home sleep testing in the diagnosis

Otolaryngol Clin N Am

40 (2007) 761–784

Home Sleep Testing in the Diagnosisand Treatment of Sleep Disordered

Breathing

Minal R. Patel, BAa, Terence M. Davidson, MDb,*aUniversity of California, San Diego, San Diego, CA, USA

bUCSD School of Medicine, VA San Diego Healthcare System, 9500 Gilman Drive,

Evergreen, La Jolla, CA 92093-0617, USA

A 29-year-old male patient presents because his wife complains his snor-ing is keeping her awake at night. As with many patients who snore, he hasbeen forced to leave the conjugal bed. In self-reporting his symptoms on thefollowing scale: 1 ¼ mild, 2 ¼ moderate, and 3 ¼ severe (Fig. 1), the patientrates snoring as a 2, his apneic episodes with a 1, and daytime sleepinesswith a 0. The patient denies other symptoms of sleep disordered breathing(SDB) and requests a surgical procedure to correct his snoring. The authors’evaluation is shown in Fig. 2. His body mass index (BMI) is 28, neck cir-cumference is 16 in, waist circumference is 38 in, Mallampati is II, tonsilgrade is 2, nose is 2/2, and uvula is 3. Fiberoptic endoscopy shows a tonguebase score of 2, a lingual tonsil of 3, and an epiglottis of 0. A multichannelhome sleep test was performed. The results are seen in Fig. 3.

The patient was diagnosed with mild SDB; however, absent other symp-toms and greater severity, the primary problem was snoring. The patientwas recommended for a continuous positive airway pressure (CPAP) trialat his own expense, but he declined. He was then offered two different sur-gical options. The first was palatal implants; the second was septoplasty,uvulectomy, palatal implants, and coblation of his lingual tonsils. Thepatient opted to proceed with palatal implants and would only considerthe more extensive surgery if this option failed. Surgery was performed inthe office. Six weeks later, the patient reported that his snoring wasdramatically reduced, and he had been invited back to his bed.

* Corresponding author.

E-mail address: [email protected] (T.M. Davidson).

0030-6665/07/$ - see front matter. Published by Elsevier Inc.

doi:10.1016/j.otc.2007.04.012 oto.theclinics.com

mailto:[email protected]

762 PATEL & DAVIDSON

SDB includes primary snoring, obstructive sleep apnea, and severalother diagnoses. A sleep test is an important tool in the evaluation ofany patient who has SDB, be it mild, moderate, or severe. Althoughsome believe they can separate snorers from sleep apneics, or mild from

Fig. 1. The history and physical examination are assessed using scaled, numeric scores.

763SLEEP DISORDERED BREATHING

severe SDB by history and physical examination, objective evaluationshave not supported this practice [1,2]. Regardless, insurance companies re-quire an objective measure of the severity of SDB before authorizingCPAP, surgery, or other treatments. Sleep testing originated with the elec-troencephalogram (EEG) and then added respiratory metrics, oximetry,leg movement sensors, chest and abdominal movement, and eye

Fig. 2. History and physical examination of a 29-year-old male self-referred for snoring.


Fig. 3. A multichannel home sleep test shows mild sleep apnea with an Apnea Hypopnea Index

of 5.6 and minimal oxygen desaturation. A comprehensive report also includes total sleep time

and positional information.


movement. Respiration has been the single most important measure and isthe only measure necessary to objectively document disease severity [3].Respiration is typically measured with a nasal cannula and/or an oralthermistor measuring mouth breathing. The nasal cannulae are most accu-rate; they measure pressure and calculate nasal flow. Adult criteria definean apneic event as a 90% or greater decrease in respiratory flow for 10 ormore seconds [4]. Hypopneas are variably defined; some define a hypopneaas a 50% decrease in airflow for 10 or more seconds, whereas others re-quire a 75% or greater decrease in airflow for 10 or more seconds [5].Some criteria even require an oxygen desaturation of 2%, 3%, or even4% before grading it as a hypopnea [6]. The apneas and hypopneas aretypically summed and reported as events per hour. Children have a fasterrespiratory rate; therefore, the duration of an apnea or hypopnea is typi-cally shortened and, depending on the age of the child, can be anywherefrom 6 to 8 seconds [7]. Time courses for adolescents have not been par-ticularly looked at or evaluated but are presumably somewhat intermedi-ate. For adults, an Apnea Hypopnea Index (AHI) of five or more eventsper hour is considered abnormal; however, most insurance companies donot cover treatment unless the AHI is 15 or more or if the AHI is 5 ormore with at least two comorbidities. The most common comorbiditiesare cardiovascular disease, obesity, daytime sleepiness, and hypertension[8–11]. Table 1 [12–25] lists common SDB comorbidities and their preva-lence. Premenopausal women may have significant SDB with much lowerseverity. Christian Guilleminualt from Stanford University’s Sleep Medi-cine Program describes a syndrome called the upper airway resistance syn-drome, in which there is an increased resistance to airflow in the throatwith a decrease in airflow measured at the nose, but not severe enough

