Editorial Revisado por pares

Unattended Recording in the Diagnosis and Treatment of Sleep-disordered Breathing

1994; Elsevier BV; Volume: 105; Issue: 5 Linguagem: Inglês

10.1378/chest.105.5.1306

ISSN

1931-3543

Autores

Ronald A. Stiller, Patrick J. Strollo, Mark H. Sanders,

Tópico(s)

Respiratory Support and Mechanisms

Resumo

To the casual observer, it would appear that the field of sleep medicine is on the verge of a revolution. Time honored diagnostic and therapeutic practices are, in some cases, being replaced by new, less traditional methodologies. The impetus for these changes arises from the recognition that sleep disorders and, in particular, sleep-disordered breathing (SDB), is prevalent in the general population with potentially serious health and social consequences.1Young T Plata M Dempsey J Skatrud J Weber S Badr S The occurrence of sleep-disordered breathing among middle-aged adults.N Engl Med. 1993; 328: 1230-1235Crossref PubMed Scopus (8320) Google Scholar Of considerable importance in the context of current economic and sociopolitical imperatives is the evolving awareness that if the diagnosis and treatment of SDB are to be comprehensively undertaken, a substantial commitment of significant healthcare resources, and therefore, dollars, will be necessary. In an effort to accommodate these realities, technology has been developed to evaluate and potentially treat patients with SDB outside the confines of the sleep laboratory in the absence of a polysomnographic technician to monitor the progress of the study. Those who favor this trend claim that such unattended monitoring affords the public health benefits of more widespread access to diagnostic services, particularly for patients living in areas remote from inhospital or “stand-alone” clinical sleep facilities, as well as reduces the waiting period for evaluation by providing an alternative to existing, overburdened facilities. Furthermore, given the unattended nature of these studies, advocates contend that expanded use of unattended monitoring will reduce the cost of care relative to conventional inlaboratory polysomnography.2Ancoli-Israel S Kripke DF Mason W Messin S Comparisons of home sleep recordings and polysomnograms in older adults with sleep disorders.Sleep. 1981; 4: 283-291Crossref PubMed Scopus (87) Google Scholar,3Stoohs R Guilleminault C Investigations of an automatic screening device (MESAM) for obstructive sleep apnea.Eur Respir J. 1990; 3: 823-829PubMed Google Scholar It has also been argued that unattended diagnostic evaluations afford clinical advantages, including elimination of nonrepresentative studies attributable to “first-night effect” by evaluating patients in more familiar, inhome surroundings. With these arguments as justification, some clinicians now employ unattended monitoring in the evaluation and treatment of patients with SDB.We, too, believe that the above goals of portable recording in the management of patients with SDB are laudable, and therefore, encourage further investigation into the role and efficacy of this new technology. We are concerned, however, that the rush to institute clinical programs employing these devices and establishing this methodology as the Standard of practice is premature. Many important scientific, economic, and philosophic issues remain incompletely addressed and need to be resolved prior to large-scale initiation of unattended monitoring programs.A primary consideration, as yet incompletely explored, is whether or not unattended monitoring systems have sufficiently high positive and negative predictive powers to provide acceptable quality of care. Although preliminary data concerning the diagnostic accuracy of portable recording devices are encouraging, the few studies which address this topic are limited by small patient populations, absence of controlled trials, and performance of studies predominantly in the laboratory environment which may not reflect conditions in the home. Perhaps more significantly, selected study populations have been primarily comprised of individuals at increased risk for SDB.2Ancoli-Israel S Kripke DF Mason W Messin S Comparisons of home sleep recordings and polysomnograms in older adults with sleep disorders.Sleep. 1981; 4: 283-291Crossref PubMed Scopus (87) Google Scholar,4Gyulay S Gould D Sawyer B Pond D Mant A Saunders N Evaluation of a microprocessor-based portable home monitoring system to measure breathing during sleep.Sleep. 1987; 10: 130-142Crossref PubMed Scopus (48) Google Scholar,5Redline 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: 1281-1286Abstract Full Text Full Text PDF PubMed Scopus (208) Google Scholar The diagnostic accuracy of this methodology in broad-based patient populations remains unclear. Another noteworthy issue is that most investigations suggest that unattended monitoring systems do not reliably distinguish obstructive, mixed, and central apneas.3Stoohs R Guilleminault C Investigations of an automatic screening device (MESAM) for obstructive sleep apnea.Eur Respir J. 1990; 3: 823-829PubMed Google Scholar, 4Gyulay S Gould D Sawyer B Pond D Mant A Saunders N Evaluation of a microprocessor-based portable home monitoring system to measure breathing during sleep.Sleep. 