Is There a Clinical Role for Sleep Apnea Apps?

Apps for detecting sleep apnea are increasingly popular, but are they effective — and is the data they generate relevant for clinicians?

Obstructive sleep apnea (OSA) affects up to 14% of men and 5% of women in the United States, causing significant morbidity and reduced quality of life.1  Research findings consistently show that a substantial number of individuals with OSA remain undiagnosed, partially due to a lack of awareness that they are experiencing airway obstruction as they sleep.2,3 While in-laboratory polysomnography (PSG) represents the gold standard in diagnosing OSA, many patients lack access to PSG due to the associated cost and time commitment.3

Although the use of home-based sleep testing is increasing, this modality also carries the risk of certain drawbacks, including financial risk for providers, administrative barriers imposed by third-party payers, and the inability to detect comorbid narcolepsy and other hypersomnias.4,5 In light of these limitations, along with the growing popularity of mobile medical applications (apps) for smartphones, there has been increasing interest in the use of such apps to aid in the detection and treatment of OSA.

Several sleep apnea apps have shown favorable results in preliminary research, including an app (Firefly)6 demonstrating sensitivity of 88.3% and specificity of 80.0% for a clinical threshold apnea-hypopnea index (AHI) of 15 or more events per hour. However, extensive testing is needed before this tool or similar apps can be reliably used in clinical practice.6

In a systematic review published in February 2022, Baptista and colleagues analyzed study results for 10 consumer-direct smartphone apps intended for the diagnosis, monitoring, and treatment of sleep-disordered breathing. These researchers concluded that the apps are generally not as accurate as traditional options and lack scientific validation.7

Overall, these apps have proven to be “inaccurate and affected by a lot of variables, and none of them record true sleep,” according to Abhinav Singh, MD, MPH, FAASM, medical director of the Indiana Sleep Center in Greenwood, clinical assistant professor at Marian University College of Medicine in Indianapolis, and member of the medical review panel at SleepFoundation.org. “None of the information collected by these apps is submissible as valid medical information in the patient’s chart,” he said in an interview with Pulmonology Advisor.

A 2018 systematic review determined that out of 73 sleep apps examined, only 3 (Sleep Time, MotionX 24/7, and Sleep Cycle) had been tested for clinical validity in comparison to PSG, and all 3 studies reported weak correlation between the apps and PSG.8 One of these 3 apps (Sleep Time) was the focus of a 2015 study in which the app demonstrated high accuracy in sleep-wake detection (85.9%) but lacked correlation with PSG regarding sleep efficiency (correlation coefficient [r] = −0.127; P =.592), light sleep percentage (r = 0.024, P =.921), deep sleep percentage (r = 0.181; P =.444), and sleep latency (Spearman’s rank correlation coefficient [rs] = 0.384, P =.094).9

In addition, the app significantly underestimated light sleep by 27.9% (95% CI, 19.4–36.4%, P <.0001), deep sleep by 11.1% (95% CI, 4.7–17.4%, P =.008), and sleep latency by 15.6 minutes (95% CI, 9.7–21.6, P <.0001).9

Another concern is that patient use of such apps could potentially increase the burden on sleep medicine specialists. This is due to the high rate of false positives produced by sleep apps, as well as the difficulty involved in analyzing and interpreting the non-standardized data generated by sleep apps.10

In select cases, Dr Singh does occasionally recommend that patients use a snoring detection app (the one he uses is SnoreLab11) for the purpose of gathering preliminary information or to increase patient awareness about their snoring. This approach is especially helpful “when the patient doesn’t have a regular bed partner to comment on their snoring, or for patients trying non-CPAP options such as posture therapy.”

Aside from apps used for detecting sleep-disordered breathing, those aimed at facilitating treatment and improving adherence have shown promise in recent studies. Research published in 2020 by Suarez-Giron and colleagues examined the feasibility and acceptance of a mobile app incorporating patient questionnaires and educational components to facilitate self-monitoring by OSA patients who recently initiated continuous positive airway pressure (CPAP) therapy.12 The results revealed that roughly 73% of patients considered it useful in managing OSA, and 65% agreed that the app could reduce hospital visits. Additionally, sleep professionals agreed on the potential utility of the app in OSA patient follow-up, especially in the first month of CPAP initiation.12

Another study published in 2020 explored the use of a mobile app to teach oropharyngeal exercises (myofunctional therapy) to patients with severe OSA over 90 sessions.13 In this pilot randomized controlled trial, participants in the app group demonstrated significant improvements compared with control participants, including reductions in AHI (from 44.7 [range 33.8-55.6] to 20.88 [14.02-27.7] events/hour; P <.001), oxygen desaturation index (from 36.31 [27.19-43.43] to 19.4 [12.9-25.98] events/hour; P =.003), and Epworth Sleepiness Scale scores (from 10.33 [8.71-12.24] to 5.37 [3.45-7.28]; P <.001).

