Chest
Volume 158, Issue 4, October 2020, Pages 1689-1700
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Sleep: Original Research
Comparison of Diagnostic Sleep Studies in Hospitalized Neurorehabilitation Patients With Moderate to Severe Traumatic Brain Injury

Portions of this data were presented at the following conferences: Current Concepts in Sleep, August 24, 2019, Clearwater, FL; Patient Centered Outcomes Research Institute Annual Conference, September 20, 2019, Washington, DC; American Congress of Rehabilitation Medicine Annual Conference, October, 2020, Atlanta, GA
https://doi.org/10.1016/j.chest.2020.03.083Get rights and content
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Background

OSA is prevalent during a time of critical neural repair after traumatic brain injury (TBI). The diagnostic utility of existing sleep studies is needed to inform clinical management during acute recovery from TBI.

Research Question

This study aimed to evaluate the non-inferiority and diagnostic accuracy of a portable level 3 sleep study relative to level 1 polysomnography in hospitalized neurorehabilitation patients with TBI.

Study Design and Methods

This is a prospective clinical trial conducted at six TBI Model System study sites between May 2017 and February 2019. Of 896 admissions, 449 were screened and eligible for the trial, with 345 consented. Additional screening left 263 eligible for and completing simultaneous administration of both level 1 and level 3 sleep studies, with final analyses completed on 214 (median age = 42 years; ED Glasgow Coma Scale = 6; time to polysomnography [PSG] = 52 days).

Results

Agreement was moderate to strong (weighted kappa = 0.78, 95% CI, 0.72-0.83) with the misclassification commonly occurring with mild sleep apnea due to underestimation of apnea hypopnea index (AHI). Most of those with moderate to severe sleep apnea were correctly classified (n = 54/72). Non-inferiority was not demonstrated: the minimum tolerable specificity of 0.5 was achieved across all AHI cutoff scores (lower confidence limits [LCL] range, 0.807-0.943), but the minimum tolerable sensitivity of 0.8 was not (LCL range, 0.665-0.764).

Interpretation

Although the non-inferiority of level 3 portable diagnostic testing relative to level 1 was not established, strong agreement was seen across sleep apnea indexes. Most of those with moderate to severe sleep apnea were correctly identified; however, there was risk of misclassification with level 3 sleep studies underestimating disease severity for those with moderate to severe AHI and disease presence for those with mild AHI during early TBI neurorehabilitation.

Key Words

brain injury
rehabilitation
sleep apnea
sleep-disordered breathing

Abbreviations

AHI
apnea-hypopnea index
GCS
Glasgow Coma Scale
HSAT
home sleep apnea testing
LCL
lower confidence limits
PSG
polysomnography
PTA
posttraumatic amnesia
RPSGT
registered polysomnography technician
SE
sensitivity
SP
specificity
TBI
traumatic brain injury
TBIMS
Traumatic Brain Injury Model System

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FUNDING/SUPPORT: Research reported in this article was funded through a Patient-Centered Outcomes Research Institute (PCORI) Award (CER-1511-33005). This research was sponsored by VHA Central Office VA TBI Model Systems Program of Research; Subcontract from General Dynamics Information Technology (W91YTZ-13-C-0015; HT0014-19-C-0004) from the Defense and Veterans Brain Injury Center and National Institute on Disability, Independent Living, and Rehabilitation Research (NSDC Grant # 90DPTB00070, #90DP0084, 90DPTB0013-01-00, 90DPTB0008, 90DPT80004-02). Clinicaltrial.gov Registration Number: NCT03033901.