Table 1

Medical conditions associated with sleep disordered breathing (SDB) and the prevalence of

their association with SDB

Category Condition References

Cardiac Hypertension 30% [12]

Drug-resistant hypertension 83% [13]

Congestive heart failure 76% [14]

Ischemic heart disease 38% [15]

Dysrhythmias 58% [16]

Atrial fibrillation 49% [17]

Respiratory Pulmonary hypertension 77% [18]

Asthma 18% [19]

Neurologic Stroke 90% [20]

Metabolic Type II Diabetes 15% [21]

Metabolic syndrome 50% [22]

Morbid Obesity (Male) 90% [23]

Morbid Obesity (Female) 50% [24]

Gastrointestinal Gastroesophageal reflux disease 60% [25]

Genitourinary Nocturia 48% [26]


to be measured as a hypopnea [26]. These can result in cortical arousal,disrupt sleep, and cause many or all symptoms of SDB. Women aremore prone to upper airway resistance syndrome and significant, symp-tomatic SDB with lower AHIs.

Oximeters are typically used for most home sleep tests. They are not thehighly sensitive oximeters physicians use in the operating room and inten-sive care units. Nonetheless, the data derived are viewed as sacrosanct.An individual who desaturates throughout their sleep study is viewed ashaving more significant SDB. Some report the lowest oxygen saturation,commonly referred to as the lowest oxygen saturation. The authors arenot convinced this is a useful tool. If the oximeter slips on the finger, the ox-ygen saturation can fall, and the lowest oxygen saturation can inaccuratelybe reported as low as 60% or 70%. Regardless, looking at the oxygen trac-ing is useful in assessing SDB. Hypoxemia, a drop in oxygen levels below90%, is also associated with daytime sleepiness and cerebral dysfunction[27,28].

Chest and abdominal belts are often used to measure obstructive versuscentral events. The authors do not find this useful for the typical patientconsulting a head and neck surgeon. Virtually everyone who snores, whichis the premier symptom of SDB, has obstructive sleep apnea. The only peo-ple who have significant central SDB are those who have advanced heartfailure or a history of stroke.

Often, central sleep apnea is described in individuals who have more com-mon SDB. For some individuals, this may be an artifact. Upon sensing theobstructive event, the respiratory effort is stopped. Abdominal and thoraciceffort stops. This would then be recorded as a central event when it actuallywas an obstructive event. Regardless, for an initial sleep test, the obstructiveand central events are summed, and whether or not they are viewed asobstructive or central is irrelevant.

Home sleep tests are easy to administer. Patients typically come to thephysician’s office; a trained technician reviews any questions the patienthas about the nature of the test and why they are taking it. The patient isthen shown how to apply the various recording devices to their body andhow these are connected to the sleep machine. They are then shown howthe recording is initiated when going to bed, how it is managed shouldone arise during the night, and how the recording is stopped upon arisingin the morning. The machine is then returned to the physician’s office wherethe information is downloaded into a computer and the data are analyzed.For most machines, autoscore capability is available, and where autoscorematches the patient’s history and physical examination, it is sufficient.Where the autoscore is borderline and the patient’s history or examinationare questionable, manual score capability is important and easily learned.Figs. 4 and 5 demonstrate the steps of administering, downloading, andevaluating a typical patient suspect for SDB. To better describe this process,several cases are presented.


Case one

An 8-year-old boy is referred for surgical evaluation for snoring. Physicalexamination shows the child has normal height, weight, and BMI; tonsilgrade is 3 plus. He is without allergic rhinitis and breathes through hisnose at night. The child’s mother had previously sought surgical consulta-tion for him. The physician had recommended that tonsillectomy be per-formed, but the parents, afraid of the risks and complications, had electednot to proceed. The patient now presents for a second opinion. Before

Fig. 4. The Embletta PDS is a six channel home sleep test that measures nasal respiration,

snoring, mouth breathing, respiratory effort, and oxygen saturation.