1987; 10: 130-142Crossref PubMed Scopus (48) Google Scholar, 5Redline 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: 1281-1286Abstract Full Text Full Text PDF PubMed Scopus (208) Google Scholar In fact, many suggest confirmatory polysomnography in the face of a positive unattended evaluation! Finally, the adequacy of unattended monitoring systems to detect nonapneic breathing disorders during sleep, eg, upper airway resistance syndrome (UARS), remains unknown. While the prevalence of UARS is uncertain, it would appear likely that this is an important diagnosis to make since directed therapy can result in substantial health benefit.6Guilleminault C Stoohs R Clerk A Cetel M Maistros P A cause of excessive daytime sleepiness: the upper airway resistance syndrome.Chest. 1993; 104: 781-787Abstract Full Text Full Text PDF PubMed Scopus (847) Google ScholarWhile the diagnostic accuracy of unattended monitoring systems remains ill-defined, even less clear is the utility of unattended recording in initiating therapy for SDB. Nonetheless, such technology is now promoted by some medical equipment manufacturers. In our view, the number of unanswered questions regarding the accuracy of these monitors suggests the need to temper enthusiasm for unattended recording in the diagnosis and management of SDB.In addition to unresolved questions regarding the diagnostic accuracy of data obtained by unattended monitoring, the cost effectiveness of this methodology over split-night or even two-night polysomnography also has yet to be demonstrated in a “real world” setting. As scientists, clinicians, and as a society, we need to determine an acceptable negative predictive value to which we can hold this methodology. In the absence of such a consensus, clinicians may be obliged to perform an additional inlaboratory study in the face of a negative unattended evaluation, before deciding to forego therapy. Such a scenario may actually increase the cost of care to the patient. Conversely, until we can be reasonably certain of correct characterization of inpatients with positive unattended studies, investigators have suggested confirmatory polysomnography. This too will mitigate any tendency towards cost savings. Although it is likely that inlaboratory polysomnography may not be the “gold-standard” we would wish for in the best of all worlds, the presence of a technologist assures some degree of technical reliability. On the other hand, a number of studies suggest that unattended recordings have a 2 to greater than 10 percent failure rate.3Stoohs R Guilleminault C Investigations of an automatic screening device (MESAM) for obstructive sleep apnea.Eur Respir J. 1990; 3: 823-829PubMed Google Scholar, 4Gyulay S Gould D Sawyer B Pond D Mant A Saunders N Evaluation of a microprocessor-based portable home monitoring system to measure breathing during sleep.Sleep. 1987; 10: 130-142Crossref PubMed Scopus (48) Google Scholar, 5Redline 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: 1281-1286Abstract Full Text Full Text PDF PubMed Scopus (208) Google Scholar,7Emsellem H 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: 748-752Crossref PubMed Scopus (77) Google Scholar Much of these data were collected during trials of unattended monitoring devices in the laboratory environment. It is likely that the failure rate and lost data rate would be even higher during application in the truly attended milieu. Lost data means additional studies which would result in reduced cost savings or actually increased cost to individual patients. Whether there is a favorable aggregate cost impact of unattended recording across large populations requires further study.The potential application of unattended recording to therapy of patients with SDB has implications significantly more far-reaching than simply its utility in establishing adequate levels of positive pressure. What effect will the absence of an attendant have on compliance with therapy? While it is commonly assumed that the comfort of the inhome study will eliminate first night effect and improve diagnostic efficacy, the potential role of the polysomnography technician in enhancing acceptance and compliance by reassuring and educating the patient during the evaluation has yet to be addressed in a controlled manner. Issues of safety must be considered as well. What is the risk associated with prolonged periods of hypoxia during initiation of therapy due to REM rebound in the absence of an attendant?8Krieger J Weitzenblum E Monassier J-P Stoeckel C Kurtz D Dangerous hypoxaemia during continuous positive airway pressure treatment of obstructive sleep apnea.Lancet. 