Diagnostic accuracy of a questionnaire and simple home monitoring device in detecting obstructive sleep apnoea in a Chinese population at high cardiovascular risk
Dashiell GANTNER
The George Institute for International Health, Royal Prince Alfred Hospital and University of Sydney,
Search for more papers by this authorJi-Yong GE
Shanghai Institute of Hypertension, Ruijin Hospital, Shanghai Jiaotong University School of Medicine,
Search for more papers by this authorLi-Hua LI
Shanghai Institute of Hypertension, Ruijin Hospital, Shanghai Jiaotong University School of Medicine,
Search for more papers by this authorNick ANTIC
Adelaide Institute for Sleep Health, Repatriation General Hospital and Flinders University, Adelaide, South Australia, Australia, and
Search for more papers by this authorSam WINDLER
Adelaide Institute for Sleep Health, Repatriation General Hospital and Flinders University, Adelaide, South Australia, Australia, and
Search for more papers by this authorKeith WONG
Woolcock Institute of Medical Research and NHMRC Centre for Clinical Research Excellence in Respiratory and Sleep Medicine, University of Sydney, Sydney, New South Wales,
Search for more papers by this authorEmma HEELEY
The George Institute for International Health, Royal Prince Alfred Hospital and University of Sydney,
Search for more papers by this authorShao-Guang HUANG
Department of Respiratory Medicine, Ruijin Hospital, Shanghai Jiaotong University School of Medicine and
Search for more papers by this authorPing CUI
Ruijin 2nd Road Community Health Center, Luwan District, Shanghai, China
Search for more papers by this authorCraig ANDERSON
The George Institute for International Health, Royal Prince Alfred Hospital and University of Sydney,
Search for more papers by this authorJi-Guang WANG
Shanghai Institute of Hypertension, Ruijin Hospital, Shanghai Jiaotong University School of Medicine,
Search for more papers by this authorCorresponding Author
Doug MCEVOY
Adelaide Institute for Sleep Health, Repatriation General Hospital and Flinders University, Adelaide, South Australia, Australia, and
Doug McEvoy, Adelaide Institute for Sleep Health, Repatriation General Hospital, Daw Park, SA 5041, Australia. Email: [email protected]Search for more papers by this authorDashiell GANTNER
The George Institute for International Health, Royal Prince Alfred Hospital and University of Sydney,
Search for more papers by this authorJi-Yong GE
Shanghai Institute of Hypertension, Ruijin Hospital, Shanghai Jiaotong University School of Medicine,
Search for more papers by this authorLi-Hua LI
Shanghai Institute of Hypertension, Ruijin Hospital, Shanghai Jiaotong University School of Medicine,
Search for more papers by this authorNick ANTIC
Adelaide Institute for Sleep Health, Repatriation General Hospital and Flinders University, Adelaide, South Australia, Australia, and
Search for more papers by this authorSam WINDLER
Adelaide Institute for Sleep Health, Repatriation General Hospital and Flinders University, Adelaide, South Australia, Australia, and
Search for more papers by this authorKeith WONG
Woolcock Institute of Medical Research and NHMRC Centre for Clinical Research Excellence in Respiratory and Sleep Medicine, University of Sydney, Sydney, New South Wales,
Search for more papers by this authorEmma HEELEY
The George Institute for International Health, Royal Prince Alfred Hospital and University of Sydney,
Search for more papers by this authorShao-Guang HUANG
Department of Respiratory Medicine, Ruijin Hospital, Shanghai Jiaotong University School of Medicine and
Search for more papers by this authorPing CUI
Ruijin 2nd Road Community Health Center, Luwan District, Shanghai, China
Search for more papers by this authorCraig ANDERSON
The George Institute for International Health, Royal Prince Alfred Hospital and University of Sydney,
Search for more papers by this authorJi-Guang WANG
Shanghai Institute of Hypertension, Ruijin Hospital, Shanghai Jiaotong University School of Medicine,
Search for more papers by this authorCorresponding Author
Doug MCEVOY
Adelaide Institute for Sleep Health, Repatriation General Hospital and Flinders University, Adelaide, South Australia, Australia, and
Doug McEvoy, Adelaide Institute for Sleep Health, Repatriation General Hospital, Daw Park, SA 5041, Australia. Email: [email protected]Search for more papers by this authorConflict of interest statement: There were no conflicts of interest on the part of any authors or researchers involved in this study. D. McEvoy received funding from Respironics and equipment donations from ResMed and Compumedics for the research reported in this manuscript. The study sponsors had no role in study design, analysis, interpretation or manuscript writing.
ABSTRACT
Background and objective: OSA is a common condition associated with cardiovascular (CV) morbidity. It remains underdiagnosed globally in part due to the limited availability and technical requirements of polysomnography (PSG). The aim of this study was to test the accuracy of two simple methods for diagnosing OSA.
Methods: Consecutive subjects identified from a community register with high CV risk were invited to complete the Berlin Sleep Questionnaire and undergo simultaneous, home, overnight PSG and ApneaLink device oximetry and nasal pressure recordings. The relative accuracies of the Berlin Questionnaire, oximetry and nasal pressure results in diagnosing PSG-defined moderate-severe OSA were assessed.
