Home Care NetWork
Home Care Literature Review: July - December 2006
Sleep Apnea:
Chong MS, Ayalon L, Marler M, Loredo JS, Corey-Bloom J, Palmer BW, Liu L,
Ancoli-Israel S. Continuous positive airway pressure reduces subjective daytime sleepiness in patients with mild to moderate Alzheimer's disease with sleep disordered breathing. J Am Geriatr Soc 2006; 54:777-781
This randomized, controlled, clinical trial of 39 community-dwelling elderly patients with mild-moderate probable Alzheimer disease and sleep-disordered breathing randomly assigned to receive 6 weeks of therapeutic continuous positive airway pressure (CPAP) or 3 weeks of sham CPAP followed by 3 weeks of therapeutic CPAP found that the Epworth Sleepiness Scale (ESS) scores were reduced from 8.89 (baseline) to 6.56 after 3 weeks of treatment (p=.04) and to 5.53 after 6 weeks of treatment (p=.004). In the sham CPAP group, there was no significant difference after 3 weeks of sham CPAP but a significant decrease from 7.68 to 6.47 (p=.01) after 3 weeks of therapeutic CPAP. This is another group of patients with sleep-disordered breathing to show improvements in daytime sleepiness with CPAP. It is particularly impressive that these, albeit mildly, demented patients tolerated CPAP. Given the difficulties with compliance associated with CPAP, I am not sure this would work outside of a clinical trials setting.
Nilius G, Happel A, Domanski U, Ruhle KH. Pressure-relief continuous positive airway pressure vs constant continuous positive airway pressure: a comparison of efficacy and compliance. Chest 2006; 130:1018-1024
This German case series used the crossover design compared polysomnographic data and compliance in sleep apnea patients receiving standard continuous positive airway pressure (CPAP) and pressure-relief CPAP (PRCPAP) [C-flex; Respironics; Murrysville, PA] as first treatment in the sleep laboratory and subsequently at home. The average apnea-hypopnea index was 5.8/h with CPAP, and 7.0/h with PRCPAP (compared with a reference of 53.3/h in the sleep laboratory). The central apnea index was 0.7/h with CPAP and 1.2/h with PRCPAP (p < 0.05). Compliance after 7 weeks was, on average, 9.4 min longer with PRCPAP than with CPAP (NS); all other measures were comparable. There were no clear advantages for either treatment in this study.
Abraham WT, Trupp RJ, Phillilps B, Bourge RC, Bailey B, Harding SM, Schofield P,
Pilsworth S, Shneerson JM, Di Salvo T, Camuso J, Johnson D, King M, Javaheri S. Validation and clinical utility of a simple in-home testing tool for sleep-disordered breathing and arrhythmias in heart failure: results of the Sleep Events, Arrhythmias, and Respiratory Analysis in Congestive Heart Failure (SEARCH) study. Congest Heart Fail 2006; 12:241-247
This prospective, multicenter case series evaluated 50 patients with New York Heart Association class III systolic heart failure and compared the diagnostic accuracy of a home-based cardiorespiratory testing system with standard attended polysomnography. Using diagnostic cutoff points of ≥5, ≥10, and ≥15 events per hour for respiratory disturbance severity, polysomnography detected a sleep-disordered breathing prevalence of 69%, 59%, and 49%, respectively. Compared with polysomnography, the cardiorespiratory testing system had positive predictive accuracies of 73%, 73%, and 75%. These numbers improved to 87%, 87%, and 83%, respectively, when analysis of covariance suggested reanalysis omitting one site's data. Another study suggesting home monitoring may be a reasonable alternative to attended polysomnography, this time in patients with heart failure.