1983; 50: 1429-1430Abstract Scopus (44) Google ScholarIn addition to important technical questions regarding the validity of data collected by unattended, inhome monitoring systems, a number of other, perhaps more philosophic issues are raised, including who will be responsible for ordering and interpreting the results of these studies? While the complexity of standard polysomnography largely limits this function to physicians with specific training and experience in the management of sleep disorders, unattended, inhome studies can be ordered for any patient by any licensed physician. It is of equal concern that interpretation and subsequent recommendations for therapeutic intervention may either fall to an “expert” who has neither seen nor examined the patient, or alternatively, it may be left to the ordering physician to interpret the study results and translate the findings into patient care, regardless of his or her level of training and experience. Conceivably, this could have undesirable medical and economic consequences. Before endorsing routine unattended monitoring, the medical community must decide whether such a practice represents an acceptable standard of care. Given the minimal time devoted to teach medical students and housestaff about sleep disorders, there are grave concerns if the care of patients with suspected SDB is left to physicians with little or no training in the field.9Rosen RC Roseking M Rosevear C Cole WE Physician education in sleep and sleep disorders: a national survey of US medical schools.Sleep. 1993; 16: 249-254PubMed Google Scholar Until questions such as these are addressed, portable recording for SDB should not become the standard of care.In the July 1993 issue of Chest, Coppola and Lawee10Coppola M Lawee D Management of obstructive sleep apnea syndrome in the home.Chest. 1993; 104: 19-25Abstract Full Text Full Text PDF PubMed Scopus (43) Google Scholar described their approach to the diagnosis and treatment of obstructive sleep apnea using portable recording equipment. These authors retrospectively reviewed their experience with 11 patients with severe obstructive sleep apnea who were both diagnosed at home using unattended recording and in whom nasal continuous positive airway pressure (CPAP) therapy was initiated and adjusted in the home setting. Following institution of therapy, all 11 patients improved as reflected by a reduction in frequency of SDB events and subjectively reduced severity of symptoms. By patient report, good compliance with therapy was maintained, and no adverse complications were attributable to the unattended setting. Coppola and Lawee10Coppola M Lawee D Management of obstructive sleep apnea syndrome in the home.Chest. 1993; 104: 19-25Abstract Full Text Full Text PDF PubMed Scopus (43) Google Scholar concluded that their retrospective study confirms that selected patients with obstructive sleep apnea can be successfully diagnosed and treated without a technician in attendance.While we commend these authors for their interest in this innovative and attractive approach to treating SDB, we believe that a critical review of this report is warranted before their experience is incorporated into general practice. As pointed out by the authors, the study was an uncontrolled, retrospective review of patients selected on the basis of successful outcome following the diagnosis and treatment of sleep apnea syndrome in the home setting. The number of patients evaluated to yield the reported study population was not stated. The CPAP titration was adjusted in a somewhat arbitrary fashion based on patient and spousal reports of reduced snoring and hypersomnolence. It is problematic that subjective reporting of daytime sleepiness is known to be imprecise,11Roth T Hartse KM Zorick F Conway W Multiple naps and the evaluation of daytime sleepiness in patients with upper airway sleep apnea.Sleep. 1980; 3: 425-439PubMed Google Scholar and therefore, should not be used to determine effectiveness of therapy. Similarly, self-reported compliance with CPAP therapy, used by Coppola and Lawee to support their claims of therapeutic success, is also of questionable reliability.12Kribbs NB Pack AI Kline LR et al.Objective measurement of patterns of nasal CPAP use by patients with obstructive sleep apnea.Am Rev Respir Dis. 1993; 147: 887-895Crossref PubMed Scopus (1065) Google Scholar In view of the limitations in study design, CPAP titration protocol and the subjective, nonsystematic assessment of compliance, the conclusions stated in this report by Coppola and Lawee10Coppola M Lawee D Management of obstructive sleep apnea syndrome in the home.Chest. 1993; 104: 19-25Abstract Full Text Full Text PDF PubMed Scopus (43) Google Scholar should be viewed as preliminary at best. Many questions remain concerning the efficacy and safety of the methods described by these authors.In summary, we are optimistic that unattended, portable recording techniques will ultimately become a successful addition to the armamentarium available for the diagnosis and possibly the management of patients with sleep apnea syndrome. Those of us who treat patients with SDB must deal with the confounding realities (too often present in medicine) of trying to provide the “best possible” healthcare at an affordable price to large numbers of patients who require expensive, labor-intensive intervention. While these objectives are compelling, we must resist the urge to institute new methodologies without documenting that they meet our expectations. We encourage Drs. Coppola, Lawee, and others to