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Decision Rules for Diagnosis of Sleep Apnea

I read with interest the article by Tsai and colleagues (1), but I feel it would be more widely accepted into clinical practice with two important further additions. First, it would be useful for the authors to estimate how long it took them to perform their upper airway physical examination protocol. Time is a precious commodity in any clinic. Second, racial differences will be important in developing prediction rules; patients with obstructive sleep apnea from different ethnic groups show differences in age and body mass index, but particularly in craniofacial and upper airway morphology (2, 3). Any decision rule that heavily relies on morphometric differences should therefore state the ethnic composition of the population from which it was derived.

The study was well thought out with many merits and these two additional pieces of information would make it more applicable, nationally and internationally, especially to those of us working in busy sleep clinics, dealing with predominantly white Northern European patients.

Keir E. Lewis

Prince Philip Hospital Wales, United Kingdom

FOOTNOTES

Conflict of Interest Statement: K.E.L. has been reimbursed by Cephalon (UK) for attending the APSS Conference 2003, including travel, conference fees, and accommodations.

REFERENCES

1. Tsai WH, Remmers JE, Brant R, Flemons WW, Davies J, MacArthur C. A decision rule for diagnostic testing in obstructive sleep apnea. Am J Respir Crit Care Med 2003;167:1427–1432.[Abstract/Free Full Text]
2. Liu Y, Lowe AA, Zeng X, Fu M, Fleetham JA. Cephalometric comparisons between Chinese and Caucasian patients with obstructive sleep apnoea. Am J Orthod Dentofacial Orthop 2000;117:479–485.[CrossRef][Medline]
3. Cakirer B, Hans MG, Graham G, Aylor J, Tishler PV, Redline S. The relationship between craniofacial morphology and obstructive sleep apnea in whites and in African-Americans. Am J Respir Crit Care Med 2001;163:947–950.[Abstract/Free Full Text]

From the Authors:

Dr. Lewis makes two excellent points with respect to the generalizing ability and practicality of our decision rule (1). There is evidence that awareness of simple decision rules does not necessarily change clinical practice (2). The reasons for this are multifactorial, but clearly time and complexity of implementation are key factors.

Our decision rule was developed with simplicity of use and the elimination of time-consuming physical examination maneuvers in mind. Assessment of the three decision rule predictors (cricomental space, overbite, and pharyngeal space) takes less than 30 seconds to complete and can obviate the need for other measurements. Aside from the cricomental space, the variables are assessed visually. Moreover, the predictors and outcome are binary and do not require algorithms to provide predictive value.

With regard to patient population, the Calgary population is predominantly European in origin, with only 15% of the 2001 census population belonging to a visible minority. Of the latter, Chinese and Southeast Asian ethnic groups make up more than half. The proportion of African American and Hispanic patients in our catchment area is very low.

Willis H. Tsai^a, Jan M. Davies^a, W. Ward Flemons^a and Colin MacArthur^b

^a University of Calgary Calgary, Alberta, Canada
^b University of Toronto Toronto, Ontario, Canada

FOOTNOTES

Conflict of Interest Statement: W.H.T., J.M.D., W.W.F., and C.M. have no declared conflict of interest.

REFERENCES

1. Tsai WH, Remmers JE, Brant R, Flemons WW, Davies J, MacArthur C. A decision rule for diagnostic testing in obstructive sleep apnea. Am J Respir Crit Care Med 2003;167:1427–1432.
2. Graham ID, Stiell IG, Laupacis A, McAuley L, Howell M, Clancy M, Durieux P, Simon N, Emparanza JI, Aginaga JR, et al. Awareness and use of the Ottawa ankle and knee rules in 5 countries: can publication alone be enough to change practice? Ann Emerg Med 2001;37:259–266.[CrossRef][Medline]

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