What Is Home Sleep Apnea Testing?

By Brandon Peters, MD

No one really sleeps very well in a sleep laboratory for an overnight sleep study. Clearly there are better ways to sleep. Many patients question the results of their testing when they have a bad night of sleep. What is the alternative? Fortunately, home sleep apnea testing may be an attractive consideration. What is home sleep apnea testing (HSAT)? Consider this convenient option, whether it might be appropriate to diagnose your sleep disorder, and the costs and limitations associated with home sleep studies.

What Is Home Sleep Apnea Testing?

As the name implies, home sleep apnea testing is the administration of a sleep study in the comfort of your home for the diagnosis of obstructive sleep apnea. There are various devices available for this testing. These might be accessed through a sleep specialist, primary care provider, or even independent for-profit companies.

Most home sleep apnea testing measures parameters useful to detect sleep-disordered breathing. Though devices vary, many detect blood oxygen levels with an oximeter, heart rate, breathing effort with a stretchy abdominal belt, snoring vibrations, and airflow through the nose with an oxygen cannula. Some devices record further measures, such as limited brain waves for sleep staging, sleep position, and even movements.

Is Home Sleep Apnea Testing Right for Me?

There are specific criteria that are used to identify patients who can undergo home sleep apnea testing. These guidelines will maximize the success of the test and ensure the proper diagnosis.

Currently, it is recommended that pediatric patients still undergo an attended diagnostic polysomnogram. Therefore, HSAT is restricted to those people who are 18 years or older. Those with a high likelihood of moderate to severe sleep apnea based on presenting symptoms and contributory anatomy should be selected for home testing. Some of the most important symptoms include:

• Loud snoring

• Witnessed apnea (pauses in breathing during sleep)

• Excessive daytime sleepiness (Epworth score >10)

• Nocturia (waking frequently to urinate)

• Bruxism (teeth grinding or clenching)

• Fragmented sleep with insomnia

• Obesity

• Middle to older age (Including post-menopausal women) 

It is often important for a board-certified sleep specialist to evaluate you to determine the appropriate test for you. In some cases, there may be contraindications to home sleep testing.

Conditions That Require In-Lab Sleep Study Evaluations

Due to the nature of the testing and its limitations, the following exclusion criteria are observed. In some cases, the factor may interfere with the proper administration of the test at home. There are also some medical conditions in which a formal sleep study in a testing center is required to properly diagnose the disorder. The most common reasons to not to have a home sleep apnea test include:

• Cognitive or language barriers that interfere with test administration

• Moderate to severe pulmonary disease

• Neuromuscular disease

• Congestive heart failure

• Suspected central sleep apnea

• Suspected periodic limb movement disorder (PLMD)

• Primary insomnia

• Circadian rhythm disorders

• Parasomnias

• Narcolepsy 

Testing may be considered on a case-by-case basis among patients who are unable to have attended polysomnography due to immobility, safety, or critical illness concerns. Patients who are insured by Medicare may require a higher index of suspicion given the more stringent scoring criteria used.

Arranging and Performing a Home Sleep Apnea Study

Patients who have been screened and are deemed appropriate for HSAT will proceed with evaluation. After your doctor has ordered the study, a technician or medical assistant will demonstrate how to apply the equipment. You will take it home and perform the test, typically over one or two nights. After the testing has been completed, the device is returned to be downloaded so the doctor can review the data and make a diagnosis and treatment recommendations.

The Pros and Cons of Home Sleep Apnea Testing

There are certain obvious benefits to having a home sleep apnea test. One of the biggest attractions is the greater convenience being able to sleep in your own bed at home. If you are a responsible caretaker for another person, including children, this may make things easier. There are fewer wires required for measurement, which makes the testing less intrusive and more comfortable. The testing is generally less expensive, often costing just several hundred dollars compared to the more than $1000 that in-lab studies frequently cost. Due to the increasing availability, it might be done more quickly with a speedy turnaround to start treatment.

Before choosing to have a home sleep apnea test, you should also consider the potential cons to this testing. As noted, this testing is used to diagnose obstructive sleep apnea alone. It is not appropriate for the evaluation of central sleep apnea, insomnia, restless legs syndrome, circadian disorders, parasomnias, narcolepsy, seizures, and other disorders.

If the test comes back as negative, with a normal result, this may not necessarily be accurate. Mild sleep apnea may be missed. This is especially important in younger women and people of normal body weight. Any time spent awake will reduce the average number of sleep apnea events observed per hour. This could change the diagnosis or lead to a false sense of normalcy. If something goes wrong in the application of the sensors or the measurements recorded, the test may have to be repeated.

