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The use of telemonitoring in the care of patients with sleep-related breathing disorders (SRBD) can enhance medical support significantly. Telemonitoring aims to help physicians detect therapy problems early and thus improve patients' therapy adherence. Diagnostics and therapy decisions in the telemonitoring process nevertheless remain the responsibility of sleep specialists. The selection of data monitored, their evaluation and resulting consequences fall to the physician, who makes decisions and prescribes therapy in consultation with the patient. In light of professional legal and ethical requirements, it must be ensured that extensive changes to the process flow in sleep medicine are designed in a way to guarantee high-quality patient care. In this position paper, the German Sleep Society, the German Respiratory Society, the Association of Pneumological Hospitals and the Federal Association of German Pneumologists comment on important aspects for implementation of telemonitoring for SRBD and describe the basic conditions required for its use. [ABSTRACT FROM AUTHOR]

Sleep related breathing disorders (SRBD) impair quality of live, morbidity and mortality of affected patients seriously. Moreover, due to their high prevalence, they have a huge impact on health care systems and national economics. The members of the German Respiratory Society, the German Society of Sleep Research and Sleep Medicine, the Association of Pneumological Clinics and the Association of Pneumologists focus strongly on the diagnosis and treatment of SRBD in their daily work. Prevailing developments in the provision of patients with SRBD, have strong impact on the quality of diagnosis and treatment, on the supply of devices, on the follow-up care and on the role and duties of the physician. Therefore, the societies estimate it essential, to publish this common position paper based on the evaluation and discussion of the scientific literature, the clinical practice and a consensus process of an expert group which is published in more detail (Randerath, Somnologie, DOI 10.1007/s11818-013-0649-2; Pneumologie 2/2014). [ABSTRACT FROM AUTHOR]

When providing sleep medical services special aspects must be taken into account in the context of the coronavirus pandemic. Despite all prevention, due to the high number of unrecognized cases, SARS-CoV2 contacts in the sleep laboratory must be expected and appropriate precautions are necessary. Nevertheless, the continuation or resumption of sleep medical services under the appropriate hygiene measures is strongly recommended to avoid medical and psychosocial complications. There is no evidence for a deterioration of COVID-19 through CPAP therapy. In principle, the application of positive pressure therapy via various mask systems can be accompanied by the formation of infectious aerosols. In the case of confirmed infection with SARS-CoV2, a pre-existing PAP therapy should be continued in an outpatient setting in accordance with the local guidelines for home isolation, since discontinuation of PAP therapy is associated with additional cardiopulmonary complications due to the untreated sleep-related breathing disorder. According to the current state of knowledge inhalation therapy, nasal high-flow (NHF), and PAP therapy can be carried out without increased risk of infection for health care workers (HCW) as long as appropriate personal protective equipment (eye protection, FFP2 or FFP-3 mask, gown) is being used. This position paper of the German Society for Pneumology and Respiratory Medicine (DGP) and the German Society for Sleep Medicine (DGSM) offers detailed recommendations for the implementation of sleep medicine diagnostics and therapy in the context of the coronavirus pandemic. [ABSTRACT FROM AUTHOR]

Reference values/intervals are generally used in medicine as a basis for diagnostic evaluation of patient-related findings. The American Academy of Sleep Medicine recommends a basic set of parameters that must be presented in the report of a polysomnographic examination. These include respiratory events, movement events, cardiac events, arousal events, and sleep scoring data. The present paper refers to reference values for sleep scoring data that characterize sleep architecture. Methodological aspects of the construction of reference intervals (statistical and choice of a reference sample), presentation options (tables and figures), and the scope of application (use of different reference values for data recorded and evaluated according to the Rechtschaffen and Kales and AASM standard) are discussed. [ABSTRACT FROM AUTHOR]

The present paper describes standardised operating procedures (SOP) within clinical sleep medicine. As such, it is a continuation of the previously published European Guidelines for the Accreditation of Sleep Medicine Centres (SMC) and European Guidelines for the Certification of Professionals in Sleep Medicine, aimed at creating standards of practice in European sleep medicine. It is also part of a broader action plan of the European Sleep Research Society (ESRS). In an updated section, the cost-effectiveness of sleep medicine and its relevance for resource allocation of general health care is emphasized. The following section of this paper is the translation of the guideline of the ESRS into German language: Fischer J, Dogas Z, Bassetti CL et al. (2012) Standard procedures for adults in accredited sleep medicine centres in Europe. J Sleep Res 2012; 21:357-368. In the current paper, the SOPs in sleep medicine centres regarding the diagnostic and therapeutic management of patients evaluated at SMC, accredited according to the European Guidelines, are primarily based on prevailing evidence-based medicine principles. In addition, parts of the SOPs are based on a formalized consensus procedure applied by a group of Sleep Medicine Experts from the European National Sleep Societies (ANSS). For the workload of the professionals in different SOPs, consensus was also achieved. The final recommendations for SOPs are categorized either as 'standard practice', 'procedure that could be useful', 'procedure that is not useful' or 'procedure with insufficient information available'. The SOPs described here include both subjective and objective testing, as well as recommendations for follow-up visits and for ensuring patient-safety in sleep medicine. The overall goal of the current SOPs is the further development of excellence in practice and quality assurance of sleep medicine in Europe. [ABSTRACT FROM AUTHOR]

