LETTERS TO THE EDITOR Diagnosing sleep-disordered breathing in neuromuscular diseases in 2021 Response to Hunasikatti M. Home portable monitoring for the diagnosis of sleep-disordered breathing in adolescents and adults with neuromuscular disorders: not yet ready for prime time. J Clin Sleep Med. 2021;17(12):2565–2566. doi:10.5664/jcsm.9652 Marta Kaminska, MDCM, MSc 1,2 ; David Zielinski, MD 3 ; Basil J. Petrof, MD 2,4 ; Jean N. Westenberg, MSc 1 ; Evelyn Constantin, MDCM, MSc 3 1 Respiratory Epidemiology and Clinical Research Unit, Translational Research in Respiratory Diseases Program, McGill University Health Centre, Montreal, Quebec, Canada; 2 Respiratory Division and Sleep Laboratory, McGill University Health Centre, Montreal, Quebec, Canada; 3 Department of Pediatrics and Pediatric Sleep Laboratory, McGill University, Montreal, Quebec, Canada; 4 Meakins Christie Laboratories, Translational Research in Respiratory Diseases Program, Research Institute of the McGill University Health Centre, Montreal, Quebec, Canada We thank Dr. Hunasikatti for the interest in our work. 1 In our study, we compared a home sleep apnea testing (HSAT) device with polysomnography (PSG) for the assessment of sleep-disordered breathing in a group of individuals with neuro- muscular disease (NMD), including adolescents, because the American Academy of Sleep Medicine allows the scoring of respiratory events as per adult criteria for adolescents aged ≥ 13 years (The AASM Manual for the Scoring of Sleep and Associated Events: Rules, Terminology and Technical Specifi- cations, version 2). 2 Our study included only a small number of adolescents, and we found the feasibility of HSAT to be quite poor in that group with the device that we used. Our conclusion states that feasibility in adolescents with NMD is not indicated. With HSAT, the lack of electroencephalography recording to detect arousals is a problem in adults as it is in adolescents. The bias between PSG and HSAT in our study is therefore not unlike that in studies of obstructive sleep apnea in the general population. 3 The use of autonomic arousals as a surrogate for electroencephalographic (EEG) arousals helps partially allevi- ate this problem. 4 Our data support the use of HSAT for ruling in but not ruling out sleep-disordered breathing in selected patients with NMD. Few participants in our study had evidence of a significant restrictive syndrome or chronic ventilatory fail- ure. Therefore, our results should not be extrapolated to popula- tions that are more severely impaired. We showed in our group that although the time with oxygen saturation < 90% was strongly correlated with daytime CO 2 values, some individuals with hypercapnia had very little noc- turnal hypoxemia. Therefore, we agree that direct measurement of CO 2 remains the most accurate method to identify sleep- related hypoventilation. The distinction between upper airway obstruction and hypoventilation from respiratory muscle weak- ness is difficult to make, because they could both appear as hypopneas on HSAT and PSG. Therefore, strong clinical suspi- cion for hypoventilation needs to be part of decision-making for treatment. Notably, in the setting of daytime hypercapnia, sleep testing is not necessary and ventilatory support (rather than continuous positive airway pressure) should be initiated. We hope that our study will encourage others to continue in this field to develop improved HSAT systems for adolescents and adults with NMD. Disadvantages of PSG include limited availability, high cost, and inconvenience to the patient with NMD (laboratories may not be adapted), which may lead to deferred testing and delayed diagnosis and treatment. HSAT holds nonnegligible advantages and represents an alternative that needs to be seriously considered to help identify sleep- disordered breathing (particularly severe sleep-disordered breathing) in selected patients with NMD. Clinical practice guidelines evolve with changing practices and new published data. We agree that current data do not allow the recommenda- tion of widespread use of HSAT instead of PSG in patients with NMD, particularly those at risk for hypoventilation. How- ever, with the recent and ongoing explosion of technological advances for use in medicine and expanding telemedicine applications, and in the context of a pandemic, we owe it to one of the most vulnerable populations—those with NMD—to explore and develop options for safe, timely, and accurate diag- nostic home sleep testing. We hope that our study will be a small stepping-stone toward achievement of this goal by the broader sleep community. CITATION Kaminska M, Zielinski D, Petrof BJ, Westenberg JN, Constantin E. Diagnosing sleep-disordered breathing in neuro- muscular diseases in 2021. J Clin Sleep Med. 2021;17(12): 2567–2568. REFERENCES 1. Hunasikatti M. Home portable monitoring for the diagnosis of sleep-disordered breathing in adolescents and adults with neuromuscular disorders: not yet ready for prime time. J Clin Sleep Med. 2021;17(12):2565–2566. 2. Berry RB, Brooks R, Gamaldo CE, et al; for the American Academy of Sleep Medicine. The AASM Manual for the Scoring of Sleep and Associated Events: Rules, Terminology and Technical Specifications. Version 2.0. Darien, IL: American Academy of Sleep Medicine; 2012. Journal of Clinical Sleep Medicine, Vol. 17, No. 12 2567 December 1, 2021 https://doi.org/10.5664/jcsm.9686 Downloaded from jcsm.aasm.org by 117.3.255.254 on March 3, 2023. For personal use only. No other uses without permission. Copyright 2023 American Academy of Sleep Medicine. All rights reserved.