Results: Of 257 eligible high CV risk subjects enrolled, 190 completed sleep studies and 143 subjects' studies were of sufficient quality to include in final analyses. Moderate-severe OSA was confirmed in 43% of subjects. The Berlin Questionnaire had low overall diagnostic accuracy in this population. However, ApneaLink recordings of oximetry and nasal pressure areas had high diagnostic utility with areas under the receiver operating characteristic curves of 0.933 and 0.933, respectively. At optimal diagnostic thresholds, oximetry and nasal pressure measurements had similar sensitivity (84% vs 86%) and specificity (84% vs 85%). Technical failure was lower for oximetry than nasal pressure (5.8% vs 18.9% of tests).
Conclusions: In patients with high CV risk overnight single-channel oximetry and nasal pressure measurements may provide high diagnostic accuracy and offer an accessible alternative to full PSG.
REFERENCES
- 1 Arzt M, Young T, Finn L et al. Association of sleep-disordered breathing and the occurrence of stroke. Am. J. Respir. Crit. Care Med. 2005; 172: 1447–51.
- 2 Gami AS, Howard DE, Olson EJ et al. Day-night pattern of sudden death in obstructive sleep apnea. N. Engl. J. Med. 2005; 352: 1206–14.
- 3 Peppard PE, Young T, Palta M et al. Prospective study of the association between sleep-disordered breathing and hypertension. N. Engl. J. Med. 2000; 342: 1378–84.
- 4 Shahar E, Whitney CW, Redline S et al. Sleep-disordered breathing and cardiovascular disease: cross-sectional results of the Sleep Heart Health Study. Am. J. Respir. Crit. Care Med. 2001; 163: 19–25.
- 5 Young T, Peppard PE, Gottlieb DJ. Epidemiology of obstructive sleep apnea: a population health perspective. Am. J. Respir. Crit. Care Med. 2002; 165: 1217–39.
- 6 Huang SG, Li QY. [Prevalence of obstructive sleep apnea-hypopnea syndrome in Chinese adults aged over 30 yr in Shanghai]. Zhonghua Jie He He Hu Xi Za Zhi 2003; 26: 268–72.
- 7 Ip MS, Lam B, Lauder IJ et al. A community study of sleep-disordered breathing in middle-aged Chinese men in Hong Kong. Chest 2001; 119: 62–9.
- 8 Sharma SK, Kumpawat S, Banga A et al. Prevalence and risk factors of obstructive sleep apnea syndrome in a population of Delhi, India. Chest 2006; 130: 149–56.
- 9 Caterson ID, Hubbard V, Bray GA et al. Prevention Conference VII: obesity, a worldwide epidemic related to heart disease and stroke: Group III: worldwide comorbidities of obesity. Circulation 2004; 110: e476–83.
- 10 Kushida CA, Littner MR, Morgenthaler T et al. Practice parameters for the indications for polysomnography and related procedures: an update for 2005. Sleep 2005; 28: 499–521.
- 11 Flemons WW, Douglas NJ, Kuna ST et al. Access to diagnosis and treatment of patients with suspected sleep apnea. Am. J. Respir. Crit. Care Med. 2004; 169: 668–72.
- 12 Young T, Evans L, Finn L et al. Estimation of the clinically diagnosed proportion of sleep apnea syndrome in middle-aged men and women. Sleep 1997; 20: 705–6.
- 13 Yusuf S, Reddy S, Ounpuu S et al. Global burden of cardiovascular diseases: part I: general considerations, the epidemiologic transition, risk factors, and impact of urbanization. Circulation 2001; 104: 2746–53.
- 14 Lopez AD, Murray CJL, World Health Organization, World Bank, Harvard School of Public Health. The Global Burden of Disease: A Comprehensive Assessment of Mortality and Disability from Diseases, Injuries, and Risk Factors in 1990 and Projected to 2020. Harvard School of Public Health on behalf of the World Health Organization and World Bank; Distributed by Harvard University Press, Cambridge, MA, 1996.
- 15 Du S, Lu B, Zhai F et al. A new stage of the nutrition transition in China. Public Health Nutr. 2002; 5: 169–74.
- 16 Wang H, Du S, Zhai F et al. Trends in the distribution of body mass index among Chinese adults, aged 20–45 years (1989–2000). Int. J. Obes. (Lond) 2007; 31: 272–8.
- 17 Collop NA, Anderson WM, Boehlecke B et al. Clinical guidelines for the use of unattended portable monitors in the diagnosis of obstructive sleep apnea in adult patients. Portable Monitoring Task Force of the American Academy of Sleep Medicine. J. Clin. Sleep Med. 2007; 3: 737–47.
- 18 Alonso Alvarez Mde L, Teran Santos J, Cordero Guevara J et al. [Reliability of home respiratory polygraphy for the diagnosis of sleep apnea-hypopnea syndrome: analysis of costs]. Arch. Bronconeumol. 2008; 44: 22–8.
