Comment of the Reviewer Jorge Rey de Castro, MD. Clínica Anglo Americana. Profesor Principal Universidad Peruana Cayetano Heredia. Lima. Perú.
.- The practical needs, the advances in technology and control of costs in the diagnosis of Sleep Apnoea/Hypopnoea Syndrome (SAHS) in recent years has inevitably led to simplifying orthodox procedures with the aim of achieving higher output without sacrificing work quality. In this sense, the concept of simplifying a test considered as the gold standard in sleep medicine has been crucial in the last few years. However, conventional polysomnography has gained this honoured position despite being a complex and expensive test.
As regards this subject, and from our point of view, there are two well defined clinical schools of thought. On the one hand the inflexible Anglo-Saxon position expressly represented by the American Academy of Sleep Medicine, cited in the literature references 11 to 15 by Alonso Alvarez et al in the article which is been commented on here. In this case polysomnography represents the procedure of choice in clinical practice for establishing a suitable diagnosis, clearly underestimating the Level III, also called screening, tests. On the other hand, the Spanish school, specifically represented by pneumonolgists and the Spanish Society of Pneumonology and Thoracic Surgery (SEPAR), who are interested in the validation of simplified diagnostic equipment and their implementation following algorithms as proposed in the article by the group of investigators from the Yagüe General Hospital in Burgos. These schools of thought have been developed under totally different contexts. We specifically look at health budgets and safety cover with substantially different realities. This makes the difference.
In the case of the less developed countries- where I work- where the budgetary restrictions are even greater than the choice of an economic technology, it is crucial. In that sense, there is little point in trying to follow a diagnostic sequence with burdensome technology if the economic means are not available to implement it, when, on the other hand, it is possible to establish with thoroughness, the nature of the disease in a patient using cheaper instruments and procedures.
The publication by the Burgos group has that merit. An algorithm is set out which sequentially establishes or rejects the diagnosis using respiratory polygraph equipment set up in the home.
There is no doubt that the group in question have experience in the subject, they suitably select the patient according to the clinical aspects and finally they have quantified, through validation comparing polysomnography, the performance of the equipment used on patients with a high and low possibility of having SAHS.
To use simplified equipment for the diagnosis of SAHS, each sleep centre, ideally, should make their own measurements with their target population, this improves the system and protects the patient from diagnostic errors. The publication by Alonso Alvarez et al, in that sense is an important contribution in the area of sleep breathing disorders.
Dra. María Luz Alonso Álvarez
Unidad de Trastornos Respiratorios del Sueño
Hospital General Yagüe
Avda. del Cid 96
09005 Burgos. España