28.01.2016

Which option to choose? Breathing disorder limited procedure, polygraphy, or polysomnography.

 

The article was published in the TU+ Health News newsletter on 13 January 2016.

Sleep-related breathing disorders are a frequent health problem, accounting for up to 30% of all sleep disorders. Sleep apnoea is the most common sleep-related breathing disorder, in the case of which the airways collapse partially or completely for at least 10 seconds, causing the decreasing of oxygen in the body and disturbances in normal sleep rhythm. Sleep apnoea is present in up to 24% of middle-aged
men and 9% of women. If sleep apnoea persists for a longer time, daytime disorders also occur.

The amount of deep sleep has decreased and the person feels tired and dizzy during the day. Sleep-related breathing disorder should be considered and the sleep centre contacted if there is daytime sleepiness, sleep does not ensure a rested feeling, despite of sufficiently long sleep there is unexplained tiredness or also insomnia. A breathing disorder should also be considered in case there are night awakenings due to holding one’s breath, gasping for air, or there are morning headaches. Bedfellows could also complain about their fellow bedfellow’s snoring or breaks from breathing. A general practitioner or physician should definitely be consulted about sleep apnoea in the case of obesity, hypertension, coronary heart disease, history of heart attack or stroke, cardiac failure, type two diabetes,
atrial fibrillation, or reflux. Higher risk for sleep apnoea threatens men, people over 50; women with a neck diameter over 40 cm and men with a neck diameter over 43 cm. Sleep apnoea is often also present in the case of mood disorders, depression,
difficulties concentrating, and memory disorders.

Breathing disorders generally get worse when consuming alcohol in the evening as well as when using sleep inducing drugs (opiates).
The main complaint of sleep apnoea is excess daytime fatigue, occurring in peaceful and monotonous situations (sitting, reading, driving the car, watching TV, eating, talking). For women, excess daytime fatigue might not be the primary complaint indicating sleep apnoea, but they could have insomnia, poor, restless sleep, increasing mood disorders and depression, bad mood, various pains in the body.

Excess daytime fatigue is the most frequent serious side effect of sleep apnoea. In case of long-term sleep apnoea, the patient might get used to the fatigue and consider concurrent troubles concentrating, memory disorders, and sleepiness while driving ordinary and normal. The patient shall understand what a danger he was to himself and other road users only after applying the treatment. In order to determine sleep-related breathing disorder, you should come to a sleep doctor’s appointment where your complaints and their duration shall be specified. Possibly, the doctor might need specified information about sleeping habits from the patient’s bedfellow.

In order to determine the quality of a patient’s sleep, the bedtime, waking up time, and the existence of night awakenings need to be identified. Certain devices are used in the sleep centre to assess the sleep-wakefulness rhythm: actimetry devices that the patient wears on the wrist for 10-14 days. It is important to find out what causes the night awakenings: whether the frequent use of the toilet (might be linked with both blood pressure disease and sleep apnoea) or the patient waking up due to his own breathing rhythm disturbances. Situations in which spouses wake up due to one another’s snoring are frequent. In this case, it must be determined whether it is caused by a dangerous breathing disorder. The recommended primary test method is screening: breathing disorder limited procedure. It is possible that the general practitioner may refer the patient to further procedures
in a sleep lab/centre.

 

Research Options

The history of sleep research started in 1929 when a German researcher Berger first recorded human brain waves and laid the foundation for sleep research. Modern sleep research presumes the use of quickly accessible research methods that allow us to recognise conditions which require treatment without overloading the patient. Sleep research is based on the condition that the more difficult and severe the disorder, the more bodily indicators needed to detected to find the disease and prescribe the cure. Currently, three main types of devices are used, which are screening devices, polygraphy, and polysomnography.

Modern sleep medicine centres and laboratories follow the guidelines of the American Academy of Sleep Medicine that highlights which patient groups can be examined at home and who should be examined at a medical institution. The advantage of a home procedure is comfort because the patient is in a familiar environment, goes to bed in a safe place and at a safe time. However, the quality of the procedure could suffer because medical staff is not monitoring the procedure at the sleep centre, due to which the procedure needs to be repeated. In case the home procedure turns out to be of low quality, the recurring procedure shall be performed in the sleep centre. At home, the breathing disorder procedure can be performed if the doctor suspects moderate or severe sleep apnoea based on the survey and there are no diseases, due to which the procedure would be more practical to be conducted in the sleep centre.

