Use Of Portable Monitoring Research Articles

Sleep Problems in Parkinson's Disease.

In his famous monograph “An Essay in Shaking Palsy,” James Parkinson provided astute descriptions of impaired sleep in his case series of patients with Parkinson's disease (PD) two centuries ago. It is only three decades ago that sleep dysfunction started to attract attention of medical and scientific communities involved in the clinical care and research of PD. Tremendous advancements in our understanding of impaired sleep and alertness associated with PD have developed since then. Sleep problems are one of the major, challenging issues in patients with PD, affecting a significant number of patients. The etiology of sleep problems is multifactorial, including disease-related nocturnal symptoms, medication adverse effects, and primary sleep disorders including restless legs syndrome, rapid eye movement sleep behavior disorder, and sleep apnea syndrome. These causes of impaired sleep-wake cycles in the PD population often coexist or even overlap, rendering the management of sleep problems in PD patients difficult. Also, excessive daytime sleepiness is observed in a significant number of patients. In PD patients, therefore, appropriate assessment of disease-related nocturnal disturbances and primary sleep disorders is imperative. This special issue addresses unmet need for understanding PD-related sleep problems. PD sleep scale 2 (PDSS-2) is a recently developed tool for screening and managing sleep disturbance in PD patients, consisting of 15 items which are clinically relevant to nocturnal problems including nonmotor and motor problems in PD [1]. The original PDSS-2 (German and English) has been translated into several languages, including Japanese [2] and Italian [3]. The PDSS-2 has been used to observe treatment response. In a double-blind, placebo-controlled trial, including 287 PD patients, mean PDSS-2 total score decreased by −5.9 points with rotigotine and by −1.9 points with placebo [4]. In this special issue, K. Horvath et al. estimated the threshold representing minimal clinically important difference of the PDSS-2 total score: the study results showed −3.44 points for detecting improvement or the threshold of 2.07 points for observing worsening. This finding is important when planning studies using the PDSS-2 as outcome measures. Full-night polysomnography (PSG) is a gold standard for diagnosing sleep apnea syndrome; however, applying PSG is often difficult in patients with PD, who have severe parkinsonism or psychiatric comorbidity. P. Gros et al. evaluated the usefulness of unattended portable monitoring (PM) for diagnosis of obstructive sleep apnea (OSA) in patients with PD. Although discrepancy between portable monitoring and PSG was greater in PD patients with more motor dysfunction, the authors confirmed the usefulness of portable monitoring in diagnosing moderate to severe OSA in PD patients. These results provide the rationale for the use of portable sleep monitoring in PD and are very relevant for circumstances where a complete PSG in a sleep laboratory is not available and/or feasible. M. Kaminska et al. performed a review on the relationship between OSA and PD. Although the clinical significance of OSA in PD has been controversial [5, 6], the authors suggest the possibility that treatment of OSA could delay cognitive decline or motor dysfunction in patients with PD. This area of research is of high significance as it is important to assess the prevalence of OSA and the impact of its treatment in the PD population. D. Martinez-Ramirez et al. correlated PSG findings and sleep disorders with clinical characteristics in PD patients and found that sleep disorders and sleep architecture were poorly predictable by clinical characteristic of PD patients. This comprehensive study demonstrates the complexity of sleep dysfunction associated with PD and its complex associations with metrics of PD. In a fine and thoughtful study K. Suzuki et al. provided an interesting insight into the complex relationship between PD and restless legs syndrome (RLS) and leg motor restlessness (LMR). A significant relationship between RLS and PD is suggested by observing a favorable response to dopaminergic treatment in both disorders. However, RLS prevalence in PD patients varies according to different studies. Recently, LMR, characterized by an urge to move the legs that does not fulfill the diagnostic criteria for RLS, has been reported more frequently in patients untreated with PD than healthy controls. This review article may provide a new insight into the relationship between RLS, LMR, and PD. Finally, the complex and still only partially understood interaction of impulse control disorders in PD and sleep is discussed in a review from the clinic of one of the guest editors. In summary, sleep problems are common but underreported by PD patients and underdiagnosed by health professionals. Further understanding of mechanisms that underlie impaired sleep and alertness in PD will allow for development of much needed treatment approaches for this nonmotor manifestation of PD. Koichi Hirata Birgit Hogl Eng King Tan Aleksandar Videnovic

Diagnostic accuracy of home-based monitoring system in morbidly obese patients with high risk for sleep apnea.

