By Lawrence J. Epstein, MD

Out of center sleep testing (OCST) technology has been around for a long time, but evidence supporting its use has taken time to develop. Practice parameters from the American Academy of Sleep Medicine (AASM) and the American Sleep Disorders Association (the precursor to the AASM) in 1994 (1), 1997 (2), and 2003 (3) found the evidence insufficient to warrant widespread clinical use. It was not until 2007 that sufficient supporting data were published to allow development of clinical guidelines with recommendations for adoption of OCST.

Validation studies to date have shown OCST can be effectively utilized in properly selected and well-managed patients. Kuna et al found that the clinical outcome and treatment adherence of patients who were diagnosed with obstructive sleep apnea using OCST and were treated with autotitrating positive airway pressure (APAP) were not inferior to those patients diagnosed by in-laboratory polysomnography and treated with fixed pressure CPAP determined through in-laboratory titration.(4)

They studied more than 200 veterans, and at the end of 3 months of treatment, the patients in the OCST pathway had slightly higher CPAP adherence and slightly greater improvement on their Functional Outcomes of Sleep Questionnaire.

In their study of 373 patients, Rosen et al found that outcomes for patients randomized to OCST plus APAP were also not inferior to in-laboratory PSG and CPAP titration.5 They found that PAP adherence was slightly higher in the OCST group and functional outcomes were similar. A cost analysis found significant financial savings with the OCST model compared to the PSG model. A concern with generalizing these studies to broad scale use of OCST is how to maintain the types of appropriate patient selection and management protocols that were utilized.

1. American Sleep Disorders Association Report. Standards of Practice Committee. Practice parameters for the use of portable recording in the assessment of obstructive sleep apnea. Sleep. 1994;17:372-7.
2. American Sleep Disorders Association Report. Standards of Practice Committee. Practice parameters for the indications for polysomnography and related procedures. Sleep. 1997;20:406-22.
3. Chesson AL, Berry R, Pack A. Practice parameters for the use of portable monitoring devices in the investigation of suspected obstructive sleep apnea in adults. A joint project sponsored by the American Academy of Sleep Medicine, the American Thoracic Society, and the American College of Chest Physicians. Sleep. 2003;26:907-13.
4. Kuna ST, Gurubhagavatula I, Maislin G, et al. Noninferiority of functional outcome in ambulatory management of obstructive sleep apnea. Am J Respir Crit Care Med. 2011;183:1238–1244.
5. Rosen CL, Auckley D, Benca R, et al. A multisite randomized trial of portable sleep studies and positive airway pressure autotitration versus laboratory-based polysomnography for the diagnosis and treatment of obstructive sleep apnea: The HomePAP Study. Sleep. 2012;35:757-767.

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