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This document summarizes suggestions of the central sleep apnea (CSA) Technical Expert Panel working group. This paper shares our vision for bringing the right device to the right patient at the right time. For patients with CSA, current coverage criteria do not align with guideline treatment recommendations. For example, CPAP and oxygen therapy are recommended but not covered for CSA. On the other hand, bilevel positive airway pressure (BPAP) without a backup rate may be a covered therapy for OSA, but it may worsen CSA. Narrow coverage criteria that require near elimination of obstructive breathing events on CPAP or BPAP in the spontaneous mode, even if at poorly tolerated pressure levels, may preclude therapy with BPAP with backup rate or adaptive servoventilation, even when those devices provide demonstrably better therapy. CSA is a dynamic disorder that may require different treatments over time, sometimes switching from one device to another; an example is switching from BPAP with backup rate to an adaptive servoventilation with automatic end-expiratory pressure adjustments, which may not be covered. To address these challenges, we suggest several changes to the coverage determinations, including: (1) a single simplified initial and continuing coverage definition of CSA that aligns with OSA; (2) removal of hypoventilation terminology from coverage criteria for CSA; (3) all effective therapies for CSA should be covered, including oxygen and all PAP devices with or without backup rates or servo-mechanisms; and (4) patients shown to have a suboptimal response to one PAP device should be allowed to add oxygen or change to another PAP device with different capabilities if shown to be effective with testing.

The current national coverage determinations (NCDs) for noninvasive ventilation for patients with thoracic restrictive disorders, COPD, and hypoventilation syndromes were formulated in 1998. New original research, updated formal practice guidelines, and current consensus expert opinion have accrued that are in conflict with the existing NCDs. Some inconsistencies in the NCDs have been noted, and the diagnostic and therapeutic technology has also advanced in the last quarter century. Thus, these and related NCDs relevant to bilevel positive airway pressure for the treatment of OSA and central sleep apnea need to be updated to ensure the optimal health of patients with these disorders. To that end, the American College of Chest Physicians organized a multisociety (American Thoracic Society, American Academy of Sleep Medicine, and American Association for Respiratory Care) effort to engage experts in the field to: (1) identify current barriers to optimal care; (2) highlight compelling scientific evidence that would justify changes from current policies incorporating best evidence and practice; and (3) propose suggestions that would form the basis for a revised NCD in each of these 5 areas (thoracic restrictive disorders, COPD, hypoventilation syndromes, OSA, and central sleep apnea). The expert panel met during a 2-day virtual summit in October 2020 and subsequently crafted written documents designed to achieve provision of "the right device to the right patient at the right time." These documents have been endorsed by the participating societies following peer review and publication in CHEST and will be used to inform efforts to revise the current NCDs.

With sleep occupying up to one-third of every adult's life, addressing sleep is essential to overall health. Sleep disturbance and deficiency are common in patients with chronic lung diseases and associated with worse clinical outcomes and poor quality of life. A detailed history incorporating nocturnal respiratory symptoms, symptoms of obstructive sleep apnea (OSA) and restless legs syndrome, symptoms of anxiety and depression, and medications is the first step in identifying and addressing the multiple factors often contributing to sleep deficiency in chronic lung disease. Additional research is needed to better understand the relationship between sleep deficiency and the spectrum of chronic lung diseases.

PurposeObstructive sleep apnea (OSA) is underdiagnosed, partially from variable clinical presentations. Emphasis is often placed on Epworth Sleepiness Scale (ESS), a subjective measure of sleepiness, but variable in OSA. We hypothesized that daytime complaints measured with Language of Sleepiness Questionnaire (LOS) in OSA are not being captured by ESS.MethodsAdults referred to a tertiary sleep clinic undergoing sleep studies completed ESS and LOS questionnaires (20 items with various patient-reported descriptors). LOS was examined in patients who had or did not haveOSA without sleepiness based on ESS