Generally, if the home sleep apnea test fails to diagnose sleep apnea, an in-lab test will be recommended to definitely evaluate the condition. If central sleep apnea is detected with a home sleep apnea test, an attended titration study for bilevel therapy is often needed. If the test does show sleep apnea, it will be easy to move along to treatment.

If you are interested in learning more about home sleep apnea testing as an option, find a board-certified sleep specialist near you and get evaluated to finally get the therapy and quality rest that you need.

Source:

Collop NA et al. “Clinical Guidelines for the Use of Unattended Portable Monitors in the Diagnosis of Obstructive Sleep Apnea in Adult Patients.” Journal of Clinical Sleep Medicine. 2007;3(7):737-747.

How to Use Fitness Trackers for Sleep Improvement

By Brandon Peters, MD

If you have purchased a fitness tracker, like millions of others, you may wonder how to use the wearable device to improve your sleep. These sleep trackers may provide some valuable insight into an important of health and well-being. They can also be completely useless. What do these wearables measure? How accurate are these measurements? How do they differ from medical sleep studies? Importantly, how should the information collected be used to make changes to improve sleep and reduce insomnia? Let’s consider these important questions and discover how to use fitness trackers to sleep better.

What Sleep Metrics Do Wearable Fitness Trackers Measure?

There are many wearable devices available that can be used to track fitness goals and even sleep. Some of the most popular options include the FitBit and Apple Watch. There are also smartphone apps, smart beds, mattress pads, and stand-alone products that can track sleep metrics. What kind of information is collected?

Movement

Most devices are tracking movement. There are variations on actigraphy. This measures movement velocity and direction with an accelerometer. It may be assumed that stillness equates with sleep, and movement corresponds with activity.

Biometrics

Sophisticated devices may detect breathing patterns, heart rate, or oxygen levels. It may even be possible to measure electrical current conductivity within the skin. Sound may also be detected, sometimes via vibration, that may correspond with snoring.

Schedule

Timing is important to sleep quality. It may also be possible to input information about your bedtime, wake time, and even naps to help track sleep patterns over an extended period. This information is often collected via sleep logs and may help to identify circadian rhythm disorders.

Environmental Characteristics

Some devices may also be able to identify other environmental characteristics, such as lighting, temperature, and noise. These may be useful to support the other variables that are measured. If the room is dark, it is nighttime, and a person is not moving, it is more likely that they would be asleep.

How Accurate Are Sleep Trackers?

It is natural to wonder how accurate sleep trackers are in measuring the characteristics of sleep. If you were dieting and using a scale, you would certainly want to ensure the weight that it was reporting was close to reality, both true to the actual value (accuracy) and repeatable over time (precision).

Sleep is more than just lying still. Someone could lie perfectly still and a wearable may believe this inactivity corresponds to sleep. Similarly, movements may occur during sleep that do not necessarily correspond with complete wakefulness. Many awakenings will go unnoticed by an individual as it can take more than 5 minutes of wakefulness before a memory is generated.

It is possible that other measurements may help to strengthen the accuracy of these observations. Breathing becomes very regular in deep, slow-wave sleep. This may indicate a person has fallen asleep. Heart rate patterns, oxygen levels, and other biometric measurements may help improve accuracy.

Unfortunately, many sleep trackers are products that are designed for consumers without scientific validation. The measurements may not be either accurate or reproducible. Artifact may interfere with the measurements. Moreover, the collected information may not correspond to the gold standard measurements.

Comparing Information to Sleep Testing and Studies

When sleep is measured by a diagnostic polysomnogram in a sleep center, there are a number of important characteristics. These include the brain wave activity as measured by EEG, muscle tone, the movement of eyes, other body movements, and sometimes additional data. No fitness trackers are able to collect all of these data. The nightly sleep patterns they provide—showing light, deep, and even REM sleep—are not as accurate as the information gathered with formal sleep testing.

In fact, sleep trackers are perhaps closest to an actigraph, a small wristwatch-like device that measures movement to give a rough pattern of sleep and wakefulness. These data can be very difficult to interpret, even by expert researchers, and the messy signals may be inscrutable to an algorithm. What is a person to do? How can you use the data that is collected via a wearable sleep tracker to optimize your sleep?

