Correspondence

Why use the home sleep test?

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I read with interest the balanced editorial in The Lancet Respiratory Medicine mentioning some of the changes in sleep medicine today. 1 Many of these changes are difficult to keep up with and are affecting the quality of patient care. In the USA, much of the decision regarding the option of an attended nocturnal polysomnogram versus an unattended home sleep test is based on an insurance company’s criteria for allowing a nocturnal polysomnogram. Existing home sleep tests are not standardised and miss several important conditions like narcolepsy, central and mixed sleep apnoea, cardiac arrhythmias during sleep, and movement disorders. Not all diagnoses in sleep medicine are obstructive sleep apnoea. Insurers argue that if diagnoses other than sleep apnoea are suspected clinically, they will reconsider the financial coverage for an in-laboratory attended sleep study. This decision is often made by a nurse or medical director with no sleep medicine training. Home sleep tests have become available to many non-sleep trained physicians including internists, family practitioners, cardiologists, and ear, nose, and throat physicians, to name a few. As a result, there has been a growing trend of ordering a home sleep test followed by no follow-up or a trial of auto continuous positive airway pressure. This is a dangerous trend because we are missing other sleep diagnoses and losing patients to poor compliance. As is well known, compliance with continuous positive airway pressure is notoriously poor if not followed on a regular basis, preferably by trained sleep physicians. Obviously in an age of cost containment, there are no easy answers, but I along with many of

my sleep medicine colleagues feel that the pendulum has swung too far. Availability of a home sleep test should be regulated and restricted to sleep medicine physicians. The home sleep test technology should be standardised. The choice of test, nocturnal polysomnogram or home sleep test, should be decided by the evaluating sleep physician with insurance company oversight, but not control. A home sleep test should be restricted to follow up of patients with a previous diagnosis of obstructive sleep apnoea with a significant change in body weight, or to follow up the effectiveness of airway surgery or mandibular advancement devices. They could also be used as a ruleout test in patients with a low pretest probability of obstructive sleep apnoea. Large head-to-head studies of patients who have been tested on both a nocturnal polysomnogram and a home sleep test could prove to be quite beneficial. I declare no competing interests.

Tapas Bandyopadhyay [email protected] Pulmonary/Critical Care/Sleep Medicine, University of Connecticut and St Francis Hospital, 8 Orchard Road, Farmington, CT 06032, USA 1

Editorial. Refining the diagnosis of obstructive sleep apnoea. Lancet Respir Med 2014; 2: 671.

Respiratory infections in patients undergoing mechanical ventilation Jordi Rello and colleagues1 highlight respiratory infections in patients undergoing mechanical ventilation. The authors focus on bacteria pathogens, identifying fewer than ten organisms implicated in most ventilator-associated respiratory infection cases. We do agree that the pathogens isolated most often in patients with ventilatorassociated pneumonia are bacteria,

mainly Staphylococcus aureus and Pseudomonas aeruginosa. However, some studies have shown that viruses might also be causative agents of ventilator-associated pneumonia. Cytomegalovirus (CMV) has been shown to be the causative agent of respiratory infections in 25 of 86 patients who were seen with acute respiratory failure or ventilatorassociated pneumonia. 2 The diagnosis was made by histological examination. A study on 242 nonimmunosuppressed intensive care unit patients showed that 16% of patients developed active CMV infection, as diagnosed by positive antigenaemia or positive rapid viral culture in bronchoalveolar lavage.3 Other herpes viruses can affect mechanically ventilated critically ill patients. Coisel and colleagues4 identified CMV infection in 24% of critically ill patients with suspected ventilator-associated pneumonia, and herpes simplex virus infection in 28% of patients. The role of the herpesviridae family of viruses as a potential pathogen or co-pathogen in ventilator-associated pneumonia should not be underestimated. We declare no competing interests.

*Julien Bordes, Sami Hraiech [email protected] Département d’Anesthésie-Réanimation, HIA Sainte Anne, Boulevard Sainte Anne, Toulon, France (JB) ; and Service de Réanimation-Détresses Respiratoires Aiguës et Infections Sévères, Hôpital Nord, Marseille, France (SH) 1

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Rello J, Lisboa T, Koulenti D. Respiratory infections in patients undergoing mechanical ventilation. Lancet Respir Med 2014; 2: 764–74. Papazian L, Bregeon F, Thirion X, et al. Effect of ventilator-associated pneumonia on mortality and morbidity. Am J Respir Crit Care Med 1996; 154: 91–97. Chiche L, Forel JM, Roch A, et al. Active cytomegalovirus infection is common in mechanically ventilated medical intensive care unit patients. Crit Care Med 2009; 37: 1850–57. Coisel Y, Bousbia S, Forel JM, et al. Cytomegalovirus and herpes simplex virus effect on the prognosis of mechanically ventilated patients suspected to have ventilator-associated pneumonia. PLoS One 2012; 7: e51340.

www.thelancet.com/respiratory Vol 2 November 2014

Respiratory infections in patients undergoing mechanical ventilation.

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