Background: The purpose of this guideline is to optimize evaluation and management of patients with obesity hypoventilation syndrome (OHS). Methods: A multidisciplinary panel identified and prioritized five clinical questions. The panel performed systematic reviews of available studies (up to July 2018) and followed the Grading of Recommendations, Assessment, Development, and Evaluation evidence-to-decision framework to develop recommendations. All panel members discussed and approved the recommendations. Recommendations: After considering the overall very low quality of the evidence, the panel made five conditional recommendations. We suggest that: 1) clinicians use a serum bicarbonate level

The American Thoracic Society Core Curriculum updates clinicians annually in adult and pediatric pulmonary disease, medical critical care, and sleep medicine, in a 3-4-year recurring cycle of topics. These topics will be presented at the 2020 Virtual Conference. Below is the adult sleep medicine core that includes topics pertinent to sleep-disordered breathing and insomnia.

Obstructive sleep apnea (OSA) is a common disorder characterized by repetitive collapse of the upper airways. The resulting intermittent hypoxia, adrenergic response and sleep fragmentation have been implicated in the development of cardiometabolic disease in OSA. OSA has been associated with hypertension, arrhythmias, coronary artery disease, stroke and heart failure. In men with severe sleep disordered breathing increased coronary and cerebrovascular morbidity and mortality have also been reported. Yet the causal relationship between OSA and cardiovascular disease remains unclear and this chapter summarizes the more recent studies exploring the influence of OSA treatment on various cardiovascular end points to delineate better the relationship between OSA and cardiovascular disease.

Continuous positive airway pressure (CPAP) is highly effective in treating sleep-disordered breathing (SDB). However, unlike surgical interventions, this treatment modality relies heavily on patient acceptance and adherence. The current definition of adherence is largely arbitrary and is mainly used by third-party payers to determine CPAP reimbursement but CPAP adherence remains sub-optimal. Strategies to augment adherence, especially early in the course of a CPAP trial, are needed in the management of SDB. An understanding of the basis for observed differences in CPAP and oral appliance (OA) use is necessary in developing these strategies, but to date no single factor has been consistently identified. Consequently, a multidimensional approach using educational, behavioural, technological and potentially pharmacological strategies to target (i) disease characteristics, (ii) patient characteristics including psychosocial factors, (iii) treatment protocols and (iv) technological devices and side effects that may influence adherence, is likely required to augment the complex behaviour of CPAP and OA use. In the near future, we envision a personalized medicine approach to determine the risk of non-adherence and set individualized adherence goals aimed at treating specific symptoms (e.g. excessive day-time sleepiness) and reducing the risk of patient-specific SDB consequences (e.g. atherosclerosis). Resources for interventions to improve adherence such as educational programmes and telemedicine encounters could then be more efficiently allocated.

Sarcoidosis is a systemic inflammatory disease associated with myriad symptoms, including fatigue. It can affect physiological processes like sleep, leading to poor sleep quality and excessive daytime sleepiness. We hypothesized that sarcoidosis patients would report more severe sleep disturbance than healthy controls and that relationships would be found with sleep disturbance and the severity of other symptoms.We enrolled 84 sarcoidosis patients and 30 healthy controls and recorded demographic and clinical characteristics. Self-report measures were used to assess sleep disturbance, psychosocial symptoms, and quality of life at enrollment and longitudinally. Relationships between different self-report outcomes were analyzed using correlation statistics.Using the General Sleep Disturbance Scale, 54% of sarcoidosis patients reported frequent and occasional sleep disturbance compared to only 17% of healthy controls (p 0.0001). This significant increase in sleep disturbance found in sarcoidosis patients strongly correlated with multiple psychosocial symptoms, including fatigue, depression, and cognitive dysfunction, and negatively impacted quality of life (p 0.01). Traditional measures of sarcoidosis disease severity or activity were not associated with sleep disturbance. Sleep disturbance scores remained stable at follow-up (mean time between first and last administration of questionnaire was 17.3 months) in 56 of the sarcoidosis patients.Sarcoidosis patients experienced significant sleep disturbance that correlated with higher levels of fatigue, depression, and cognitive dysfunction, and poorer quality of life. These associations were present regardless of disease severity or activity and result in decrements in quality of life and mental health.