How to Use Data to Improve Sleep

Though the data collected by wearables or other sleep trackers may be imperfect, it can still be useful. It may be important to take a bird’s eye view of the information that is collected. Consider these simple recommendations:

1. Trust your own experiences.

Before buying into the data collected by an imprecise, and possibly wholly inaccurate device, reflect on your own sense of how you are sleeping. Do you recall waking 30 times in the night? Do you remember dreaming, even though the device reported no dream sleep? Are you having difficulty explaining the sleep pattern it provides? If you feel like you are sleeping well, consider simply ignoring the sleep data your device may provide.

2. Use the information to reinforce good sleep habits.

It is helpful to keep a regular sleep-wake schedule. Get up at the same time every day, including weekends. Try to get 15 to 30 minutes of sunlight upon awakening. Go to bed at about the same time every day. Go to bed when you are feeling sleepy. Try to get at least 7 to 9 hours of sleep nightly, meeting your own sleep needs. Avoid naps when possible. If the sleep tracker helps to reinforce a regular schedule, it may be useful.

3. Don’t sweat the details.

There is evidence that data collected by sleep trackers can stress people out. It can add to anxiety and make insomnia worse. People become obsessed with the details, trying to explain every little blip in the data. If you find this is leading to obsessive behaviors for you, this could be a problem. Let it go. It may not be accurate anyway.

4. Corroborate the data with witness testimony.

There may be some inexplicable findings from your sleep tracker data. Perhaps some unremembered steps accumulated in the night. There may be frequent awakenings or restless sleep. The device may even report loud snoring. Try to verify these reports by asking a witness: consider questioning a bed partner. Learn if you sleepwalk, restlessly toss in the night, or rattle the windows with snoring. If there is a discrepancy, consider gathering more information before jumping to any conclusions.

5. If you are not sleeping well, get help.

Many people use sleep trackers because they are not sleeping well. They are hopeful that they may learn a little bit about why they are having difficulty sleeping. If the insomnia persists, this search can become desperate. Although some insight may be gleaned, more evaluation may be necessary. If you have poor sleep, especially if you have trouble sleeping through the night with frequent awakenings or experience daytime sleepiness, get evaluated by a board-certified sleep physician to sort out what might be contributing to your troubles.

Conclusion

It is fun to learn about ourselves. Sleep can be mysterious. Most of the night goes unremembered. It is natural to want to lift the curtain and glimpse a little about what occurs once our eyes close and we fall asleep. Be careful about positing too much faith into the accuracy of sleep trackers. The technology may improve with time, but these devices may be more novelties than serious scientific analyses. If you are struggling to sleep, get help from an expert.

How to Choose a Sleep Doctor

By Brandon Peters, MD

If you are having difficulties sleeping, you may need a referral to a sleep specialist, but how should you choose a sleep doctor? There are certain characteristics that you should consider when selecting a specialist so that you get the appropriate testing and help that you need.

Who is My Sleep Specialist?

There are many individuals who will be involved in your care if you seek treatment for a sleep disorder. You will likely start your evaluation with your primary health care provider. This may result in a referral to a sleep specialist, most often a physician but sometimes a midlevel provider such as a nurse practitioner or a physician’s assistant working under the supervision of a physician. There may be ancillary staff involved as well, including polysomnographic technologists who do the sleep studies.

Sleep Doctor Training

Physicians who are certified as sleep specialists have many years of education. To become a doctor they graduate from college with a four-year degree and attend four years of medical school. They then complete a medical residency and a fellowship in sleep medicine. Many specialists can pursue a sleep fellowship, including: pulmonologists, neurologists, psychiatrists, otolaryngologists (ear, nose and throat specialists) and even general practitioners in family medicine, pediatrics, or internal medicine. Some physicians may dabble in sleep medicine, even if they do not have formal board certification.

Finding a Specialist with Credentials

No matter the specialty training, it is advisable to seek out a physician who is certified with appropriate sleep medicine credentials from the American Board of Medical Specialties. This implies that your doctor’s education has been verified and that they have been able to pass a board examination that tests their knowledge of sleep medicine. If you are to undergo additional sleep testing, you may want to find a sleep center that with accreditation from the American Academy of Sleep Medicine.

Selecting an Appropriate Center

Finding a sleep specialist can be a little intimidating, but once you have found a reputable provider, you may want to evaluate whether he or she can meet your needs. You may rely on friends or family for recommendations. It is also important to consider how your condition may be evaluated. You will want to select a center that can provide a thorough and appropriate evaluation, including any necessary testing such as:

• Home sleep apnea testing

• Polysomnography

• Multiple sleep latency testing (MSLT)

As part of this consideration, you may need to take into account cost as well as your insurance coverage. The resources available to you are always expanding and with a little research you should be able to find a reputable sleep specialist to meet your needs.