No previous studies have validated the use of portable monitoring (PM) for the diagnosis of obstructive sleep apnea (OSA) in morbidly obese individuals. Our aim was to investigate the accuracy of PM for detecting respiratory events in morbidly obese patients that will be undergoing bariatric surgery. This was a prospective study involving patients with body mass index (BMI) ≥35 kg/m(2) who were recruited from the Sleep Clinic of Universidade Federal de São Paulo. Sleep-disordered breathing (SDB) was evaluated during full-night polysomnography (PSG). PM use was randomized and used on two consecutive nights: (1) at home (STDHome) and (2) at the sleep laboratory with PSG (PSG_STDLab). Although 58 participants initially underwent the recordings, 26 (45%) were excluded because of technical problems. The patients' mean age was 42.9 ± 10.9 (SD) years, and 56% were female. The mean BMI was 40.8 ± 5.2 kg/m(2). All patients had high risk for OSA, as defined by the Stop-Bang questionnaire, and the mean apnea-hypopnea index (AHI) was 46.9 ± 30.4/h. The intraclass coefficient of the correlation between AHI_PSG and AHI_STDLab was r = 0.92 (p = 0.0001); the intraclass coefficient for AHI_PSG and AHI_STDHome was r = 0.84 (p = 0.0001). The Kappa index was 0.87 (p > 0.0001) for severe cases. The sensitivity and the positive predictive value increased with the disease severity. A Bland-Altman analysis showed good agreement between the investigated methods. PM is an efficacious method for diagnosing OSA in obese patients who have a high clinical probability of the disease. The method displays good sensitivity and specificity in severe cases; nevertheless, the high rate of data loss must be taken into account.

Portable Monitoring for Diagnosis of Sleep Apnea

Economic and access issues are driving the use of portable monitoring for primary diagnosis of obstructive sleep apnea (OSA) in selected adults. Its applicability has been demonstrated for adults at high risk of sleep apnea, but many caveats and research questions remain. For technical reasons, most limited-channel diagnostic devices tend to underestimate the severity of the disease. In addition, portable monitoring is of little value for sleep disorders other than OSA and has not been advocated for children or the elderly. Similarly, auto-continuous positive airway pressure (APAP) is an alternative to in-laboratory continuous PAP titration. The cost-effectiveness of portable diagnostic testing and APAP titration in actual practice is yet to be determined, but will be a critical question in the years ahead. Future research should examine their use for extended populations, and the economic effect of these modalities, to determine the best use of these techniques as alternatives to traditional in-laboratory testing.

Diagnostik schlafbezogener Atmungsstörungen mittels portabler Verfahren

Portable monitoring of sleep disordered breathing is the first diagnostic method not only in Germany but today in other countries as well. The conditions under which portable monitoring can be done with reliable results are now well defined. The limitations for the use of portable monitoring are specified as well. The devices used for portable monitoring are classified in four categories according to the number and the kind of signals recorded. New technical developments in the field of portable monitoring (polygraphy) use an indirect assessment of sleep disordered breathing based on signals not directly recording respiration. The recording of ECG and deriving respiration, the analysis of the plethysmographically recorded pulse wave, the recording of jaw movements using magnets, and advanced analysis of respiratory sounds are recent approaches. These new methods are presented with few studies until now. More and larger clinical studies are needed in order to show which of these systems is useful in the diagnosis of sleep disordered breathing and which are the specific strengths and weaknesses.