systematically address the unresolved issues which remain with regard to the role of unattended monitoring in the care of patients with SDB. To the casual observer, it would appear that the field of sleep medicine is on the verge of a revolution. Time honored diagnostic and therapeutic practices are, in some cases, being replaced by new, less traditional methodologies. The impetus for these changes arises from the recognition that sleep disorders and, in particular, sleep-disordered breathing (SDB), is prevalent in the general population with potentially serious health and social consequences.1Young T Plata M Dempsey J Skatrud J Weber S Badr S The occurrence of sleep-disordered breathing among middle-aged adults.N Engl Med. 1993; 328: 1230-1235Crossref PubMed Scopus (8320) Google Scholar Of considerable importance in the context of current economic and sociopolitical imperatives is the evolving awareness that if the diagnosis and treatment of SDB are to be comprehensively undertaken, a substantial commitment of significant healthcare resources, and therefore, dollars, will be necessary. In an effort to accommodate these realities, technology has been developed to evaluate and potentially treat patients with SDB outside the confines of the sleep laboratory in the absence of a polysomnographic technician to monitor the progress of the study. Those who favor this trend claim that such unattended monitoring affords the public health benefits of more widespread access to diagnostic services, particularly for patients living in areas remote from inhospital or “stand-alone” clinical sleep facilities, as well as reduces the waiting period for evaluation by providing an alternative to existing, overburdened facilities. Furthermore, given the unattended nature of these studies, advocates contend that expanded use of unattended monitoring will reduce the cost of care relative to conventional inlaboratory polysomnography.2Ancoli-Israel S Kripke DF Mason W Messin S Comparisons of home sleep recordings and polysomnograms in older adults with sleep disorders.Sleep. 1981; 4: 283-291Crossref PubMed Scopus (87) Google Scholar,3Stoohs R Guilleminault C Investigations of an automatic screening device (MESAM) for obstructive sleep apnea.Eur Respir J. 1990; 3: 823-829PubMed Google Scholar It has also been argued that unattended diagnostic evaluations afford clinical advantages, including elimination of nonrepresentative studies attributable to “first-night effect” by evaluating patients in more familiar, inhome surroundings. With these arguments as justification, some clinicians now employ unattended monitoring in the evaluation and treatment of patients with SDB. We, too, believe that the above goals of portable recording in the management of patients with SDB are laudable, and therefore, encourage further investigation into the role and efficacy of this new technology. We are concerned, however, that the rush to institute clinical programs employing these devices and establishing this methodology as the Standard of practice is premature. Many important scientific, economic, and philosophic issues remain incompletely addressed and need to be resolved prior to large-scale initiation of unattended monitoring programs. A primary consideration, as yet incompletely explored, is whether or not unattended monitoring systems have sufficiently high positive and negative predictive powers to provide acceptable quality of care. Although preliminary data concerning the diagnostic accuracy of portable recording devices are encouraging, the few studies which address this topic are limited by small patient populations, absence of controlled trials, and performance of studies predominantly in the laboratory environment which may not reflect conditions in the home. Perhaps more significantly, selected study populations have been primarily comprised of individuals at increased risk for SDB.2Ancoli-Israel S Kripke DF Mason W Messin S Comparisons of home sleep recordings and polysomnograms in older adults with sleep disorders.Sleep. 1981; 4: 283-291Crossref PubMed Scopus (87) Google Scholar,4Gyulay S Gould D Sawyer B Pond D Mant A Saunders N Evaluation of a microprocessor-based portable home monitoring system to measure breathing during sleep.Sleep. 1987; 10: 130-142Crossref PubMed Scopus (48) Google Scholar,5Redline 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: 1281-1286Abstract Full Text Full Text PDF PubMed Scopus (208) Google Scholar The diagnostic accuracy of this methodology in broad-based patient populations remains unclear. Another noteworthy issue is that most investigations suggest that unattended monitoring systems do not reliably distinguish obstructive, mixed, and central apneas.3Stoohs R Guilleminault C Investigations of an automatic screening device (MESAM) for obstructive sleep apnea.Eur Respir J. 1990; 3: 823-829PubMed Google Scholar, 4Gyulay S Gould D Sawyer B Pond D Mant A Saunders N Evaluation of a microprocessor-based portable home monitoring system to measure breathing during sleep.Sleep. 