Extrinsic effects on health and sleep are getting more and more attention. Studies have been conducted that aim to quantify annoyance due to increases in external noise increases and its physiological effects. Recent research on noise effects was performed in order to identify the causes and effects of these extrinsic influences. Research on aircraft and airfield noise near airports is of special interest because air traffic increases and airports expand. This noise has special characteristics compared to other forms of traffic noise. A large study near the Frankfurt airport with sub-studies near the Stuttgart and Cologne airports (NORAH study) could confirmed results from previous studies and even presented more precise results on some aspects. This study had a special focus on an excellent quantitative assessment of blood pressure and sleep by unattended home polysomnography according to AASM recommendations. Effects on blood pressure were not significant. Only trends were shown which were within the confidence intervals of previous studies. Related to the effects on sleep, a sound pressure exposure-response relationship could be shown for the objective wake-up probability. After the opening of a new landing runway and the introduction of night landing restrictions, wake-up probability decreased. Remarkably the study demonstrated that personal opinion on aircraft noise is a strong modifier for objective sleep quality. In our paper we compare the results of the NORAH study with results from previous studies with a focus on annoyance, blood pressure and sleep. [ABSTRACT FROM AUTHOR]

Many patients with the obstructive sleep apnoea syndrome (OSAS) look tier alternative conservative or surgical therapies to avoid treatment with continuous positive airway pressure. In view of the high prevalence and the relevant impairment of the patients, lots of methods are offered that promise a definitive cure or relevant improvement of OSAS. The "Apnoea" working group of the German Society of Sleep Medicine and Research established a task force to evaluate the scientific literature on non-CPAP therapies in the treatment of OSAS according to the standards of evidence-based medicine (EBM). This paper presents the results of the task force. The authors performed a literature search until 31 December 2005 (Medline and hand search of relevant papers). The studies were evaluated according the recommendations of the "Oxford Centre for Evidence-based Medicine Levels of Evidence". The data were unsatisfactory for most of the methods. Sufficient data were available for intraoral appliances (IOA) and maxillomandibular osteotomy (MMO). IOAs can reduce mild to moderate respiratory disturbances; MMOs are efficient in the short- and long-term but are performed only in special situations such as craniofacial dysmorphias. Weight reduction and body positioning cannot be recommended as a single treatment of OSAS. Most surgical procedures still lack sufficient data according to EBM criteria. Resections of muscular tissue within the soft palate have to be strictly avoided. But even success following gentle soft palate procedures is difficult to predict and often decreases over the years. Results in other anatomical regions seem to be more stable over time. Today combined surgeries in the sense of multilevel surgery concepts are of increasing interest in the secondary treatment after failure of nasal ventilation therapy, although more data from prospective controlled studies are needed. There is no evidence for any other treatment options studied in this paper. [ABSTRACT FROM AUTHOR]

The recording of ECG and heart rate are indispensable parameters of cardiorespiratory polysomnography. Complementing neurophysiological signals this allows an assessment of the autonomous nervous regulation during sleep. An evaluation of the nocturnal ECG is possible in terms of cyclical variations of heart rate and in terms of respiration modulated changes of ECG morphology (amplitude of R wave and T wave). This provides a reliable estimation of sleep disordered breathing. The autonomous nervous system is regulated in a totally different way during slow wave sleep and during REM sleep. An assessment of beat-to-beat variability of heart rate allows deriving sleep stages based on the difference in autonomous nervous system regulation. In addition the transitions from wakefulness to sleep can be tracked to some degree by an analysis of heart rate variability. This paper presents the technical development of the analysis in a historical sequence from 1980 to 2015. Linked to this the increase in physiological and pathophysiological knowledge derived from the technical developments is presented. [ABSTRACT FROM AUTHOR]