Michaelson PG, Allan P, Chaney J, Mair EA. Validations of a portable home sleep study with twelve-lead polysomnography: comparisons and insights into a variable gold standard. Ann Otol Rhinol Laryngol 2006; 115:802-809
This case series of 59 patients presenting to a single sleep laboratory with symptoms of obstructive sleep apnea exam on the correlation coefficient, receiver operating characteristic curve analysis, and the Bland-Altman curves, as well as sensitivity, specificity, interreader variability, positive predictive value, and negative predictive value and found "statistically sound" correlation the accuracy in terms of apnea-hypopnea index SNAP (SNAP Laboratories, LLC, Wheeling, Illinois), a portable home sleep test, with overnight polysomnography. The small study will probably not convince those who are skeptical about home testing for obstructive sleep apnea, but, while the SNAP system was not perfect, it did seem reasonably sensitive in this study.
Home Care Literature Reviews 2004
Sleep Apnea:
DeMolles DA, Sparrow D, Gottlieb DJ, Friedman R. A pilot trial of a telecommunications system in sleep apnea management. Med Care. 2004;42:764-9.
This randomized clinical trial of continuous positive airway pressure (CPAP) for therapy for obstructive sleep apnea syndrome (OSAS) assigned patients to the use of a computer telephone system designed to improve CPAP adherence (telephone-linked communications for CPAP [TLC-CPAP]) in addition to usual care (n = 15) or to usual care alone (n = 15) for a period of 2 months. The TLC-CPAP system monitors patients' self-reported behavior and provides education and reinforcement through a structured dialogue. Patients randomized to TLC-CPAP had fewer reported sleep-related symptoms (9.4 vs. 13.4, p = 0.047) than those receiving usual care. The average nightly CPAP use in the TLC-CPAP group was 4.4 hours compared with 2.9 hours (p = 0.076) in the usual-care group. This pilot study needs to be confirmed by a larger scale study but it does support the effectiveness of computer based patient training and monitoring in improved adherence with CPAP.
Lankford DA. Wireless CPAP patient monitoring: accuracy study. Telemed J E Health. 2004;10:162-9.
This study compared data from a novel method for transmitting continuous positive airway pressure treatment (CPAP) compliance and usage using wireless and Internet technology to transmit/receive clinical data with the same data collected using a direct down-load to a PC during a clinic visit in 21 adults who had been previously diagnosed with obstructive sleep apnea (7 stable CPAP users for ≥ one year and 14 new users). There was 100% agreement between data sets transmitted wirelessly and the same data set downloaded onsite across all six clinical parameters. This study demonstrates the reliability of this wireless technology for transmitting compliance and efficacy data in both new and established users of CPAP. Potential benefits of this technology include advanced compliance and efficacy along with a potential reduction in health-care costs. One can imagine using the technology described in this study with the technology in the preceding study to further improve adherence in OSA. As with the prior study, this pilot study is suggestive but the value of this technology must be confirmed in larger trials.
Noseda A, Kempenaers C, Kerkhofs M, Braun S, Linkowski P, Jann E. Constant vs auto-continuous positive airway pressure in patients with sleep apnea hypopnea syndrome and a high variability in pressure requirement. Chest. 2004;126:31-7.
This Belgium single-blind, randomized, cross-over study (2 x 8 weeks) compared auto-CPAP with constant CPAP in 24 patients judged to be good candidates for auto-CPAP because of a high within-night variability in pressure requirement. The percent of nights on the machine, median apnea index were not different but the mean Epworth sleepiness score was significantly (p < 0.01) lower on auto-CPAP (5.1; SD, 2.8). The differences between auto-CPAP and regular CPAP were not impressive in this selected group.
Su S, Baroody FM, Kohrman M, Suskind D. A comparison of polysomnography and a portable home sleep study in the diagnosis of obstructive sleep apnea syndrome. Otolaryngol Head Neck Surg. 2004;131:844-50.
This case series of 60 subjects with obstructive sleep apnea compared in portables sleep monitoring device with and laboratory polysomnography to assess technical and reader variability and found no significant difference between total number of apneas and hypopneas, respiratory disturbance index, and minimum oxygen obtained by the two systems. There was a significant difference between sleep time and mean oxygen. This study demonstrated reasonable validity for a convenient portable device. Studies like this continue to increase our confidence in the relatively inexpensive screening devices can be useful in diagnosing constructed sleep apnea.
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