What Other Options May Be Considered

The evidence is lacking to support unattended use of a portable monitor in the patient's home as a stand-alone approach to diagnosis of OSA. However, in the proper setting, with appropriate patient selection, and careful follow-up including ready access to attended PSG, unattended Level III home portable studies are feasible. Based on an i ntegration of the evidence available, the following conditions would appear to be necessary:

1. A high pretest probability (i.e., a high prevalence of OSA in the patient population), ideally to exceed 70%. There are a number of equations that use readily available data such as BMI, sex, history of snoring, neck circumference, and so on, or more complicated data such as X-rays of the upper airway with cephalometric measurements (68,71-76).

2. The availability of attended PSG for patients with a strong clinical history and a negative or nondiagnostic portable monitoring study.

3. The availability of treatment including PSG titration for CPAP.

4. An experienced sleep practitioner who is capable of evaluating both the clinical and portable monitoring information.

The approach to CPAP titration is beyond the scope of this chapter; there has been a trend to use auto-titrating positive airway pressure (APAP) machines unattended in the patient's home (see also Chapter 8). The reader is referred to an evidence-based review of the topic and guidelines published by the AASM (77,78) and a Canadian technology review (79), which indicate that unattended use for CPAP titration is not established for CPAP naïve patients. Subsequent to publication of the guidelines, at least one study has provided evidence that APAP can lead to favorable outcomes in CPAP naïve patients (80). In general, such an approach should only be carried out with the knowledge that the evidence for the efficacy of unattended home CPAP titration in CPAP naïve patients is in evolution.

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