The present paper summarises the changes of the International Classification of Sleep Disorders, (ICSD-3, published in 2014) in comparison to its predecessor, ICSD-2 (2005). Changes within sleep-related breathing disorders are described in the article by Stuck and Weeß in this issue. Polysomnographic recordings and sleep scoring in the diagnostic process should always use the most recent version of the AASM manual. Insomnias are newly classified as either chronic or short term. Chronic insomnia includes all former insomnia forms with the exception of adjustment insomnia (acute insomnia). The minimal duration is now defined as 3 months. Non-restorative sleep no longer constitutes an insomnia-specific symptom. The term 'hypersomnias of central nervous origin' has been replaced by 'disorders of hypersomnolence'. Hypersomnolence is understood as excessive daytime sleepiness. The new classification of narcolepsy differs between narcolepsy type 1 (with cataplexy or with hypocretin-1 deficiency) and narcolepsy type 2 (without cataplexy). The circadian rhythm sleep-wake disorders have barely changed. The group of parasomnias now includes 'sleep-related eating disorders'. The former diagnosis 'sleep drunkenness' in the category confusional arousal was replaced by 'confused awakening'. The criteria for the diagnosis of 'nightmares' have been operationalized for the first time. The diagnosis 'periodic limb movement disorder' should no longer be used when either RLS, narcolepsy, REM sleep behavior disorder or untreated sleep apnea syndrome coexists. Isolated symptoms and normal variants are now directly associated with each diagnostic category. [ABSTRACT FROM AUTHOR]

Diagnosis and treatment of sleep disordered breathing (SDB) undergo substantial changes, both in terms of increasing scientific knowledge and also in terms of patient provision and socio-economic aspects. Increasing evidence shows the relevance of SDB on morbidity and mortality of affected patients. The precise differentiation of different phenotypes of SDBs has improved substantially in recent years. These proceedings influence the approach to the patients suspected of suffering from SDB. The scientific advances on the one hand are facing intentions to simplify diagnostical processes and treatment initiation and intentions to translate duties of physicians to non-medical personnel on the other hand. This consensus paper presents the principals of diagnosis, treatment initiation and provision, including the role of different participants of the healthcare system, and compares different treatment options. Major aspects include the differentiation of the diagnostical process in screening, affirmation of diagnosis and differential diagnosis. In addition, it focusses on the relevance of the pretest probability and describes a therapeutical algorithm. [ABSTRACT FROM AUTHOR]

This paper describes the development and validation of a phonetic-acoustic measurement procedure for a speech-based detection of sleepiness. The advantages of this automatic real-time approach are that obtaining speech data is unobtrusive and free from sensor application and calibration efforts. The chosen measurement process follows the speech-adapted steps of pattern recognition: (1) recording speech, (2) computation of 170 features describing prosody, articulation, and voice quality, (3) machine learning, and (4) evaluation. In a sleep deprivation study, a total of 380 simulated driver assistance samples ( n=32; 8:00 p.m.-4:00 a.m.) were recorded. One self and two observer assessments were used to obtain a Karolinska Sleepiness Scale (KSS) value, which served as an external validation reference. Features that proved to be especially sensitive to sleepiness are cepstral coefficients, formant bandwidth, intensity, and spectral measures. The best machine learning method, the support vector machine (SVM), achieved a significant validation correlation of r=0.46 in predicting sleepiness on unseen speakers. [ABSTRACT FROM AUTHOR]

Patients with excessive daytime sleepiness are impaired in all work-related and social areas of their lives. Expert opinions are recommended for pension proceedings, regarding driving licenses, and for work restrictions in the workplace. Experts have to consider all differential diagnoses of sleep disorders. Polysomnography is imperative in this process. Several neuropsychological tests are available to confirm sleepiness and attention deficits. Prior to final medical assessment, optimal treatment should be pursued. In the current German regulation of driver licenses (Fahrerlaubnisverordnung, FeV), an untreated sleep disorder with daytime sleepiness is judged as a reason for inability to drive. The importance of daytime sleepiness in other occupations should be assessed according to the needs at the workplace. Before the patients respond to an appropriate therapy, they are often temporarily unable to work. The patient should be informed of the appraisal with regard to career choice and workplace design. The expert, thus, has the responsibility of performing an interdisciplinary differential diagnosis of pathological sleepiness and monitoring treatment success using appropriate test methods. In the present paper the legal guidelines in Germany and available test methods are presented. [ABSTRACT FROM AUTHOR]

The purpose of this paper is to confirm a hypothesis claiming that in clinically healthy term infants sleep-wake cycle development and maturation of breathing control – as objectivated in polysomnography – proceed in parallel. Irregular breathing movements as equivalent of Active (REM-)Sleep and paradoxical patterns of thoracic and abdominal breathing movements decrease in the first year of life whereas regular breathing movements – the equivalent of Quiet Sleep – and coordinated patterns of thoracic and abdominal breathing movements increase. With growing maturation, periodic breathing and the different kinds of respiratory pauses decrease. Deviations from normal respiratory phenomena were seen as well in sick and in preterm infants as in infants belonging to epidemiologically defined groups at high risk of Sudden Infant Death. Thus, breathing patterns were impaired by prematurity, after intrauterine exposure to nicotine and drugs, and during upper airway infections. At last, in prospective studies of infants,who subsequently died of sudden infant death, peculiar breathing behavior was described. [ABSTRACT FROM AUTHOR]