Level of recommendation (Standard, Guideline, and Option) definitions are provided at the end of the "Major Recommendation" field.
Type 2 Portable Monitoring (PM) Devices: Comprehensive Portable Polysomnography
- The clinical use of Type 2 PM devices in the attended setting is not recommended to evaluate patients with suspected obstructive sleep apnea (OSA). (Option)
- The clinical use of Type 2 PM devices in the unattended setting is not recommended to evaluate patients with suspected OSA. (Option)
Type 3 PM Devices: Modified Portable Sleep Apnea Testing
Recommendations concerning the use of Type 3 PM devices to reduce the probability that a patient has an apnea-hypopnea index (AHI) less than 15 (i.e., rule out a diagnosis of OSA at a level selected by the review-paper authors for their statistical cutoff; this is also one of the levels set by Medicare to reflect a level of significance)
- The use of some Type 3 PM devices in an attended setting can decrease the probability that the patient has an AHI greater than 15. (Standard)
- The use of Type 3 PM devices in an unattended setting is not recommended to decrease the probability that the patient has an AHI greater than 15. (Guideline)
Recommendations concerning the use of Type 3 PM devices to increase the probability that a patient has an AHI greater than 15 (i.e., rule in a diagnosis of OSA at a level selected by the review-paper authors for their statistical cutoff; this is also one of the levels set by Medicare to reflect a level of significance)
- Some Type 3 PM devices can be used in an attended setting to increase the probability that a patient has an AHI greater than 15. (Standard)
- The use of Type 3 PM devices in an unattended setting is not recommended to increase the probability that a patient has an AHI greater than 15. (Guideline)
Recommendations concerning the use of Type 3 PM devices to both increase and decrease the likelihood that a patient has a diagnosis of OSA with a single threshold, which is the most practical clinical use.
- The use of Type 3 PM devices may be acceptable in an attended in-laboratory setting to both rule in and rule out a diagnosis of OSA. Such a use, however, would require limitations (see original guideline document). (Flemons et al., 2003; sections 4.1.3 and 4.3.2.4) (Standard)
- The use of Type 3 PM devices in an unattended setting is not recommended to rule in and rule out a diagnosis of OSA. (Guideline)
Type 4 PM Devices: Continuous Single Or Dual Bioparameter Recording
Recommendations concerning the use of Type 4 PM devices in the attended setting to increase, decrease, or both increase and decrease the probability of the patient having an AHI greater than 15.
- The routine use of Type 4 PM devices with oximetry and at least one other airflow parameter in an attended setting is not recommended to increase the probability that a patient has an AHI greater than 15. (Option)
- The routine use of Type 4 PM devices with oximetry and at least one other airflow parameter in an attended setting is not recommended to decrease the probability that a patient has an AHI greater than 15. (Option)
- The routine use of Type 4 PM devices with oximetry and at least one other airflow parameter is not recommended in an attended setting to both increase and decrease the probability that a patient has an AHI greater than 15. (Option)
Recommendations concerning the use of Type 4 PM devices in the unattended setting to increase, decrease, or both increase and decrease the probability of a patient having an AHI greater than 15.
- The use of Type 4 PM devices in the unattended setting with oximetry and one other airflow parameter is not recommended for diagnosing OSA or confirming that a patient has an AHI greater than or less than 15. (Guideline)
Areas Requiring Special Attention
- The use of PM devices is not recommended for general screening or clinical use without available knowledge of the patient's sleep-related history and complaints.
- The use of PM devices is not recommended in patients with comorbid conditions or secondary sleep complaints because there is little evidence to support the use of PM devices in evaluating these conditions or to diagnose other sleep disorders.
- Even when PM devices are noted as being possibly useful, the general use of all types of devices across that category is not necessarily recommended. The laboratory should confirm that the commercial device selected in a category has specific studies documenting its performance and that it conforms to the use characteristics of that category as a whole.
- The review of raw data and the use of manual scoring for interpreting data from PM devices are recommended.
- Physicians with sleep training and familiarity with the devices and their limitations should interpret studies generated by PM devices and should review the raw data, as noted above. Trained and qualified technicians should perform any technical scoring.
Definitions:
Standard: This is a generally accepted patient-care strategy that reflects a high degree of clinical certainty. The term standard generally implies the use of Level I evidence, which directly addresses the clinical issue, or overwhelming Level II evidence.
Guideline: This is a patient-care strategy that reflects a moderate degree of clinical certainty. The term guideline implies the use of Level II evidence or a consensus of Level III evidence.
Option: This is a patient-care strategy that reflects uncertain clinical use. The term option implies either inconclusive or conflicting evidence or conflicting expert opinion.