Evaluation of a Portable Monitor (Watch-PAT100) and Implications for Clinical Guidelines for the Use of Portable Monitors in Diagnosing OSAS

Objective: To evaluate, industry independently, the accuracy of the Watch-PAT100 system (WP100) (Itamar Medical; Caesarea, Israel), a portable home sleep test, compared to polysomnography, the gold standard for diagnosing obstructive sleep apnea syndrome. Methods: Prospective clinical trial. 27 patients (24 male, 3 female) were evaluated at our institution's sleep laboratory. The apnea hypopnea index and oxygen desaturation index were used to compare the 2 testing modalities. Results: Non-parametrical testing showed a Kendall's tau = 0.685 for apnea hypopnea index and 0.748 for oxygen desaturation index. We found that the WP100 system overestimated the severity of obstructive sleep apnea syndrome in 33% when compared to polysomnography. The test-agreement was in particular poor when the WP100 indicated moderate to severe obstructive sleep apnea syndrome. Conclusion: The WP100 seems accurate for classification of obstructive sleep apnea syndrome severity up to a WP100- measured apnea hypopnea index of 15. In patients with an apnea hypopnea index of more than 15 as measured with the WP100, additional polysomnography should be performed.

Healthcare “Practice”–Is it Misguided?

Healthcare “Practice”–Is it Misguided?

Initial use of portable monitoring versus polysomnography to confirm obstructive sleep apnea in symptomatic patients: An economic decision model

Background When using portable (level III and level IV) studies to “rule in” obstructive sleep apnea (OSA) in symptomatic patients, the pre-test probability ( P) needs to be sufficiently high to minimize patients with negative tests who require full polysomnography. Methods We used a theoretical decision analysis model to assess the pre-test probability above which it would be appropriate to use portable studies to rule in disease in symptomatic patients with suspected OSA. For the base case, we considered a symptomatically sleepy patient referred with a probability of OSA of P. We determined the lower threshold of P appropriate for a clinical algorithm based upon an initial ambulatory study compared to initial diagnosis with PSG by comparing costs using the PSG algorithm with a diagnostic algorithm involving initial assessment with a portable study. Results In our base case, the pre-test probability above which portable testing would be less costly than initial diagnostic PSG would be 0.47. When an initial split night study was compared to portable testing, the pre-test probability above which portable testing was more economically attractive was greater (0.68). Values of P, however, varied considerably depending on values of many variables, including costs of diagnostic testing and CPAP compliance. Conclusions Using a decision model, we have developed a theoretical framework to ascertain the pre-test disease probability above which portable studies would be economically attractive as an initial test in the assessment of patients with suspected OSA.

Canadian Sleep Society/Canadian Thoracic Society position paper on the use of portable monitoring for the diagnosis of obstructive sleep apnea/hypopnea in adults

The present position paper on the use of portable monitoring (PM) as a diagnostic tool for obstructive sleep apnea⁄hypopnea (OSAH) in adults was based on consensus and expert opinion regarding best practice standards from stakeholders across Canada. These recommendations were prepared to guide appropriate clinical use of this new technology and to ensure that quality assurance standards are adhered to. Clinical guidelines for the use of PM for the diagnosis and management of OSAH as an alternative to in-laboratory polysomnography published by the American Academy of Sleep Medicine Portable Monitoring Task Force were used to tailor our recommendations to address the following: indications; methodology including physician involvement, physician and technical staff qualifications, and follow-up requirements; technical considerations; quality assurance; and conflict of interest guidelines. When used appropriately under the supervision of a physician with training in sleep medicine, and in conjunction with a comprehensive sleep evaluation, PM may expedite treatment when there is a high clinical suspicion of OSAH.

Clinical Guidelines for the Use of Unattended Portable Monitors in the Diagnosis of Obstructive Sleep Apnea in Adult Patients

Clinical Guidelines for the Use of Unattended Portable Monitors in the Diagnosis of Obstructive Sleep Apnea in Adult Patients