Fig. 5. In an office setting, a trained technician can show a patient how to put on a multichannel

home sleep test.


rendering an opinion on history and examination alone, a multichannelhome sleep test was administered. The child wearing the sleep unit is seenin Fig. 6. While an ongoing study looking at the neuropsychologic conse-quences of sleep apnea in children was underway, the child enrolled intothe research study whereby a neuropsychologic battery was also adminis-tered. Given the abnormalities seen in the neuropsychologic evaluationand an abnormal sleep test, namely an AHI of 4.2 events per hour, a recom-mendation for tonsillectomy was made, and the parents agreed. The proce-dure was uneventful, and the child made a normal recovery. Three monthslater, the sleep test and neuropsychologic evaluation were repeated. The re-sults of the home sleep test and the neuropsychologic data before and aftersurgery are shown in Figs. 7 and 8 and Table 2. In children, an abnormalAHI has not yet been determined. However, current opinion for prepubes-cent children is that an AHI of 1 or more is in fact abnormal. The authors’

Fig. 6. The Embletta PDS can be worn comfortably by pediatric patients above the age of

4 years.


Fig. 7. Sleep test of an 8-year-old child referred for snoring. The test shows an Apnea

Hypopnea Index of 4.2, a value considered abnormal for a child.


Fig. 8. The repeat sleep test on the 8-year-old child 6 months later demonstrates that tonsillec-

tomy successfully corrected the SDB.


experience has been that an AHI of 5 or more will most likely not only showimprovement in snoring following tonsillectomy, but will also show im-provement in behavioral and cognitive functioning.

Assuming that 10% of children snore and 1% or 2% have sleep apnea, itseems that there is no documented benefit to operating on the 10%. Theonly documented benefit is operating on the 2%, a group that presumablyhas an AHI of 5 or more. The home sleep test seems to be an excellenttool for determining who may or may not benefit from surgical proceduresin correcting SDB. The authors’ experience is that current home sleep testsare accurate in children no younger than 4 years of age. Less than age 4,children simply do not have enough respiratory volume to accurately drivethe respiratory meters.

Case two

A 47-year-old male presents with a primary complaint of snoring. He hadbeen snoring for most of his life, but with a recent 10-pound weight gain, thefrequency and the loudness of his snoring had increased. His wife com-plained that, not only did he snore, but he occasionally stopped breathingat night. The patient was a hard-working executive. He had some daytimesleepiness, but believed that this was simply a function of age, work inten-sity, and lack of regular exercise and normal sleep. On a self-report of hissymptoms based on the aforementioned scale in case one (see Fig. 1), he re-ported his snoring to be a 3, frequency of snoring to be 2, apneic episodeswere 2, and daytime sleepiness was 2. History and physical examinationare shown in Fig. 9. His neck circumference is 17 in, nose is 2/2, Mallampatiis 3, tonsil grade is 0, uvula is 2, and his comorbidities are obesity andhypertension. His endoscopic measurements indicated tongue is 3, lingualtonsils are 1, and epiglottis is 0. The patient underwent a multichannelhome sleep test. The results are shown in Fig. 10. The AHI is 16, which isabnormal. In this case, oxygen desaturations are seen, which is associatedwith deeper stages of sleep. One could argue that this is a milder case ofsleep apnea. However, the patient has daytime sleepiness; elevated BMI;

Table 2

Pre- and post-neuropsychologic results for an 8-year-old child (raw scores)

Test Domain Presurgery Postsurgery

Statue Attention/executive function 29 27

Visual attention Attention/executive function 34 37

Knock–tap Attention/executive function 28 28

Finger tapping PH Sensorimotor function 6 9

Finger tapping NPH Sensorimotor function 9 11

Sequential tapping PH Sensorimotor function 20 19

Sequential tapping NPH Sensorimotor function 32 36

Abbreviations: NPH, nonpreferred hand; PH, preferred hand.


elevated AHI; oxygen desaturations; and on physical examination, this isa Friedman Stage III, based primarily on the Mallampati examination.This is sleep apnea. This individual is recommended for CPAP. Nasal sur-gery and palatal surgery would be unlikely to provide benefit. This individ-ual should not be confused as a snorer but, instead, has sleep apnea, and,

Fig. 9. History and physical for a 47-year-old male referred for snoring.


absent significant weight loss, he will continue to have sleep apnea and needsto be treated effectively with CPAP.

