Is there evidence for using hotels as sleep laboratories?

Hotels as Sleep Laboratories: Evidence and Considerations

There is insufficient evidence to support the use of hotels as sleep laboratories for diagnosing sleep disorders, as current guidelines recommend either in-laboratory polysomnography or home sleep apnea testing under the auspices of accredited sleep medicine programs.

Current Guidelines on Sleep Testing Environments

• The American Thoracic Society, American College of Chest Physicians, and American Academy of Sleep Medicine consider in-laboratory polysomnography (Type I) as the gold standard for diagnosing obstructive sleep apnea (OSA) 1, 2
• Portable monitoring (PM) is categorized into four levels:
  • Level I: Attended polysomnography in a laboratory setting
  • Level II: Full polysomnography outside the laboratory setting
  • Level III: Limited channel polysomnography (four or more cardiopulmonary parameters)
  • Level IV: Testing with only one or two cardiopulmonary parameters 1

Evidence on Alternative Testing Environments

• Current guidelines do not specifically address hotels as sleep laboratories 1
• Home sleep apnea testing (HSAT) has been studied as an alternative to in-laboratory testing, but these studies focus on testing in patients' homes rather than hotel settings 1, 3
• When portable monitoring is used outside laboratory settings, it should be performed under the auspices of an AASM accredited comprehensive sleep medicine program with established policies and procedures 1

Technical and Quality Considerations

• Home sleep studies typically underestimate the severity of OSA by approximately 10-26% compared to in-laboratory polysomnography 3
• Technical limitations of portable monitoring include:
  • Lack of EEG, EOG, and EMG sensors needed to accurately determine sleep versus wake states 3
  • Limited diagnostic accuracy of automatic scoring algorithms 3
  • Higher rates of data loss (3-18%) in unattended settings compared to attended settings 1
  • Inability to detect other sleep disorders or comorbid conditions 1

Clinical Decision-Making Impact

• Home-based therapeutic decisions were found adequate when AHI (Apnea-Hypopnea Index) was high but deficient in patients with mild to moderate AHI 1, 3
• The disparity between in-laboratory polysomnography and home sleep testing could significantly affect clinical management decisions in a substantial percentage of patients 3

Recommendations for Sleep Testing

• Raw data from portable monitoring must be reviewed and interpreted by a physician who is either board-certified in sleep medicine or overseen by a board-certified sleep medicine physician 1, 3
• A quality performance improvement program for portable monitoring, including inter-scorer reliability assessment, must be in place to ensure accuracy and reliability 1
• If portable monitoring tests are technically inadequate or do not provide the expected result based on clinical suspicion, in-laboratory polysomnography should be performed 1

Potential Pitfalls and Caveats

• The use of portable monitoring devices is not recommended for general screening or clinical use without available knowledge of the patient's sleep-related history and complaints 1
• Portable monitoring is not recommended in patients with comorbid conditions or secondary sleep complaints due to insufficient evidence supporting evaluation in these conditions 1
• Night-to-night variability in sleep parameters can affect test results, with studies showing that 28% of patients had severity of illness reclassification between testing nights 1
• Sleep position affects the accuracy of results, and most portable monitors do not accurately record sleep position 1

In conclusion, while there is ongoing research into alternative settings for sleep testing, current guidelines do not provide evidence supporting the use of hotels specifically as sleep laboratories. Any sleep testing outside of accredited sleep laboratories should follow established protocols under the supervision of sleep medicine specialists.