With further refinement, testing, and validation, sleep apnea apps may ultimately become viable for a variety of clinical purposes in patients with OSA. Meanwhile, these tools may be most appropriate for occasional use in certain patients as adjunct to established approaches for OSA monitoring.7

To glean further insights regarding this emerging technology, Pulmonology Advisor interviewed Temitayo O. Oyegbile-Chidi, MD, PhD, sleep medicine specialist and associate professor of neurology at the University of California, Davis, School of Medicine in Sacramento, and board member of the National Sleep Foundation.

What are your thoughts about the growing interest in sleep-focused apps?

Dr Oyegbile-Chidi: We know that both consumers and health care personnel are always on the lookout for new and innovative ways to use mobile apps. It is true that apps have become more common in a variety of medical specialties. While there are apps that allow users to report and analyze their sleep duration and quality, this data is subjective. Long-term monitoring of sleep requires more practical methods, which only a sleep specialist can assist with.

How relevant are sleep apnea apps in clinical practice currently?

Dr Oyegbile-Chidi: There are many inexpensive or free, readily available apps that claim to monitor sleep and are increasingly popular among patients. However, since their accuracy is still unknown, these apps should not replace clinical diagnosis and recommendations.

If an individual has been formally diagnosed with sleep apnea with an in-lab or home sleep study and with a sleep physician, sleep apnea smartphone apps may be helpful specifically to note any changes that may suggest a need for a re-evaluation. Currently most of these apps do not directly correlate with findings on a formal sleep study, so accuracy is yet to be established, but these apps can be helpful if there is a significant change from baseline. If a significant change occurs on the sleep apnea app, I recommend that patients see their sleep physician.

What are some of the limitations of using these apps?

Dr Oyegbile-Chidi: While it appears that sleep apps are becoming a mainstream method for sleep self-management, a lot more work is needed for them to be used with confidence. Sleep apps must undergo rigorous authentication studies to ensure that their claims are evidence-based. Lastly, sleep apps are not meant, by any means, to replace or reduce doctor-patient interactions. OSA is a clinical diagnosis that needs to come from a clinician. Apps can be useful tools, but they don’t take the role of a trained professional.

References

1. Slowik JM, Collen JF. Obstructive sleep apnea. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing. Updated February 10, 2022. Accessed March 30, 2022. https://www.ncbi.nlm.nih.gov/books/NBK459252/

2. Goodchild TT, Lefer DJ. Obstructive sleep apnea: The not-so-silent killer. Circ Res. 2020;126(2):229-231. doi:10.1161/CIRCRESAHA.119.316359

3. Osman AM, Carter SG, Carberry JC, Eckert DJ. Obstructive sleep apnea: current perspectives. Nat Sci Sleep. 2018;10:21-34. doi:10.2147/NSS.S124657

4. Donovan LM, Patel SR. Making the most of simplified sleep apnea testing. Ann Intern Med. 2017;166(5):366-367. doi:10.7326/M16-2902

5. Rosenberg R, Hirshkowitz M, Rapoport DM, Kryger M. The role of home sleep testing for evaluation of patients with excessive daytime sleepiness: focus on obstructive sleep apnea and narcolepsy. Sleep Med. 2019;56:80-89. doi:10.1016/j.sleep.2019.01.014

6. Tiron R, Lyon G, Kilroy H, et al. Screening for obstructive sleep apnea with novel hybrid acoustic smartphone app technology. J Thorac Dis. 2020;12(8):4476-4495. doi:10.21037/jtd-20-804

7. Baptista PM, Martin F, Ross H, O’Connor Reina C, Plaza G, Casale M. A systematic review of smartphone applications and devices for obstructive sleep apnea. Braz J Otorhinolaryngol. Published online February 4, 2022. 2022:S1808-8694(22)00005-2. doi:10.1016/j.bjorl.2022.01.004

8. Choi YK, Demiris G, Lin SY, et al. Smartphone applications to support sleep self-management: Review and evaluation. J Clin Sleep Med. 2018;14(10):1783-1790. doi:10.5664/jcsm.7396

9. Bhat S, Ferraris A, Gupta D, et al. Is there a clinical role for smartphone sleep apps? Comparison of sleep cycle detection by a smartphone application to polysomnography. J Clin Sleep Med. 2015;11(7):709-715. doi:10.5664/jcsm.4840

10. Ananth S. Sleep apps: current limitations and challenges. Sleep Sci. 2021;14(1):83-86. doi:10.5935/1984-0063.20200036

11. SnoreLab.com. SnoreLab: Record your snoring. Accessed March 30, 2022.

12. Suarez-Giron M, Garmendia O, Lugo V, et al. Mobile health application to support CPAP therapy in obstructive sleep apnoea: design, feasibility and perspectives. ERJ Open Res. 2020;6(1):00220-2019. doi:10.1183/23120541.00220-2019

13. O’Connor-Reina C, Ignacio Garcia JM, Rodriguez Ruiz E, et al. Myofunctional therapy app for severe apnea-hypopnea sleep obstructive syndrome: pilot randomized controlled trial. JMIR Mhealth Uhealth. 2020;8(11):e23123. doi:10.2196/23123

This article originally appeared on Pulmonology Advisor