Case three

A 43-year-old male presents with the identical history as the previouspatient. The history and physical examination in Fig. 11 is identical, exceptthat the Mallampati is 4. An overnight home sleep study was performed; re-sults are shown in Fig. 12. In this example, the AHI of 67 events per hour isclearly severe. Fig. 13 demonstrates that the oxygen desaturations are muchmore evident and much more marked. This is severe SDB. The severity ofthe condition was explained to the patient. The importance of treatmentwas also explained, and the patient was recommended for CPAP treatment.The patient was fitted with a nasal mask and an autotitrating positive airwaypressure machine. He returned for follow-up 2 weeks later and stated thatthe autotitrating positive airway pressure machine had changed his life.He was able to sleep 6 or 7 hours per night and feel refreshed in the morning.He stated that it was the most restful sleep he had in years. He began dream-ing and, in fact, for the first several nights, his entire sleep was filled withdreams, a phenomenon called rapid eye movement rebound. The patientfound himself with more energy during the day, and he no longer fell asleepat work. Before CPAP, his hypertension was poorly controlled on threedrugs; now, his blood pressure was rapidly returning toward normal. Ofequal benefit, the patient, who did not use alcohol and had suffered fromnightly gastroesophageal reflux disease, found that this rather unpleasantmalady had disappeared completely.

There are several home sleep diagnostic machines available on themarket. All of the cases presented in this article were done on the EmblettaPortable Diagnostic System (PDS) (Embla, Denver, Colorado). The Em-bletta is a comprehensive multichannel test that measures respiration byway of a nasal cannula, breathing effort through respiratory belts, oximetry,mouth breathing through an oral thermistor, and snoring through a sensor.Electroencephalogram as an extra component is also available with this par-ticular device. Embla also manufactures a simpler device called the Com-pass, which can be used as an effective screening tool. The Compass onlyrequires two channels: a nasal cannula and a finger oximeter. A similar de-vice is the ApneaLink (ResMed, Poway, California). This screening toolalso has a nasal cannula and oximeter. In cases whereby a nasal cannulamay be intrusive to a patient, the Watch-PAT100 (Itamar Medical, Ltd.,Caesarea, Israel) can be administered. This device detects apneic events inthe finger by interpreting sympathetic nervous system activity by way ofa probe. Disposables for the Embletta, Compass, and ApneaLink are lessthan $5. The Watch-PAT100 probe is slightly more costly, approximately$75 each. The current procedural terminology code for the Embletta andWatch-PAT100 is 95806, whereas the code for the screening devices is


95806-52. The authors have extensive experience with the aforementioneddevices. The home sleep diagnostic industry has grown during the pastdecade, and various sleep machines are currently available on the market.A list of devices with manufacturer websites is provided in Table 3.

The matter of home sleep study validity compared with polysomnogram(PSG) has been greatly debated in recent years. It often seems the argumentsare more emotional and economic than they are scientific. Fortunately, thevast majority of insurance companies reimburse for home sleep studies inthe greater San Diego area and permit initiation of treatment based on theseresults. Unfortunately, there are other portions of the country in which thisdoes not occur. It will only occur if head and neck surgeons, other healthprofessionals interested in sleep medicine, and their patients talk with theirlocal consultants and urge them to reconsider the matter.

The discussion seems to come to the question of whether home sleep test-ing is a valid alternative to PSG. Polysomnogram has never been establishedas a gold standard in the diagnosis of SDB and, in fact, the current practiceof split night studies has never been validated against the historical practiceof full-night PSG. CMS uses the measure of the AHI or Respiratory Distur-bance Index as the criteria for diagnosis and therefore treatment. Homesleep testing and PSG use the exact same equipment to measure respiration.The other PSG measures, most notably sleep stages, which are measured byEEG, are not used for the diagnosis of garden variety obstructive sleepapnea. Therefore, the added channels of the PSG make no contributionto the diagnosis or treatment.

Comparing PSG to home sleep studies:

� Patients sleep in a lab rather than testing in their own home and bed.� Many PSGs employ split-night studies, so 2 to 4 hours are devoted to di-agnosis, and 2 to 4 hours are devoted to setting a CPAP titration pressure;inadequate time periods for both studies; and neither validated againstthe historical standard of 1 to 2 nights PSG and 1 night CPAP titration.� PSG uses the same respiratory detectors, oximeter, chest and abdomensensors, and position sensors as do multichannel home sleep tests.� PSG provides electroencephalographic information regarding arousals,yet this information has high interpreter variability, and ultimately diag-noses are made first by the respiratory information, second by the pa-tient’s history and physical examination, and third by the oximetryrecordings. So in fact, electroencephalograms and arousals make little

Fig. 10. An overnight multichannel home sleep test for the 47-year-old patient in case 2. The

patient slept for 6 hours and 27 minutes. The Apnea Index was 5.5 events per hour, Hypopnea

Index was 10.9 events per hour, and Apnea Hypopnea Index was 16.5 events per hour. He had

3.6 obstructive events per hour and 1.4 central events per hour. The Oxygen Desaturation Index

was 12.8 events per hour, the Average Oxygen Desaturation was 94.1% (normal is 96%), and

the lowest oxygen saturation was 87%. The impression is moderate SDB.