Streptococcus anginosus has long been recognized to cause invasive pyogenic infections. This holds true for thoracic infections where S. anginosus has a propensity for abscess and empyema formation. Early diagnosis is important given the significant morbidity and mortality associated with thoracic S. anginosus infections. Yet, distinguishing thoracic S. anginosus clinically is difficult. We present three cases of thoracic S. anginosus that demonstrated radiographic extension across tissue planes, including the interlobar fissure, diaphragm, and chest wall. Few infectious etiologies are known to cross tissue planes. Accordingly, we propose S. anginosus be considered among the differential diagnosis of potential infectious etiologies causing radiographic extension across tissue planes.

Type 3 home sleep apnea tests may underestimate the apnea-hypopnea index (AHI) due to overestimation of total sleep time (TST). We aimed to evaluate the effect of manual editing of the total recording time (TRT) on the TST and AHI.Thirty 15-channel in-home polysomnography studies (AHI 0 to 30 events/h) scored using American Academy of Sleep Medicine criteria were rescored by two blinded polysomnologists after data from electroencephalogram, electrooculogram, and electromyogram were masked. In method 1, periods of probable wakefulness and artifact were manually edited and removed from analysis. Method 2 identified TST as the TRT without manual editing. PairedTST (mean [standard deviation, SD]) by polysomnography, method 1, and method 2 was 366.0 (70.1), 447.1 (59.0), and 542 (61.9) min, respectively. The corresponding AHI was 12.5 (8.2), 10.8 (7.0), and 9.1 (6.1) events/h, respectively. Compared to polysomnography, both alternative methods overestimated the TST (method 1: mean difference [SD] 81.1 [56.1] min, method 2: 176.0 [89.7] min; both p0.001) and underestimated the AHI (method 1: mean difference [SD] -1.6 [3.3], method 2: -3.3 [3.9]; both p0.001). The sensitivity was 100% and 70.0% for method 1, and 91.3% and 40.0% for method 2 for identifying sleep-disordered breathing using AHI cutoffs of ≥ 5 and ≥ 15 events/h, respectively.Manual editing of TRT reduces the overestimation of TST and improves the sensitivity for identifying studies with sleep-disordered breathing.A commentary on this article appears in this issue on page 9.

Birt-Hogg-Dube syndrome (BHD) is a rare autosomal dominant disorder caused by mutations in the Folliculin gene and is characterized by the formation of fibrofolliculomas, early onset renal cancers, pulmonary cysts, and spontaneous pneumothoraces. The exact pathogenesis of tumor and lung cyst formation in BHD remains unclear. There is great phenotypic variability in the clinical features of BHD, and patients can present with any combination of skin, pulmonary, or renal findings. More than 80% of adult patients with BHD have pulmonary cysts on high-resolution computed tomography scan of the chest.

Obstructive sleep apnea (OSA) is a clinical syndrome characterized by recurrent episodes of upper airway obstruction during sleep, resulting in chronic intermittent hypoxia, arousals, and sleep fragmentation. Timely diagnosis is critical, as OSA may lead to adverse clinical sequelae and positive air

Portable monitor testing is being increasingly used as an alternative strategy for the diagnosis and treatment of patients with obstructive sleep apnea. Portable monitors have become progressively sophisticated but lack standardization. Recent studies comparing clinical outcomes of ambulatory management pathways using portable monitor testing support their use in patients with a high pretest probability for obstructive sleep apnea. Whether ambulatory management is cost-effective and will improve patient access to diagnosis and treatment requires further investigation.

