Sleep Disorder Management: Diagnostic and Treatment Guidelines Summary

Clinical Practice Brief

AIM Specialty Health® (AIM) issued updated guidelines on polysomnography and home sleep testing in 2019. AIM is a national organization in specialty benefits management. AIM promotes safe, cost-effective and appropriate specialty services. Guidelines are devised based on grading of evidence. Advanced practice nurses (APNs) are familiar with identifying sleep disorders and referring patients for sleep studies. Most sleep studies are conducted in a sleep lab attended by sleep technicians and clinicians. APNs should be aware of situations where home sleep studies may be appropriate.

Home sleep studies are unattended studies and are indicated for adults aged 18 years and up for the conditions below. The AIM guidelines specify that these criteria (1, 2 or 3, below) should be met to appropriately order home testing:

  1. Observed apneas during sleep.
  2. A combination of at least two of the following (a–e):
    a.
    Excessive daytime sleepiness, as evidenced by an Epworth Sleepiness Scale score greater than 10, inappropriate daytime napping (e.g., during driving, conversation or eating) or sleepiness that interferes with daily activities and is not explained by other conditions.
    b.
    Habitual snoring, or gasping/choking episodes associated with awakenings.
    c.
    Treatment-resistant hypertension (i.e., persistent hypertension in a patient taking three or more antihypertensive medications).
    d.
    Obesity, defined as a body mass index greater than 30 kg/m2, or increased neck circumference, defined as greater than 17 inches in men or greater than 16 inches in women.
    e.
    Craniofacial or upper airway soft tissue abnormalities, including adenotonsillar hypertrophy, or neuromuscular disease.
  3. History of stroke (greater than 30 days previously), transient ischemic attack, coronary artery disease or sustained
    supraventricular tachycardia or bradycardia in patients who meet one of the criteria in 2a–e above (AIM Specialty Health, 2019, p. 8).

Home sleep studies may also be ordered for confirmed obstructive sleep apnea (OSA) to evaluate the effectiveness of surgery or to re-evaluate the diagnosis OSA and need for continuous positive airway pressure (CPAP).

  • Need to consider re-evaluation of OSA with alternative treatments, including:
    – Weight loss.
    – Surgical modification, i.e., uvulopalatopharyngoplasty (UPPP), tonsillectomy and/or adenoidectomy.
    – Use of an oral or a mandibular advancement device.

Home sleep studies are contraindicated in the following:

  • Patient is 18 years old or younger.
  • Patient has a history of moderate or severe chronic obstructive pulmonary disease (COPD).
  • Patient has class III or IV congestive heart failure (CHF).
  • Patient has CHF with sustained ventricular fibrillation or tachycardia without an implanted defibrillator.
  • Patient has impaired cognitive dysfunction.
  • Patient is physically unable to apply apparatus.
  • Patient has a history of selected sleep disorders (e.g., central sleep apnea, periodic limb movement disorder, narcolepsy, idiopathic hypersomnia, parasomnia and nocturnal seizures).
  • Patient has failed a home sleep study (duration of at least two nights).
  • The clinical suggestion of OSA is not supported by home sleep study or oxygen dependency.
  • Patient meets any of the following:
    – History of stroke within last 30 days.
    – Chronic opiate use.
    – Oxygen dependent.
    – Patient’s BMI is greater than 33 and serum bicarbonate is greater than 28, or patient has received a diagnosis of obesity hypoventilation syndrome.

If the patient meets any of the above criteria and has a contraindication to a home sleep study, an in-lab attended sleep
study is recommended (AIM Specialty Health, 2019, p. 9).

Attended sleep studies are also indicated for central sleep apnea, narcolepsy, nighttime seizures, parasomnias, idiopathic hypersomnia, periodic limb movement disorder, nocturnal desaturation or unexplained right heart failure, pulmonary hypertension, polycythemia or cardiac arrhythmias.

In-lab, attended sleep studies are indicated for individuals younger than 18 years of age for the evaluation of the following:

  • Habitual snoring in association with one or more of the following:
    – Restless or disturbed sleep.
    – Behavioral disturbance.
    – Learning disorders, including deterioration in academic performance, attention deficit disorder, hyperactivity, frequent awakenings, enuresis (bedwetting), growth retardation or failure to thrive.
  • Excessive daytime somnolence or altered mental status not explained by other conditions.
  • Polycythemia not explained by other conditions.
  • Cor pulmonale not explained by other conditions.
  • Witnessed apnea with duration greater than two respiratory cycles; labored breathing during sleep.
  • Hypertrophy of the tonsils or adenoids in patients at significant surgical risk such that the exclusion of OSA would allow
    avoidance of surgery.
  • Suspected congenital central alveolar hypoventilation syndrome or sleep-related hypoventilation due to neuromuscular
    disease or chest wall deformities.
  • Clinical evidence of a sleep-related breathing disorder in infants who have experienced an apparent life-threatening event.
  • Exclusion of OSA in a patient who has undergone adenotonsillectomy for suspected OSA more than eight weeks previously or for whom the initial sleep study was inadequate, equivocal or nondiagnostic and the child’s parents or caregiver report that the breathing patterns observed at home were different from those during testing (AIM Specialty Health, 2019, p.11).
  • Initial diagnostic polysomnograph (PSG) or home sleep test (HST) indicate oxygen desaturations during the study:
    – O2 sat below 90% for 30% recording during previous PSG or HST.
    – O2 sat below 80% for greater than 1% recording on PSG or HST.

The guidelines for PSG and HST are part of a publication by AIM Specialty Health on sleep disorder management, diagnosis and treatment. The reader is referred to this document for further guidance on use of CPAP and bilevel positive airway pressure BiPap.

References

AIM Specialty Health (2019). Sleep Disorder Management Diagnostic & Treatment Guidelines. Retrieved from: https://aimspecialtyhealth.com/wp-content/uploads/2019/09/AIMSleepDisorderManagement_Guidelines_JUN_2019.pdf

This Practice Brief, Sleep Disorder Management Diagnostic and Treatment, was developed by an American Association of Nurse Practitioners® (AANP) workgroup collaboration between the AANP Practice Committee and AANP Specialty Practice Group co-chairs.

Principal Authors and Contributors

Allen Prettyman, PhD, FNP-BC, FAANP, AANP Practice Committee Chair
Karen Greco, PhD, ANP-BC, FAAN, FAANP, AANP Practice Committee
Nanette Alexander, DNP, APRN, ANP-BC, FAANP, AANP Pulmonary and Sleep SPG Co-chair
Diane Padden, PhD, CRNP, FAANP, AANP staff
Kat Van Duyn, AANP staff

Practice Committee Review Panel

Irene Bean, DNP, APRN, PMHNP, FAANP
Tina Bettin, DNP, MSN, RN, FNP-BC, APNP, FAANP
Susan Conaty-Buck, DNP, APRN, FNP-C, FAANP
Tearsanee Davis, DNP, FNP-BC
Michelle Edwards, DNP, APRN, FNP, ACNP, FAANP
Joy Elwell, DNP, FNP-BC, CNE, FAAN, FAANP
Karen Greco, PhD, ANP-BC, FAAN, FAANP
Allen Prettyman, PhD, FNP-BC, FAANP
Anthony Roberson, PhD, PMHNP-BC, RN, FAANP
Brett Snodgrass, FNP-C, CPE, FACPP, FAANP

Download the Guideline