HSAT: home sleep apnea testing; PSG: polysomnography; GOLD: global initiative for obstructive lung disease; COPD: chronic obstructive pulmonary disease; NYHA: New York Heart Association; CSA: central sleep apnea; OSA: obstructive sleep apnea; AASM: American Academy of Sleep Medicine; CPAP: continuous positive airway pressure; CMS: Centers for Medicare and Medicaid Services; AHI: apnea hypopnea index; RDI: respiratory disturbance index; PAT: peripheral arterial tonometry.
* While PSG is ideal, many insurers require a negative HSAT before proceeding with PSG.
¶ We agree with the AASM that a split-night rather than full-night in-laboratory PSG may be appropriate in most patients in whom moderate to severe OSA is observed during a minimum of two hours during PSG testing AND in whom at least three hours are available for CPAP titration. However, the CMS will accept an AHI or RDI that is calculated based upon less than two hours of recorded sleep, if the total number of recorded events to calculate the AHI or RDI during sleep testing is at least the number of events that would have been required in a two hour period.
Δ In-laboratory PSG remains the gold standard for diagnostic testing for OSA; HSAT is an alternative in a select group of patients. For most patients with suspected mild OSA, in-laboratory PSG is preferred since HSAT may lead to the underdetection of sleep-related events in this population. In patients with suspected moderate to severe OSA, HSAT is adequate only in a select group of patients. ◊ We favor the AASM definition when clinically assessing patient risk for OSA. The AASM states that patients at high risk of moderate to severe OSA include those with daytime hypersomnolence and at least two of the following three criteria: habitual loud snoring, witnessed apnea or gasping/choking, or diagnosed hypertension. However, for those in whom reliable assessment for the risk of OSA cannot be made, such as those who do not have hypersomnolence, in-laboratory polysomnography is preferred. Refer to UpToDate text on clinical presentation and diagnosis of obstructive sleep apnea in adults.
§ Patients may have reasons that prohibit home or laboratory sleep testing such as inability to get to a laboratory, cost, homelessness, space constraints.
¥ In the rare circumstance that a patient has reasons that prohibit both HSAT and in-laboratory PSG, additional testing (eg, overnight oximetry, clinical tools, questionnaires, predictive algorithms) is insensitive. Recurrent attempts should be taken to resolve the issues and get some form of sleep testing or to empirically treat those who are assessed as having OSA.
‡ HSAT should be performed with a technically adequate device that incorporates a minimum of nasal pressure, chest and abdominal inductance plethysmography, and oximetry, OR PAT with oximetry and actigraphy. In addition, it should only be administered by an accredited sleep center under the supervision of a board-certified sleep physician. If one HSAT is negative, inconclusive, or technically inadequate AND the suspicion for OSA remains, in-laboratory PSG should be performed, if feasible. In patients with conditions that increase the risk of non-obstructive breathing, HSAT is considered less accurate and may underdiagnose OSA and/or not detect other sleep-related events.