:


difference. Sleep stages, time, and efficiency are useful information, butnot necessary to make a diagnosis.� CPAP pressures are determined by a single night 2- to 4-hour manual ofa CPAP pressure calculated to last the patient for the upcoming yearswith no regard to night-to-night variability or pressure requirementchanges overtime.

Fig. 11. History and physical for a 43-year-old male referred for snoring and drug-resistant

hypertension.


Fig. 12. Multichannel home sleep test shows an Apnea Hypopnea Index of 66. The patient’s

average oxygen desaturation is 94%, which is below normal ranges during sleep.


Fig. 13. The oxygen tracings for the 43-year-old male patient with an Apnea Hypopnea Index

of 66 show significant desaturations during recurrent apneic events.


Home sleep tests:

� Use the same respiratory equipment and analysis as do PSG.� Use the same oximetry equipment and analysis as do PSG.� Use the same chest and abdominal equipment as do PSG.� Use the same position sensors as do PSG.� Report the same AHI except uses a denominator of total time in bed,rather than total time asleep, which for those who have SDB seemsnot to be an issue.

Home sleep tests have several advantages over polysomnograms:

� They are performed in the patient’s own home, bed, and privacy.� The wires, leads, and so forth are less numerous, and the patient’s sleepis more comfortable and therefore more indicative of their normal sleep.� Home sleep tests are substantially less expensive: 2% to 30% the costof PSG.� Home sleep diagnostic dispensing and titration is easier than PSG labsetups and therefore can be performed by a greater number of practi-tioners, including all pulmonologists, cardiologists, anesthesiologists,and head and neck surgeons.

The entire controversy comes down to a single issue: If in fact PSG is themost accurate sleep diagnostic paradigm (this issue is easily argued to the

Table 3

Home sleep diagnostic devices, manufacturers, and websites

Device Manufacturer URL

ApneaLink ResMed http://www.resmed.com

Apnea Risk Evaluation

System

Advanced Brain

Monitoring

http://www.b-alert.com

Apnoescreen Viasys Health care http://www.viasyshealthcare.com

Compas Embla http://www.embla.com

Edentec SleepMed http://www.sleepmed.md

Embletta Embla http://www.embla.com

LifeShirt VivoMetrics http://www.lifeshirt.com

MESAM IV MAP http://www.map-med.com

Monet Embla http://www.embla.com

Novasom QSG Sleep Solutions http://www.sleep-solutions.com

Poly-MESAM MAP http://www.map-med.com

Remmers Sleep Recorder

(formerly SnoreSat)

SagaTech http://www.sagatech.ca

Sandman Puritan Bennett http://www.sandmansleep.com

SNAP Snap Laboratories http://www.snaplab.com

Somnocheck Weinmann http://www.weinmann.de

Somnotrac Pro Viasys Health Care http://www.viasyshealthcare.com

Somte Compumedics http://www.compumedics.com

Stardust II Respironics http://www.respironics.com

WatchPAT 100 Itamar Medical http://www.itamar-medical.com

http://www.resmed.com

http://www.b-alert.com

http://www.viasyshealthcare.com

http://www.embla.com

http://www.sleepmed.md


http://www.lifeshirt.com

http://www.map-med.com


http://www.sleep-solutions.com

http://www.map-med.com

http://www.sagatech.ca

http://www.sandmansleep.com

http://www.snaplab.com

http://www.weinmann.de

http://www.viasyshealthcare.com

http://www.compumedics.com

http://www.respironics.com

http://www.itamar-medical.com

Tab

Stu

Aut rrelation Sensitivity Specificity Accuracy Country

Red 6 86% 95% 92% USA

Ma 7 86% 95% 92% Canada

Bra 5 100% 92% d UK

Fleu 3 100% 87% d France

Kie 2 100% 92% 86% Ireland

Wh d d d UK

Gug 5 97% 77% d Switzerland

Aly 97% 93% d Germany

Ma 7 92% 79% d France

Bal 95% 92% d Spain

Jim

e

96% d d Spain

Cla 6 86% 95% d USA

Rei 95/91 91/83 d USA

Bar 7 d d d Israel

Coy 7 86% 100% d USA

Din 8/0.74 d d d UK

Pitt 91% 86% d USA

Su, 2 98% 40% 95% USA

Wa 8 100% 88% d Germany

Aya 7 91% 84% d USA

Zou d d d Sweden

780

PATEL&

DAVID

SON

le 4

dies demonstrating strong correlations between polysomnography and home sleep testing