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JCSMJC2100611_proof.pdfLETTERS TO THE EDITOR
Diagnosing sleep-disordered breathing in neuromuscular diseases in 2021 Response to Hunasikatti M. Home portable monitoring for the diagnosis of sleep-disordered breathing in adolescents and adults with neuromuscular disorders: not yet ready for prime time. J Clin Sleep Med. 2021;17(12):2565–2566. doi:10.5664/jcsm.9652 Marta Kaminska, MDCM, MSc1,2; David Zielinski, MD3; Basil J. Petrof, MD2,4; Jean N. Westenberg, MSc1; Evelyn Constantin, MDCM, MSc3
1Respiratory Epidemiology and Clinical Research Unit, Translational Research in Respiratory Diseases Program, McGill University Health Centre, Montreal, Quebec, Canada; 2Respiratory Division and Sleep Laboratory, McGill University Health Centre, Montreal, Quebec, Canada; 3Department of Pediatrics and Pediatric Sleep Laboratory, McGill University, Montreal, Quebec, Canada; 4Meakins Christie Laboratories, Translational Research in Respiratory Diseases Program, Research Institute of the McGill University Health Centre, Montreal, Quebec, Canada
We thank Dr. Hunasikatti for the interest in our work.1 In our study, we compared a home sleep apnea testing (HSAT) device with polysomnography (PSG) for the assessment of sleep-disordered breathing in a group of individuals with neuro- muscular disease (NMD), including adolescents, because the American Academy of Sleep Medicine allows the scoring of respiratory events as per adult criteria for adolescents aged ≥ 13 years (The AASM Manual for the Scoring of Sleep and Associated Events: Rules, Terminology and Technical Specifi- cations, version 2).2 Our study included only a small number of adolescents, and we found the feasibility of HSAT to be quite poor in that group with the device that we used. Our conclusion states that feasibility in adolescents with NMD is not indicated.
With HSAT, the lack of electroencephalography recording to detect arousals is a problem in adults as it is in adolescents. The bias between PSG and HSAT in our study is therefore not unlike that in studies of obstructive sleep apnea in the general population.3 The use of autonomic arousals as a surrogate for electroencephalographic (EEG) arousals helps partially allevi- ate this problem.4 Our data support the use of HSAT for ruling in but not ruling out sleep-disordered breathing in selected patients with NMD. Few participants in our study had evidence of a significant restrictive syndrome or chronic ventilatory fail- ure. Therefore, our results should not be extrapolated to popula- tions that are more severely impaired.
We showed in our group that although the time with oxygen saturation < 90% was strongly correlated with daytime CO2
values, some individuals with hypercapnia had very little noc- turnal hypoxemia. Therefore, we agree that direct measurement of CO2 remains the most accurate method to identify sleep- related hypoventilation. The distinction between upper airway obstruction and hypoventilation from respiratory muscle weak- ness is difficult to make, because they could both appear as hypopneas on HSAT and PSG. Therefore, strong clinical suspi- cion for hypoventilation needs to be part of decision-making for treatment. Notably, in the setting of daytime hypercapnia, sleep testing is not necessary and ventilatory support (rather than continuous positive airway pressure) should be initiated.
We hope that our study will encourage others to continue in this field to develop improved HSAT systems for adolescents and adults with NMD. Disadvantages of PSG include limited availability, high cost, and inconvenience to the patient with NMD (laboratories may not be adapted), which may lead to deferred testing and delayed diagnosis and treatment. HSAT holds nonnegligible advantages and represents an alternative that needs to be seriously considered to help identify sleep- disordered breathing (particularly severe sleep-disordered breathing) in selected patients with NMD. Clinical practice guidelines evolve with changing practices and new published data. We agree that current data do not allow the recommenda- tion of widespread use of HSAT instead of PSG in patients with NMD, particularly those at risk for hypoventilation. How- ever, with the recent and ongoing explosion of technological advances for use in medicine and expanding telemedicine applications, and in the context of a pandemic, we owe it to one of the most vulnerable populations—those with NMD—to explore and develop options for safe, timely, and accurate diag- nostic home sleep testing. We hope that our study will be a small stepping-stone toward achievement of this goal by the broader sleep community.
