep apnea in a cost efficient way?  How can other sleep disorders be assessed?  What tools would you use and why?

29. Scenario 2  Your objective is to screen a population of factory workers for sleep apnea as part of a wellness program you are consulted about  You have 2500 middle-aged men and women to screen  Your budget total budget for sleep screening is $20 per person but you can get some equipment through a different grant

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

31. Scenario 3  Your objective is to measure sleep and rule out sleep apnea in a study of obese individuals contemplating bariatric surgery and stress  This is a pilot study and you have essentially no budget but you have friend who will help with the sleep part for free (within reason).

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

33. Further reading  http://www.cms.hhs.g ov/mcd/viewtechasse ss.asp?from2=viewte chassess.asp&where =index&tid=48& http://www.cms.hhs.g ov/mcd/viewtechasse ss.asp?from2=viewte chassess.asp&where =index&tid=48&  Or, go to www.ahrq.gov and search for completed technology assesments in 2007 www.ahrq.gov