Welcome to The Breath Factory - Your Partner in Sleep Health!

Physician and Nurse Practitioner Resources: Sleep Diagnostics Made Simple

Navigating sleep-disordered breathing shouldn’t add to your administrative load. The Breath Factory offers validated home sleep testing and clinically meaningful reporting throughout the Maritimes. We work as an extension of your team to ensure your patients are seen quickly and your reports are easy to interpret.

Use this portal to:

Access streamlined referral forms.
Download guides for interpreting home sleep studies.
Stay updated on clinical education, including why we prioritize metrics like hypoxic burden over traditional AHI.

We’re here to help you make informed decisions without the usual diagnostic delays.

CLINICAL CONTACT:

You can reach Dr. Robin LeBlanc (Otolaryngology) on Virtual Hallway from anywhere in Atlantic Canada. Join free at https://virtualhallway.ca; we are extremely timely getting back to those who request help, whether it is related to sleep disturbances or other Otolaryngology related issues. If you have concerns about your patient and you need advice, this is the most time efficient way of doing so.

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Screening for Obstructive Sleep Apnea

It can be daunting when a patient comes asking for help about their sleep related issues.

The most common issues you might encounter might be related to snoring and/or obstructive sleep apnea, and / or possibly related to insomnia. These are all very common sets of sleep related problems that can affect our patients, and they can definitely co-exist.

Fortunately, we do have some screening tools we can use to help determine if our patients are at risk and need to proceed to more defined characterization.

Snoring is fairly evident, but sometimes a single sleeper is not aware of whether they snore.

A sore throat in the morning, or feeling dry is not necessarily just normal mouth breathing (which is not normal either). It can occur due to the microtraumas that take place in the uvula and tongue base, which can vibrate quite aggressively. Some patients end up with post-sleep uvular swelling.

Obstructive sleep apnea follows in the spectrum of sleep disordered breathing. This might also include upper airway resistance syndrome, which would include patients who have respiratory disturbances, but while they would not necessarily qualify as true hypopnea or apnea, they can lead to arousals and fragmented sleep. We are seeing that long term fragmented sleep can adversely affect cognitive function and cardiac health over time.

We have advocated the STOP BANG screening tool (see below) as a time-efficient validated tool. If your patient has 3 or more positive responses to the STOPBANG, particularly if their BMI > 35, then there is high probability of detecting OSA on physiologic testing. That being said, some of those might still end up with mild OSA (AHI < 15), which you might not necessarily treat aggressively unless the patient was very symptomatic with daytime symptoms, or had significant comorbidities.

Insomnia is also quite common, particularly in perimenopausal women and the elderly. Fortunately, there is cognitive behavioural therapy effective at managing insomnia. The Insomnia Severity Index is a helpful tool to determine if your patient's insomnia is detrimental to their lifestyle (see below).

Other Common Screening Tests

Here are some of the common screening tools available to clinicians. Let's go over them and their utility to assess patient risk.

The Epworth Sleepiness Score

The Epworth Sleepiness Score (ESS) is a test to assess daytime sleepiness. It is not adequate to screen for sleep apnea, which could cause sleepiness, but is only one of many entities that could trigger an elevated ESS.

The questionnaire is a validated tool with eight situations during which the user describes how likely they might fall asleep. The test scores can range from 0 to 24.

0 to 5: Low daytime sleepiness (normal).
6 to 10: High daytime sleepiness (normal).
11 to 12: Mild excessive daytime sleepiness.
13 to 15: Moderate excessive daytime sleepiness.
16 to 24: Severe excessive daytime sleepiness.

For those with scores above 16, they should be warned about driving or using heavy equipment, and they should be further assessed for sleep related disorders.

This test coordinates well with the STOPBANG; the STOPBANG can identify OSA, while the ESS can objectively quantify the impact of OSA (with daytime sleepiness).

The BERLIN questionnaire

The Berlin Questionnaire is a symptom-based screening tool designed to identify patients at increased risk of obstructive sleep apnea (OSA) in non-surgical settings, particularly primary care. It assesses three domains: snoring and witnessed apneas, daytime sleepiness or fatigue, and cardiometabolic risk (specifically hypertension and obesity). Patients are classified as high risk if they score positive in two or more categories. Unlike STOP-BANG, which emphasizes peri-operative safety and favors sensitivity, the Berlin Questionnaire places greater weight on symptom burden and clinical context, making it more reflective of how OSA presents in routine practice.

Its main strength lies in identifying patients with clinically significant, symptomatic OSA, rather than simply anatomical or demographic risk. While it is more time-consuming and somewhat less sensitive than STOP-BANG, it offers better specificity in primary care and can help reduce over-referral.

In practice, the Berlin Questionnaire is most useful as a risk-stratification tool to guide decisions about objective sleep testing, particularly when combined with clinical judgment and adjunctive measures such as the Epworth Sleepiness Scale.

The NoSAS score

The NoSAS score is a concise, objective screening tool developed to estimate the risk of clinically relevant obstructive sleep apnea, particularly moderate to severe disease, in community and primary care settings.

It incorporates five readily available variables: neck circumference, obesity (BMI), snoring, age, and sex, generating a numeric score that stratifies patients into low- or higher-risk categories.

Unlike symptom-heavy questionnaires, NoSAS relies more on anthropometric and demographic risk factors, which improves its specificity and reduces false positives compared with tools such as STOP-BANG. This makes it particularly useful in primary care when the goal is not just to rule in risk, but also to confidently rule out OSA in low-risk patients and avoid unnecessary testing.

Scores range from 0 to 17. Scores over 8 represent higher risk of obstructive sleep apnea.

While it does not capture daytime sleepiness or functional impairment, NoSAS performs well as an initial triage tool to determine who warrants objective sleep testing, and it pairs effectively with adjunctive measures such as the Epworth Sleepiness Scale to assess symptom burden and clinical impact.

STOP BANG / NoSAS / ESS Calculator

Home Sleep Studies

SleepImage Ring

This ring measures cardiopulmonary coupling (CPC) and based on PSG-based algorithms determines risks for OSA. Suitable in children over age 2 and adult. This test is free for patients.

WatchPAT One

The WP One is a recyclable device the patient buys. It measures peripheral arterial tonometry and based on PSG-based algorithms determines risks for OSA. Using a chest sensor it also determines risks for central sleep apnea (CSA). It can also detect arrhythmia such as atrial fibrillation. Suitable for patients over the age of 12 years old.

ARES 620

The ARES 620 device measures EMG, nasal cannulae, SpO2, heart rate, snoring, actigraphy and position channels to determine risks for OSA.

NOX T3s

The NOX T3s device measures chest and abdominal effort, nasal cannulae, SpO2, heart rate, snoring, actigraphy and position channels to determine risks for OSA. It is a true level III home sleep study used in facilities across the world. Suitable for pediatric and adult use.