1987; 10: 130-142Crossref PubMed Scopus (48) Google Scholar, 5Redline 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: 1281-1286Abstract Full Text Full Text PDF PubMed Scopus (208) Google Scholar In fact, many suggest confirmatory polysomnography in the face of a positive unattended evaluation! Finally, the adequacy of unattended monitoring systems to detect nonapneic breathing disorders during sleep, eg, upper airway resistance syndrome (UARS), remains unknown. While the prevalence of UARS is uncertain, it would appear likely that this is an important diagnosis to make since directed therapy can result in substantial health benefit.6Guilleminault C Stoohs R Clerk A Cetel M Maistros P A cause of excessive daytime sleepiness: the upper airway resistance syndrome.Chest. 1993; 104: 781-787Abstract Full Text Full Text PDF PubMed Scopus (847) Google Scholar While the diagnostic accuracy of unattended monitoring systems remains ill-defined, even less clear is the utility of unattended recording in initiating therapy for SDB. Nonetheless, such technology is now promoted by some medical equipment manufacturers. In our view, the number of unanswered questions regarding the accuracy of these monitors suggests the need to temper enthusiasm for unattended recording in the diagnosis and management of SDB. In addition to unresolved questions regarding the diagnostic accuracy of data obtained by unattended monitoring, the cost effectiveness of this methodology over split-night or even two-night polysomnography also has yet to be demonstrated in a “real world” setting. As scientists, clinicians, and as a society, we need to determine an acceptable negative predictive value to which we can hold this methodology. In the absence of such a consensus, clinicians may be obliged to perform an additional inlaboratory study in the face of a negative unattended evaluation, before deciding to forego therapy. Such a scenario may actually increase the cost of care to the patient. Conversely, until we can be reasonably certain of correct characterization of inpatients with positive unattended studies, investigators have suggested confirmatory polysomnography. This too will mitigate any tendency towards cost savings. Although it is likely that inlaboratory polysomnography may not be the “gold-standard” we would wish for in the best of all worlds, the presence of a technologist assures some degree of technical reliability. On the other hand, a number of studies suggest that unattended recordings have a 2 to greater than 10 percent failure rate.3Stoohs R Guilleminault C Investigations of an automatic screening device (MESAM) for obstructive sleep apnea.Eur Respir J. 1990; 3: 823-829PubMed Google Scholar, 4Gyulay S Gould D Sawyer B Pond D Mant A Saunders N Evaluation of a microprocessor-based portable home monitoring system to measure breathing during sleep.Sleep. 1987; 10: 130-142Crossref PubMed Scopus (48) Google Scholar, 5Redline 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: 1281-1286Abstract Full Text Full Text PDF PubMed Scopus (208) Google Scholar,7Emsellem H 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: 748-752Crossref PubMed Scopus (77) Google Scholar Much of these data were collected during trials of unattended monitoring devices in the laboratory environment. It is likely that the failure rate and lost data rate would be even higher during application in the truly attended milieu. Lost data means additional studies which would result in reduced cost savings or actually increased cost to individual patients. Whether there is a favorable aggregate cost impact of unattended recording across large populations requires further study. The potential application of unattended recording to therapy of patients with SDB has implications significantly more far-reaching than simply its utility in establishing adequate levels of positive pressure. What effect will the absence of an attendant have on compliance with therapy? While it is commonly assumed that the comfort of the inhome study will eliminate first night effect and improve diagnostic efficacy, the potential role of the polysomnography technician in enhancing acceptance and compliance by reassuring and educating the patient during the evaluation has yet to be addressed in a controlled manner. Issues of safety must be considered as well. What is the risk associated with prolonged periods of hypoxia during initiation of therapy due to REM rebound in the absence of an attendant?8Krieger J Weitzenblum E Monassier J-P Stoeckel C Kurtz D Dangerous hypoxaemia during continuous positive airway pressure treatment of obstructive sleep apnea.Lancet. 