CITATION
Kaminska M, Zielinski D, Petrof BJ, Westenberg JN, Constantin E. Diagnosing sleep-disordered breathing in neuro- muscular diseases in 2021. J Clin Sleep Med. 2021;17(12): 2567–2568.
REFERENCES
1. Hunasikatti M. Home portable monitoring for the diagnosis of sleep-disordered breathing in adolescents and adults with neuromuscular disorders: not yet ready for prime time. J Clin Sleep Med. 2021;17(12):2565–2566.
2. Berry RB, Brooks R, Gamaldo CE, et al; for the American Academy of Sleep Medicine. The AASM Manual for the Scoring of Sleep and Associated Events: Rules, Terminology and Technical Specifications. Version 2.0. Darien, IL: American Academy of Sleep Medicine; 2012.
Journal of Clinical Sleep Medicine, Vol. 17, No. 12 2567 December 1, 2021
https://doi.org/10.5664/jcsm.9686 D
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SUBMISSION & CORRESPONDENCE INFORMATION
Submitted for publication September 22, 2021 Submitted in final revised form September 22, 2021 Accepted for publication September 22, 2021
Address correspondence to: Marta Kaminska, MDCM, MSc, Respiratory Division, McGill University Health Centre, 1001 Decarie, Montreal, QC, Canada H4A 3J1; Tel: (514) 934-1934, extension 32117; Email: [email protected]
DISCLOSURE STATEMENT
All authors have seen and approved the manuscript. The study referred to in this response letter was funded by Muscular Dystrophy Canada. M.K. is a member of the advisory board at Biron Soins du Sommeil and receives unrestricted research support from VitalAire, Philips Respironics, and Fisher Paykel. B.J.P. is a consultant for Sanofi Genzyme. The other authors report no conflicts of interest.
M Kaminska, D Zielinski, BJ Petrof, et al. Letter to the editor
Journal of Clinical Sleep Medicine, Vol. 17, No. 12 2568 December 1, 2021
D ow
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fr om
jc sm
.a as
m .o
rg b
y 11
7. 3.
25 5.
25 4
on M
ar ch
3 , 2
02 3.
F or
p er
so na
Diagnosing sleep-disordered breathing in neuromuscular diseases in 2021 Response to Hunasikatti M. Home portable monitoring for the diagnosis of sleep-disordered breathing in adolescents and adults with neuromuscular disorders: not yet ready for prime time. J Clin Sleep Med. 2021;17(12):2565–2566. doi:10.5664/jcsm.9652 Marta Kaminska, MDCM, MSc1,2; David Zielinski, MD3; Basil J. Petrof, MD2,4; Jean N. Westenberg, MSc1; Evelyn Constantin, MDCM, MSc3
1Respiratory Epidemiology and Clinical Research Unit, Translational Research in Respiratory Diseases Program, McGill University Health Centre, Montreal, Quebec, Canada; 2Respiratory Division and Sleep Laboratory, McGill University Health Centre, Montreal, Quebec, Canada; 3Department of Pediatrics and Pediatric Sleep Laboratory, McGill University, Montreal, Quebec, Canada; 4Meakins Christie Laboratories, Translational Research in Respiratory Diseases Program, Research Institute of the McGill University Health Centre, Montreal, Quebec, Canada
We thank Dr. Hunasikatti for the interest in our work.1 In our study, we compared a home sleep apnea testing (HSAT) device with polysomnography (PSG) for the assessment of sleep-disordered breathing in a group of individuals with neuro- muscular disease (NMD), including adolescents, because the American Academy of Sleep Medicine allows the scoring of respiratory events as per adult criteria for adolescents aged ≥ 13 years (The AASM Manual for the Scoring of Sleep and Associated Events: Rules, Terminology and Technical Specifi- cations, version 2).2 Our study included only a small number of adolescents, and we found the feasibility of HSAT to be quite poor in that group with the device that we used. Our conclusion states that feasibility in adolescents with NMD is not indicated.
