HST: The Case for Multi-Night Studies from the View of a Sleep Physician

In the world of sleep medicine, the evaluation of sleep-disordered breathing, particularly obstructive sleep apnea (OSA), has seen a paradigm shift with the introduction of home sleep tests (HSTs). As a sleep physician, I often grapple with the decision of whether to recommend a one-night or multi-night HST for my patients. While the choice may appear to be a matter of convenience and cost-effectiveness, it is far more nuanced than it seems. This article delves into the perspective of a sleep physician and explores the compelling case for multi-night studies.

The Versatility of Home Sleep Tests

HSTs have gained popularity due to their ability to provide valuable insights into an individual’s sleep patterns in the comfort of their own home. These tests involve the use of portable devices that monitor various physiological parameters, allowing us to detect signs of sleep disorders, primarily OSA. However, not all HSTs provide the same data, and they may have different types of sensors and bio-signals.

The One-Night vs. Multi-Night Debate

While one-night HSTs are convenient and cost-effective, multi-night studies offer a deeper understanding of sleep patterns and variations. From a sleep physician’s perspective, the choice between one-night and multi-night HSTs hinges on several crucial factors.^1-3

One-Night Home Sleep Test

1. Simplicity and Cost-Effectiveness: One-night HSTs are relatively simple for patients to use and more affordable. They involve a single night of monitoring at home, and the data is subsequently analyzed.
2. Screening for Severe Cases: For patients with severe OSA, a one-night HST might suffice, as their condition is often readily detected within this brief timeframe. It is important to be able to screen for patients that may have severe OSA, such as a very elevated Epworth Sleepiness Scale, STOP-BANG score, Berlin questionnaire score, and medical co-morbidities, before deciding whether to do one night or more. But even 20% of cases that use a single night may be misclassified.

Multi-Night Home Sleep Test

1. Comprehensive Data: Multi-night studies offer a wealth of data, painting a more detailed and complete picture of a patient’s sleep patterns and potential variations from one night to the next.
2. Detecting Variability: Sleep patterns can vary significantly, and some individuals experience “night-to-night variability.” Multi-night HSTs are instrumental in detecting these variations and ensuring a more accurate diagnosis.
3. Uncovering Mild and Moderate Cases: For patients with milder forms of sleep apnea or other sleep disorders, a single-night test might not capture the full extent of the issue. Multi-night studies are often indispensable for making a conclusive diagnosis in these cases.

Benefits of Multi-Night Home Sleep Studies

From a sleep physician’s standpoint, multi-night HSTs offer a range of benefits:

1. Increased Diagnostic Accuracy: The most significant advantage of multi-night HSTs is the heightened diagnostic accuracy they provide. These tests can capture variations in sleep patterns and are instrumental in diagnosing mild to moderate sleep apnea cases.
2. Unveiling Night-to-Night Variability: Night-to-night variability is a phenomenon in which sleep patterns change from one night to the next. A single-night HST may overlook this variability, potentially leading to an inaccurate diagnosis. Multi-night studies help account for this phenomenon.⁴
3. Enhanced Patient Engagement: Patients often find it more convenient to undergo several nights of testing at home rather than in-lab sleep studies, which can be disruptive, uncomfortable, and delay times for scheduling. Enhanced engagement leads to a more accurate assessment.
4. Personalized Treatment: Understanding a patient’s sleep patterns over multiple nights allows sleep physicians to design more personalized treatment plans. Each patient’s sleep issues are unique, and multi-night studies help us tailor recommendations accordingly.
5. Detecting a Range of Sleep Disorders: While HSTs are primarily employed for OSA, multi-night studies may also aid in identifying other sleep issues, such as insomnia, pain-related sleep difficulties, or the possibility of periodic limb movement disorder, contributing to a more personalized and holistic understanding of the patient’s sleep health.

The Perspective of a Sleep Physician

As a sleep physician, my primary goal is to provide the best care for my patients, and that includes making accurate diagnoses and delivering effective treatments. While one-night HSTs are suitable for severe cases of OSA and offer a quick diagnosis, multi-night studies are invaluable for capturing the complexity of sleep patterns, detecting variability, and diagnosing milder cases. In my practice, I often lean toward multi-night HSTs for the following reasons:

1. Diagnostic Precision: Accurate diagnosis is fundamental to effective treatment. Multi-night studies offer a comprehensive view of a patient’s sleep, helping me make more informed decisions.
2. Night-to-Night Variability: I’ve seen many cases where patients exhibit different sleep patterns on different nights. Multi-night HSTs are the best way to account for this variability.
3. Patient-Centered Care: I prioritize patient comfort and engagement. By reducing the patient burden, patients are more likely to use the device for multiple nights, have an improved, less intrusive experience, and I am able to obtain the information I need for diagnostic purposes.
4. Personalized Approach: Every patient is unique. With multi-night studies, I can tailor treatment plans to address individual sleep issues effectively.
5. Holistic Understanding: Sleep disorders are not limited to OSA. Multi-night studies enable me to explore a broader range of possible sleep conditions, ensuring a more holistic approach to my patients’ sleep health.

Conclusion

The decision between one-night and multi-night home sleep tests is far from straightforward. From a sleep physician’s perspective, the choice depends on the patient’s specific circumstances and the need for diagnostic precision. While one-night HSTs are convenient and cost-effective, multi-night studies offer a deeper insight into a patient’s sleep patterns, accommodating night-to-night variability and diagnosing milder cases accurately. To provide the best care, I believe in the value of multi-night studies, ensuring that my patients receive the most personalized and precise sleep medicine possible.

Dr. Haramandeep Singh is a board-certified sleep physician licensed in all 50 states and CEO of iSleep Physicians, which offers sleep interpretations and telemedicine in all 50 states for both pediatric and adult patients.

References

1. Punjabi NM, Patil SP, Crainiceanu CM, Aurora RN. Variability and misclassification of sleep apnea severity based on Multi-Night Testing. Chest. 2020;158(1):365-373. doi:10.1016/j.chest.2020.01.03
2. Tschopp S, Wimmer W, Caversaccio M, Borner U, Tschopp K. Night-to-night variability in obstructive sleep apnea using peripheral arterial tonometry: a case for multiple night testing. Journal of Clinical Sleep Medicine. 2021;17(9):1751-1758. Doi:10.5664/jcsm.93
3. Lechat B, Naik GR, Reynolds A, et al. Multinight prevalence, variability, and diagnostic misclassification of obstructive sleep apnea. American Journal of Respiratory and Critical Care Medicine. 2022;205(5):563-569. doi:10.1164/rccm.202107-1761o
4. Sforza É, Roche F, Chapelle C, Pichot V. Internight variability of Apnea-Hypopnea index in obstructive sleep apnea using ambulatory polysomnography. Frontiers in Physiology. 2019;10. doi:10.3389/fphys.2019.00849