Streptococcus anginosus has long been recognized to cause invasive pyogenic infections. This holds true for thoracic infections where S. anginosus has a propensity for abscess and empyema formation. Early diagnosis is important given the significant morbidity and mortality associated with thoracic S. anginosus infections. Yet, distinguishing thoracic S. anginosus clinically is difficult. We present three cases of thoracic S. anginosus that demonstrated radiographic extension across tissue planes, including the interlobar fissure, diaphragm, and chest wall. Few infectious etiologies are known to cross tissue planes. Accordingly, we propose S. anginosus be considered among the differential diagnosis of potential infectious etiologies causing radiographic extension across tissue planes.

Obstructive sleep apnoea (OSA) is associated with cardiovascular disease. Dyslipidaemia has been implicated as a mechanism linking OSA with atherosclerosis, but no consistent associations with lipids exist for OSA or positive airway pressure treatment. We assessed the relationships between fasting lipid levels and obesity and OSA severity, and explored the impact of positive airway pressure treatment on 2-year fasting lipid level changes. Analyses included moderate-to-severe OSA patients from the Icelandic Sleep Apnoea Cohort. Fasting morning lipids were analysed in 613 untreated participants not on lipid-lowering medications at baseline. Patients were then initiated on positive airway pressure and followed for 2 years. Sub-classification using propensity score quintiles, which aimed to replicate covariate balance associated with randomised trials and, therefore, minimise selection bias and allow causal inference, was used to design the treatment group comparisons. 199 positive airway pressure adherent patients and 118 non-users were identified. At baseline, obesity was positively correlated with triglycerides and negatively correlated with total cholesterol, and low-density and high-density lipoprotein cholesterol. A small correlation was observed between the apnoea/hypopnoea index and high-density lipoprotein cholesterol. No effect of positive airway pressure adherence on 2-year fasting lipid changes was observed. Results do not support the concept of changes in fasting lipids as a primary mechanism for the increased risk of atherosclerotic cardiovascular disease in OSA.

There has been an exponential increase in the use of home noninvasive ventilation (NIV). Despite growing use, there is a paucity of evidence-based guidelines and practice standards in the United States to assist clinicians in the initiation and ongoing management of home NIV. Consequently, home NIV practices are being influenced by complicated local reimbursement policies and coding. This article aims to provide a practice management perspective for clinicians providing home NIV, including Local Coverage Determination reimbursement criteria for respiratory assist devices, Durable Medical Equipment coding, and Current Procedural Terminology coding to optimize clinical care and minimize lost revenue. It highlights the need for further research and development of evidence-based clinical practice standards to ensure best practice policies are in place for this rapidly evolving patient population.

STUDY OBJECTIVES To evaluate reliability of single objective tests in assessing sleepiness. DESIGN Subjects who completed polysomnography underwent a 4-nap multiple sleep latency test (MSLT) the following day. Prior to each nap opportunity on MSLT, subjects performed the psychomotor vigilance test (PVT) and divided attention driving task (DADT). Results of single versus multiple test administrations were compared using the intraclass correlation coefficient (ICC) and adjusted for test administration order effects to explore time of day effects. Measures were explored as continuous and binary (i.e., impaired or not impaired). SETTING Community-based sample evaluated at a tertiary, university-based sleep center. PARTICIPANTS 372 adult commercial vehicle operators oversampled for increased obstructive sleep apnea risk. INTERVENTIONS N/A. MEASUREMENTS AND RESULTS AS CONTINUOUS MEASURES, ICC WERE AS FOLLOWS: MSLT 0.45, PVT median response time 0.69, PVT number of lapses 0.51, 10-min DADT tracking error 0.87, 20-min DADT tracking error 0.90. Based on binary outcomes, ICC were: MSLT 0.63, PVT number of lapses 0.85, 10-min DADT 0.95, 20-min DADT 0.96. Statistically significant time of day effects were seen in both the MSLT and PVT but not the DADT. Correlation between ESS and different objective tests was strongest for MSLT, range [-0.270 to -0.195] and persisted across all time points. CONCLUSIONS Single DADT and PVT administrations are reliable measures of sleepiness. A single MSLT administration can reasonably discriminate individuals with MSL < 8 minutes. These results support the use of a single administration of some objective tests of sleepiness when performed under controlled conditions in routine clinical care.