© 2004 American Thoracic Society
Diagnostic Access for Sleep Apnea in Hong KongTo the Editor:The study by Flemons and colleagues (1) is an important document providing a handy reference or benchmark for medical practitioners/administrators involved in management of sleep apnea all over the world. I would like to take this opportunity to share with your readers the situation on the provision of sleep laboratory service to children in the Hong Kong Special Administrative Region, China. Hong Kong has a population of 6.5 million, and about 1 million are younger than 15 years of age. There are two pediatric sleep laboratories in Hong Kong with four beds. The pediatric sleep laboratory of the Kwong Wah Hospital, a 1,000-bed publicly funded general hospital, has 2 beds offering full-sleep polysomnography study, including routine end-tidal CO2. It operates four nights per week and is funded by the government with no charge for patients. For urgent cases, limited polysomnographic study (Somte, Compumedics, Victoria, Australia) is offered. The waiting time for full-sleep study currently is 6 months. Sleep studies are ordered by one of three sleep specialists, all pulmonologists, after assessment in the pediatric sleep disorders clinic. All referrals are screened by the specialist staff who would fast-track those deemed to be at high risk; otherwise, the time between initial routine referral and sleep clinic appointment currently is 18 months. General practitioners refer 20% of the patients to the service and 80% are referred by hospital specialists. Obstructive sleep apnea syndrome (OSAS) was diagnosed in 46% of our patients who underwent sleep study. The prevalence of severity is as follows: mild—apnea–hypopnea index between 2.1 and 5 (60%); moderate—apnea–hypopnea index from 5.1–15 (28%); and severe—apnea–hypopnea index greater than 15 (12%). Continuous positive airway pressure titration is required only in 5% of patients who usually have neuromuscular diseases. Tonsillectomy and adenoidectomy are offered to those with moderate or severe OSAS. For mild OSAS, weight reduction, treatment of allergic rhinitis, or both usually are offered. Hong Kong has not defined the minimal requirement for pediatric sleep specialists or sleep polysomnography technologists. Currently, there are approximately 17 registered polysomnographic technicians, as certified by the Board of Registered Polysomnographic Technologists in Hong Kong. A phone questionnaire survey done in this department showed that the prevalence of habitual snoring and observed obstructive apneic episodes to be 11% and 1.5%, respectively. In theory, all these children should undergo a full-sleep study (2). Hence, I am afraid the situation 5–10 years from now will be exactly what Dr. Pack stated when ending his editorial (3), unless we have some technologic breakthrough in diagnosing OSAS or a collective ignorance could be imposed on both parents and referring physicians, thus reducing demand.
Kwong Wah Hospital Hong Kong SAR, China FOOTNOTES Conflict of Interest Statement: D.K.N., K.-L.K., P.-Y.C., and M.-Y.C. do not have a financial relationship with a commercial entity that has an interest in the subject of this letter. Dr. Flemons was given an opportunity to respond to this letter but declined to do so. REFERENCES
From the Editorialist: The letter of Ng and colleagues in response to my editorial (1) adds further support that around the globe the major issue for the clinical problem of sleep-disordered breathing is access to diagnosis and treatment. This letter adds a new perspective from Hong Kong. The authors also raise new issues. First, as they correctly point out, there are a number of different strategies to address the issue of limited access. Although previous discussion has focused on the role of ambulatory diagnostic strategies (1), there are other potential solutions: (1) provision of an adequate number of sleep specialists and facilities; and (2) triage strategies such as those currently used by Ng and colleagues to identify and fast-track those patients at greatest risk. The validity of such triage strategies and their impact need to be fully studied. The letter of Ng and colleagues refers to pediatric patients with sleep apnea and, hence, goes beyond the data reported by Flemons and colleagues for adults (2). New guidelines for management of childhood obstructive sleep apnea syndrome developed by the American Academy of Pediatrics (3) indicate a prominent role for full in-laboratory polysomnography in evaluation of such patients. But, currently, little is known about the availability of facilities for such studies in children in the United States or other countries. It seems likely that the situation will not be better than for adults and, indeed, is likely to be worse, given the current state of development of pediatric sleep medicine. It would be helpful if a similar analysis to that done by Flemons and colleagues (2) was performed for the pediatric population.
University of Pennsylvania Philadelphia, Pennsylvania Acknowledgments A.I.P. has a grant from ResMed, Inc. to study the relative role of ambulatory recording of sleep-disordered breathing as it compares to full-sleep study; he also receives royalties from Marcel Dekker Publishers for a book he edited entitled Sleep Apnea: Pathogenesis, Diagnosis and Treatment; and he has a patent pending related to the use of serotonin agonists to treat sleep apnea in mammals. REFERENCES
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