Insider’s Guide to Home Sleep Testing for the by Randy Clare
Why is home sleep testing an important tool for sleep apnea treatment providers?
Perhaps the greatest challenge presented to the sleep apnea dentist is the fact that calibrating the oral appliance on an awake patient leaves you with, um,…a well-adjusted awake patient. The patient’s sleep apnea occurs unobserved at night and often one night is not exactly like another night. How then can the clinical team avoid over- and under-titrations (recognized as the major cause of treatment noncompliance)? Or in cases where the clinical team has decided that from a dental perspective, further appliance titration may compromise dentition or raise joint concerns, can they select a combination therapy with CPAP, positional therapy or weight loss to support a dental sleep apnea treatment plan? For years there was no option beyond full in lab polysomnogram (PSG). Even with all of its flaws it would be hard to argue that PSG isn’t the best way to examine sleep efficiency and quantitively evaluate sleep treatments (PAP is perfect for this model). The challenge for dentists is that the cost of attended studies is just too high to use PSG for titration, leaving home sleep testing as the only option. In the United States, insurance companies have begun to resist PSG in favor of home diagnostic for simple sleep apnea (their term, not mine). The great news is that these sleep diagnostic devices are giving dentists the ability to calibrate their appliances with a degree of accuracy that is similar to a CPAP titrated in the sleep lab. Table 1: In 1994 the American Academy of Sleep Medicine divided sleep diagnostic devices into 4 types Type I
Full attended polysomnography (>7 channels) in a laboratory setting
Full unattended polysomnography (> 7 channels)
Limited channel devices (usually 4-7 channels)
1 or 2 channels usually using oximetry as 1 of the parameters
30 DSP | Spring 2017
I feel that when comparing Continuous Positive Airway Pressure (CPAP) therapy with Oral Appliance Therapy (OAT) there are a few major differences generally centered on the initial calibration and ongoing titration. CPAP is titrated in lab with a sleep technician observing the sleeping patient while adjusting the CPAP pressure (often this is the only time the patient’s pressure will be calibrated). Oral Appliances, on the other hand, are titrated in the dental office using subjective patient or bed partner reports of snoring and sleepiness. A further complication is that as patients habituate to the appliance, muscles and ligaments relax and lengthen over the first few months of appliance wear. The patient may be 100% compliant with the appliance however the adjustment may no longer be adequate to maintain a patent airway. The dental relationship is such that the patient will receive an annual or biannual follow-up in order to manage their therapy. Home testing is an important part of this ongoing management of the patient’s sleep apnea. Clearly, using a home sleep diagnostic device gives the clinical team the opportunity to monitor, evaluate and adjust therapy to suit each individual’s needs. So how to select an HST device that will provide enough clinical value while at the same time be simple enough for the patient to use unattended in their home?