 

Breathing Disorder Limited Procedure

Why is it used: used as diagnostic procedure for discovering breathing disorders in the sleep centre. The procedure does not differentiate between breathing disorder types. Used as a screening in first level health care by giving a yes/no answer for the probability of sleep apnoea.
Where the procedure is performed: in an outpatient setting (at patient’s home).
Who gives the patient the results: depending on the objective of the procedure, either a sleep medicine specialist (in case of diagnostic procedure) or a general practitioner (screening).
How the procedure is performed: giving guidelines on attaching the procedure device to the patient. The patient shall be given precise instructions in the center, over a period of half an hour, on how to attach the device to himself. Attaching the device to the body only takes a few minutes at home. A sensor that measures breathing shall be placed into the nostrils, a device with movement sensor and recorder shall be placed around the thorax to measure breathing effort, and a sensor monitoring body’s oxygen supply shall be placed at the fingertip. Breathing disorder limited procedure can be used for diagnosing sleep apnoea only in the sleep centre and only by a trained specialist. The procedure can used only on these patients who are suspected of suffering from moderate and severe sleep apnoea and who have no other concurrent diseases which are the contraindication of conducting a home procedure.
What happens after the procedure: depending on the results, the patient can be referred to the sleep centre for an additional consultation, as required.

 

Polygraphy

Why is it used: diagnostic procedure. Allows to diagnose the occurrence of the following sleep-related breathing disorders: obstructive sleep apnoea, central sleep apnoea, mixed type sleep apnoea, sleep-related hypoventilation, sleep-related hypoxemia.
Where the procedure is performed: in an outpatient (at patient’s home) or inpatient setting (at the sleep centre).
Who gives the results to the patient: a sleep medicine specialist.

How the procedure is performed: attaching the test device to the patient’s body takes about 1 hour. Depending on the objective of the procedure, a different amount of sensors is attached to the examinee, which allows the following to be measured: ECG, oxygen content in the body, airflow changes in airways, breathing effort, heart rate, body position, limb movements, and the sound of snoring. In the sleep laboratory, a transcutaneous capnography sensor could also be added to the procedure to identify hypoventilation in order to determine carbon dioxide accumulation in the body through the skin. What happens after the procedure: patient is prescribed appropriate treatment method (PAP-treatment – treatment with a positive airway pressure device; intra-oral occlusion invisalign; surgical treatment that ensures nasal breathing, plastic surgical treatment for tightening the pharyngeal region; other sleep disorder treatment).

 

Polysomnography

Why is it used: diagnostic procedure. Allows for different sleep-related breathing disorders to be diagnosed: obstructive sleep apnoea, central sleep apnoea, mixed type sleep apnoea, sleep-related hypoventilation, and sleep-related hypoxemia.

In addition to sleep-related breathing disorders, polysomnography also permits the diagnosis of other sleep disorders, such as: other disorders with excess daytime fatigue (e.g. narcolepsy), parasomnias (sleep-related movement disorders), insomnias (forms that are not easily controlled by treatment), periodic limb movement disorder, night epilepsy.

Where the procedure is performed: in an inpatient setting (at the sleep centre).

Who gives the results to the patient: a sleep medicine specialist.

 

How the procedure is performed: attaching the test devices to the patient’s body takes about 1.5 hour. Sensors that measure the following are attached to the examinee: brain waves, eye muscle activity, ECG, muscle activity from jaw region muscles, oxygen content in the body, airflow changes in airways, breathing effort, heart rate, body position, limb movements, snoring sound, and video recording for the entire night. In the sleep laboratory, a transcutaneous capnography sensor may also be added to the procedure to identify hypoventilation, in order to determine carbon dioxide accumulation in the body through the skin.

 

What happens after the procedure: patient is prescribed the appropriate treatment method (PAP-treatment – treatment with a positive airway pressure device; intra-oral occlusion invisalign; surgical treatment that ensures nasal breathing, plastic surgical treatment for tightening the pharyngeal region; other sleep disorder treatment). The treatment outcome must be assessed depending on the sleep disorder. A breathing limited procedure shall be used for this purpose, which can also be performed at the patient’s home, in order to assess the efficiency of snoring invisalign and pharyngeal region surgical treatment. In case a positive airways pressure device is prescribed as a sleep apnoea treatment, its compliance and outcome could also be monitored over a cloud solution and the patient does not have to come to the centre, as the possible problems are solved interactively.

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