- 19 China NBSPR. China Statistical Yearbook 2007, 26th edn. China Statistics Press, 2007.
- 20 Ip M, Chung KF, Chan KN et al. Previously unrecognized obstructive sleep apnea in Chinese subjects with essential hypertension. Lung 1999; 177: 391–400.
- 21 Netzer NC, Stoohs RA, Netzer CM et al. Using the Berlin Questionnaire to identify patients at risk for the sleep apnea syndrome. Ann. Intern. Med. 1999; 131: 485–91.
- 22 ICH Harmonised Tripartite Guideline, Guideline for Good Clinical Practice, E6(R1). 1996. [Accessed 3 June 2010]. Available from URL: http://www.ich.org/LOB/media/MEDIA482.pdf
- 23 Barzi F, Patel A, Gu D et al. Cardiovascular risk prediction tools for populations in Asia. J. Epidemiol. Community Health 2007; 61: 115–21.
- 24 Zhou BF. Effect of body mass index on all-cause mortality and incidence of cardiovascular diseases—report for meta-analysis of prospective studies open optimal cut-off points of body mass index in Chinese adults. Biomed. Environ. Sci. 2002; 15: 245–52.
- 25 Chobanian AV, Bakris GL, Black HR et al. The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure: the JNC 7 report. JAMA 2003; 289: 2560–72.
- 26 Johns MW. A new method for measuring daytime sleepiness: the Epworth sleepiness scale. Sleep 1991; 14: 540–5.
- 27 Heitman SJ, Atkar RS, Hajduk EA et al. Validation of nasal pressure for the identification of apneas/hypopneas during sleep. Am. J. Respir. Crit. Care Med. 2002; 166: 386–91.
- 28 EEG arousals: scoring rules and examples: a preliminary report from the Sleep Disorders Atlas Task Force of the American Sleep Disorders Association. Sleep 1992; 15: 173–84.
- 29 Rechtschaffen A, Kales A. A Manual of Standardized Terminology, Techniques and Scoring System for Sleep Stages of Human Subjects. University of California Los Angeles, Brain Information Service, 1968.
- 30 Sleep-related breathing disorders in adults: recommendations for syndrome definition and measurement techniques in clinical research. The Report of an American Academy of Sleep Medicine Task Force. Sleep 1999; 22: 667–89.
- 31 Iber C, Redline S, Kaplan Gilpin AM et al. Polysomnography performed in the unattended home versus the attended laboratory setting—Sleep Heart Health Study methodology. Sleep 2004; 27: 536–40.
- 32 Golbin JM, Somers VK, Caples SM. Obstructive sleep apnea, cardiovascular disease, and pulmonary hypertension. Proc. Am. Thorac. Soc. 2008; 5: 200–6.
- 33 Ruehland WR, Rochford PD, O'Donoghue FJ et al. The new AASM criteria for scoring hypopneas: impact on the apnea hypopnea index. Sleep 2009; 32: 150–7.
- 34 Bland JM, Altman DG. Statistical methods for assessing agreement between two methods of clinical measurement. Lancet 1986; 1: 307–10.
- 35 Wilson EB. Probable inference, the law of succession, and statistical inference. J. Am. Stat. Assoc. 1927; 22: 209–12.
- 36 Flemons WW, Littner MR. Measuring agreement between diagnostic devices. Chest 2003; 124: 1535–42.
- 37 Shanghai Municipal Office of Medical Insurance. Shanghai Municipal Human Resources and Social Security Bureau, Shanghai, 2009.
- 38 Miniati M, Monti S, Bottai M. A structured clinical model for predicting the probability of pulmonary embolism. Am. J. Med. 2003; 114: 173–9.
- 39 Wicki J, Perneger TV, Junod AF et al. Assessing clinical probability of pulmonary embolism in the emergency ward: a simple score. Arch. Intern. Med. 2001; 161: 92–7.
- 40 Vazquez JC, Tsai WH, Flemons WW et al. Automated analysis of digital oximetry in the diagnosis of obstructive sleep apnoea. Thorax 2000; 55: 302–7.
- 41 Ragette R, Wang Y, Weinreich G et al. Diagnostic performance of single airflow channel recording (ApneaLink) in home diagnosis of sleep apnea. Sleep Breath. 2009; 10.1007/s11325-009-0290-2.
- 42 Erman MK, Stewart D, Einhorn D et al. Validation of the ApneaLink for the screening of sleep apnea: a novel and simple single-channel recording device. J. Clin. Sleep Med. 2007; 3: 387–92.
- 43 Chen H, Lowe AA, Bai Y et al. Evaluation of a portable recording device (ApneaLink) for case selection of obstructive sleep apnea. Sleep Breath. 2009; 13: 213–19.
- 44 Ng SS, Chan TO, To KW et al. Validation of a portable recording device (ApneaLink) for identifying patients with suspected obstructive sleep apnoea syndrome. Intern. Med. J. 2009; 39: 757–62.
- 45 Ghegan MD, Angelos PC, Stonebraker AC et al. Laboratory versus portable sleep studies: a meta-analysis. Laryngoscope 2006; 116: 859–64.