1983; 50: 1429-1430Abstract Scopus (44) Google Scholar In addition to important technical questions regarding the validity of data collected by unattended, inhome monitoring systems, a number of other, perhaps more philosophic issues are raised, including who will be responsible for ordering and interpreting the results of these studies? While the complexity of standard polysomnography largely limits this function to physicians with specific training and experience in the management of sleep disorders, unattended, inhome studies can be ordered for any patient by any licensed physician. It is of equal concern that interpretation and subsequent recommendations for therapeutic intervention may either fall to an “expert” who has neither seen nor examined the patient, or alternatively, it may be left to the ordering physician to interpret the study results and translate the findings into patient care, regardless of his or her level of training and experience. Conceivably, this could have undesirable medical and economic consequences. Before endorsing routine unattended monitoring, the medical community must decide whether such a practice represents an acceptable standard of care. Given the minimal time devoted to teach medical students and housestaff about sleep disorders, there are grave concerns if the care of patients with suspected SDB is left to physicians with little or no training in the field.9Rosen RC Roseking M Rosevear C Cole WE Physician education in sleep and sleep disorders: a national survey of US medical schools.Sleep. 1993; 16: 249-254PubMed Google Scholar Until questions such as these are addressed, portable recording for SDB should not become the standard of care. In the July 1993 issue of Chest, Coppola and Lawee10Coppola M Lawee D Management of obstructive sleep apnea syndrome in the home.Chest. 1993; 104: 19-25Abstract Full Text Full Text PDF PubMed Scopus (43) Google Scholar described their approach to the diagnosis and treatment of obstructive sleep apnea using portable recording equipment. These authors retrospectively reviewed their experience with 11 patients with severe obstructive sleep apnea who were both diagnosed at home using unattended recording and in whom nasal continuous positive airway pressure (CPAP) therapy was initiated and adjusted in the home setting. Following institution of therapy, all 11 patients improved as reflected by a reduction in frequency of SDB events and subjectively reduced severity of symptoms. By patient report, good compliance with therapy was maintained, and no adverse complications were attributable to the unattended setting. Coppola and Lawee10Coppola M Lawee D Management of obstructive sleep apnea syndrome in the home.Chest. 1993; 104: 19-25Abstract Full Text Full Text PDF PubMed Scopus (43) Google Scholar concluded that their retrospective study confirms that selected patients with obstructive sleep apnea can be successfully diagnosed and treated without a technician in attendance. While we commend these authors for their interest in this innovative and attractive approach to treating SDB, we believe that a critical review of this report is warranted before their experience is incorporated into general practice. As pointed out by the authors, the study was an uncontrolled, retrospective review of patients selected on the basis of successful outcome following the diagnosis and treatment of sleep apnea syndrome in the home setting. The number of patients evaluated to yield the reported study population was not stated. The CPAP titration was adjusted in a somewhat arbitrary fashion based on patient and spousal reports of reduced snoring and hypersomnolence. It is problematic that subjective reporting of daytime sleepiness is known to be imprecise,11Roth T Hartse KM Zorick F Conway W Multiple naps and the evaluation of daytime sleepiness in patients with upper airway sleep apnea.Sleep. 1980; 3: 425-439PubMed Google Scholar and therefore, should not be used to determine effectiveness of therapy. Similarly, self-reported compliance with CPAP therapy, used by Coppola and Lawee to support their claims of therapeutic success, is also of questionable reliability.12Kribbs NB Pack AI Kline LR et al.Objective measurement of patterns of nasal CPAP use by patients with obstructive sleep apnea.Am Rev Respir Dis. 1993; 147: 887-895Crossref PubMed Scopus (1065) Google Scholar In view of the limitations in study design, CPAP titration protocol and the subjective, nonsystematic assessment of compliance, the conclusions stated in this report by Coppola and Lawee10Coppola M Lawee D Management of obstructive sleep apnea syndrome in the home.Chest. 1993; 104: 19-25Abstract Full Text Full Text PDF PubMed Scopus (43) Google Scholar should be viewed as preliminary at best. Many questions remain concerning the efficacy and safety of the methods described by these authors. In summary, we are optimistic that unattended, portable recording techniques will ultimately become a successful addition to the armamentarium available for the diagnosis and possibly the management of patients with sleep apnea syndrome. Those of us who treat patients with SDB must deal with the confounding realities (too often present in medicine) of trying to provide the “best possible” healthcare at an affordable price to large numbers of patients who require expensive, labor-intensive intervention. While these objectives are compelling, we must resist the urge to institute new methodologies without documenting that they meet our expectations. We encourage Drs. Coppola, Lawee, and others to systematically address the unresolved issues which remain with regard to the role of unattended monitoring in the care of patients with SDB.

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