With HSAT, the lack of electroencephalography recording to detect arousals is a problem in adults as it is in adolescents. The bias between PSG and HSAT in our study is therefore not unlike that in studies of obstructive sleep apnea in the general population.3 The use of autonomic arousals as a surrogate for electroencephalographic (EEG) arousals helps partially allevi- ate this problem.4 Our data support the use of HSAT for ruling in but not ruling out sleep-disordered breathing in selected patients with NMD. Few participants in our study had evidence of a significant restrictive syndrome or chronic ventilatory fail- ure. Therefore, our results should not be extrapolated to popula- tions that are more severely impaired.
We showed in our group that although the time with oxygen saturation < 90% was strongly correlated with daytime CO2
values, some individuals with hypercapnia had very little noc- turnal hypoxemia. Therefore, we agree that direct measurement of CO2 remains the most accurate method to identify sleep- related hypoventilation. The distinction between upper airway obstruction and hypoventilation from respiratory muscle weak- ness is difficult to make, because they could both appear as hypopneas on HSAT and PSG. Therefore, strong clinical suspi- cion for hypoventilation needs to be part of decision-making for treatment. Notably, in the setting of daytime hypercapnia, sleep testing is not necessary and ventilatory support (rather than continuous positive airway pressure) should be initiated.
We hope that our study will encourage others to continue in this field to develop improved HSAT systems for adolescents and adults with NMD. Disadvantages of PSG include limited availability, high cost, and inconvenience to the patient with NMD (laboratories may not be adapted), which may lead to deferred testing and delayed diagnosis and treatment. HSAT holds nonnegligible advantages and represents an alternative that needs to be seriously considered to help identify sleep- disordered breathing (particularly severe sleep-disordered breathing) in selected patients with NMD. Clinical practice guidelines evolve with changing practices and new published data. We agree that current data do not allow the recommenda- tion of widespread use of HSAT instead of PSG in patients with NMD, particularly those at risk for hypoventilation. How- ever, with the recent and ongoing explosion of technological advances for use in medicine and expanding telemedicine applications, and in the context of a pandemic, we owe it to one of the most vulnerable populations—those with NMD—to explore and develop options for safe, timely, and accurate diag- nostic home sleep testing. We hope that our study will be a small stepping-stone toward achievement of this goal by the broader sleep community.
CITATION
Kaminska M, Zielinski D, Petrof BJ, Westenberg JN, Constantin E. Diagnosing sleep-disordered breathing in neuro- muscular diseases in 2021. J Clin Sleep Med. 2021;17(12): 2567–2568.
REFERENCES
1. Hunasikatti M. Home portable monitoring for the diagnosis of sleep-disordered breathing in adolescents and adults with neuromuscular disorders: not yet ready for prime time. J Clin Sleep Med. 2021;17(12):2565–2566.
2. Berry RB, Brooks R, Gamaldo CE, et al; for the American Academy of Sleep Medicine. The AASM Manual for the Scoring of Sleep and Associated Events: Rules, Terminology and Technical Specifications. Version 2.0. Darien, IL: American Academy of Sleep Medicine; 2012.
Journal of Clinical Sleep Medicine, Vol. 17, No. 12 2567 December 1, 2021
https://doi.org/10.5664/jcsm.9686 D
ow nl
oa de
d fr
om jc
sm .a
as m
.o rg
b y
11 7.
3. 25
5. 25
4 on
M ar
ch 3
, 2 02
3. F
or p
er so
SUBMISSION & CORRESPONDENCE INFORMATION
Submitted for publication September 22, 2021 Submitted in final revised form September 22, 2021 Accepted for publication September 22, 2021
Address correspondence to: Marta Kaminska, MDCM, MSc, Respiratory Division, McGill University Health Centre, 1001 Decarie, Montreal, QC, Canada H4A 3J1; Tel: (514) 934-1934, extension 32117; Email: [email protected]
DISCLOSURE STATEMENT
All authors have seen and approved the manuscript. The study referred to in this response letter was funded by Muscular Dystrophy Canada. M.K. is a member of the advisory board at Biron Soins du Sommeil and receives unrestricted research support from VitalAire, Philips Respironics, and Fisher Paykel. B.J.P. is a consultant for Sanofi Genzyme. The other authors report no conflicts of interest.
M Kaminska, D Zielinski, BJ Petrof, et al. Letter to the editor
Journal of Clinical Sleep Medicine, Vol. 17, No. 12 2568 December 1, 2021
D ow
nl oa
de d
fr om
jc sm
.a as
m .o
rg b
y 11
7. 3.
25 5.
25 4
on M
ar ch
3 , 2
02 3.
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so na
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