hor Year Equipment

#

Patients Male Female Age BMI Syn

A

Syn

AHI-

PSG

AHI-

Sleep

Test Co

line, et al [29] 1991 Edentec 25 20 5 53 31 20 5 37 36 0.9

n & Kang [30] 1995 PolyG 104 d d d d 104 0 d d 0.9

dley, et al [31] 1995 Autoset 31 26 5 46 30 31 0 25 d 0.8

ry, et al [32] 1996 Autoset 44 34 10 52 29 44 0 19 17 0.9

ly, et al [33] 1996 Autoset 36 27 9 45 28 28 0 19 18 0.9

ittle, et al [34] 1997 Edentec 23 19 4 50 30 23 27 25 d

ger [35] 1997 Autoset 67 58 9 51 31 67 0 26 30 0.9

mow, et al [36] 1999 Embletta 97 d d d d 79 0 25 0.9

yer, et al [37] 2000 Autoset 95 79 16 53 31 95 0 43 34 0.8

lester, et al [38] 2000 Sibel Home 116 65 51 47 26 116 0 9.5 6.9 d

enez-Gomez,

t al [39]

2000 Edentec 62 58 4 53 25–28 62 0 d d d

man, et al [40] 2001 BedBugg 42 d d d d 42 0 d d 0.9

chart, et al [41] 2003 NovaSom 51 38 13 52 30 51 51 d d d

, et al [42] 2003 WatchPAT 102 78 69 41 27 102 14 d d 0.8

le, et al [43] 2003 LifeShirt 10 10 d d d 0 10 28 27 0.9

gli, et al [44] 2003 Embletta 101 80 21 48 32 40 61 d d 0.9

man, et al [45] 2004 WatchPAT 29 21 8 43 34 29 29 32 34 d

et al [46] 2004 SNAP 60 25 35 45 36 60 0 27 26 0.9

ng, et al [47] 2003 ApneaLink 50 d d d d 50 0 d d 0.9

s, et al [48] 2003 WatchPAT 30 19 11 47 31 30 0 23 23 0.8

, et al [49] 2006 WatchPAT 98 55 43 60 28 98 0 25 27 0.9


converse), are home sleep tests sufficiently accurate to be used for routinesleep apnea/SDB cases? It seems that the primary focus of discussion proPSG is the efficacy of PSG versus home sleep testing. There are numerousvalidation studies of home sleep testing versus PSG. Currently, there areat least 19 studies including 1173 patients that demonstrate excellent corre-lation between multichannel home sleep tests and PSG. These are shown inTable 4 [29–49].

Further strengthening the urgency for improved capability to diagnoseSDB is the recognition that SDB can result in an early and untimely death.A study published in the Journal of Internal Medicine in 1991 brought thisto the world’s attention, reporting that nighttime cardiovascular death wasmore common among those who snored than for those who did not:‘‘Habitual snoring was found to be a risk factor for morning death(P!.01)’’ [50]. The European Respiratory Journal in 2005 reported the haz-ard of mortality in sleep apnea increases with apnea severity as indexed bythe Respiratory Disturbance Index [51]. The New England Journal of Med-icine in 2005 also reported: ‘‘People with obstructive sleep apnea havea peak in sudden death from cardiac causes during the sleeping hours, whichcontrasts strikingly with the nadir of sudden death from cardiac causes dur-ing this period in people without obstructive sleep apnea and in the generalpopulation’’[52].

The authors’ conclusions are:

� Sleep testing is easily and accurately performed by numerous home sleeptest paradigms.� Home sleep testing reduces cost.� Home sleep testing improves access.� Home sleep testing is reimbursed by private sector ‘‘Fee For ServiceInsurers.’’� Multichannel home sleep testing is currently approved by CMS carriersin areas where in-lab PSG is not available. Home sleep testing is used byother health programs such as the VA Health care System and by KaiserPermanente.� Home sleep testing should be approved as a valid SDB test paradigm.

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