Application of videotape in the screening of obstructive sleep apnea in children

Development and Validation of a Nomogram for Predicting Obstructive Sleep Apnea Severity in Children

Purpose

The clinical presentation of Obstructive Sleep Apnea (OSA) in children is insidious and harmful. Early identification of children with OSA, particularly those at a higher risk for severe symptoms, is essential for making informed clinical decisions and improving long-term outcomes. Therefore, we developed and validated a risk prediction model for severity in Chinese children with OSA to effectively identify children with moderate-to-severe OSA in a clinical setting.

Patients and Methods

From June 2023 to September 2023, we retrospectively analyzed the medical records of 367 Children diagnosed with OSA through portable bedside polysomnography (PSG). Predictor variables were screened using the least absolute shrinkage and selection operator (LASSO) and logistic regression techniques to construct nomogram to predict the severity of OSA. Receiver operating characteristic curve (ROC), calibration curve, decision curve analysis (DCA), and clinical impact curve (CIC) were used to determine the discrimination, calibration, and clinical usefulness of the nomogram.

Results

A total of 367 children with a median age of 84 months were included in this study. Neck circumference, ANB, gender, learning problem, and level of obstruction were identified as independent risk factors for moderate-severe OSA. The consistency indices of the nomogram in the training and validation cohorts were 0.841 and 0.75, respectively. The nomogram demonstrated a strong concordance between the predicted probabilities and the observed probabilities for children diagnosed with moderate-severe OSA. With threshold probabilities ranging from 0.1 to 1.0, the predictive model demonstrated strong predictive efficacy and yielded improved net benefit for clinical decision-making. ROC analysis was employed to classify the children into high and low-risk groups, utilizing the Optimal Cutoff value of 0.39.

Conclusion

A predictive model using LASSO regression was developed and validated for children with varying levels of OSA. This model identifies children at risk of developing OSA at an early stage.

Comparison of home ambulatory type 2 polysomnography with a portable monitoring device and in-laboratory type 1 polysomnography for the diagnosis of obstructive sleep apnea in children

STUDY OBJECTIVES

To compare type 2 polysomnography (T2PSG) to the gold standard type 1 in-laboratory polysomnography (T1PSG) for diagnosing obstructive sleep apnea (OSA) in children; validate home T2PSG in children with suspected OSA.

METHODS

Eighty-one participants (ages 6-18) with suspected OSA had simultaneous T1PSG and T2PSG in the sleep laboratory, 47 participants (ages 5-16) had T1PSG in the sleep laboratory and T2PSG performed at home. Sleep scientists staged and scored polysomnography data, and pediatric sleep physicians assigned a diagnosis of normal or OSA. Participant demographics, polysomnography variables, and diagnoses were compared using chi-square and Fisher's exact tests for nominal variables, t test for continuous variables and Cohen's kappa to assess concordance.

RESULTS

Acceptable recordings were obtained for every home T2PSG. When T1PSG and T2PSG were simultaneous, correlation between the number of arousals, respiratory disturbance index, and sleep stages was excellent. T2PSG at home demonstrated less stage 2 sleep, more rapid eye movement sleep, and higher sleep efficiency. Comparison of home T2PSG to T1PSG for diagnosing OSA showed a false-positive rate of 6.6% and false-negative rate of 3% for those performed at home.

CONCLUSIONS

T2PSG in the home is feasible with excellent concordance with T1PSG for the purposes of diagnosing OSA in children aged 5-18 years. Home T2PSG may be more representative of a "normal" night for children and could benefit those suspected of having OSA by reducing waiting times for laboratory PSG, improving access to PSG and possibly reducing costs of investigating and treating OSA.

CITATION

Withers A, Maul J, Rosenheim E, O'Donnell A, Wilson A, Stick S. Comparison of home ambulatory type 2 polysomnography with a portable monitoring device and in-laboratory type 1 polysomnography for the diagnosis of obstructive sleep apnea in children. J Clin Sleep Med. 2022;18(2):393-402.

Observational Study of Pulse Transit Time in Children With Sleep Disordered Breathing

Background: Pulse transit time (PTT) is a non-invasive measure of arousals and respiratory effort for which we aim to identify threshold values that detect sleep disordered breathing (SDB) in children. We also compare the sensitivity and specificity of oximetry with the findings of a multi-channel study. Methods: We performed a cross-sectional observational study of 521 children with SDB admitted for multi-channel sleep studies (pulse oximetry, ECG, video, sound, movement, PTT) in a secondary care centre. PTT data was available in 368 children. Studies were categorised as normal; primary snoring; upper airway resistance syndrome (UARS); obstructive sleep apnoea (OSA), and "abnormal other." Receiver operator characteristic curves were constructed for different PTT (Respiratory swing; Arousal index) thresholds using a random sample of 50% of children studied (training set); calculated thresholds of interest were validated against the other 50% (test set). Study findings were compared with oximetry categories (normal, inconclusive, abnormal) using data (mean and minimum oxygen saturations; oxygen desaturations > 4%) obtained during the study. Results: Respiratory swing of 17.92 ms identified SDB (OSA/UARS) with sensitivity: 0.80 (C.I. 0.62-0.90) and specificity 0.79 (C.I. 0.49-0.87). PTT arousal index of 16.06/ hour identified SDB (OSA/UARS) with sensitivity: 0.85 (95% C.I. 0.67-0.92) and specificity 0.37 (95% C.I. 0.17-0.48). Oximetry identified SDB (OSA) with sensitivity: 0.38 (C.I. 0.31-0.46) and specificity 0.98 (C.I. 0.97-1.00). Conclusions: PTT is more sensitive but less specific than oximetry at detecting SDB in children. The additional use of video and sound enabled detection of SDB in twice as many children as oximetry alone.

Accuracy of clinical scoring tools for the diagnosis of pediatric obstructive sleep apnea

OBJECTIVES

To assess the diagnostic test accuracy of questionnaire and clinical examination-based scoring tools in the diagnosis of pediatric obstructive sleep apnea (OSA).

METHODS

A comprehensive literature search was performed to identify studies published from 1960 to 2018 that evaluated the accuracy of clinical scoring tools in the diagnosis of pediatric OSA. Studies that did not include attended polysomnography as a reference standard were excluded. The study populations were children under 18 years old without craniofacial abnormalities, congenital syndromes, or other complex medical conditions. Outcomes measures were diagnostic test accuracy (DTA) statistics including sensitivity, specificity, and area under the curve (AUC) from receiver operating characteristic curve analysis.

RESULTS

Fifteen different scoring tools were identified. Authors chose different polysomnographic criteria to diagnose OSA. Four of the tools had undergone multiple DTA studies by different authors (OSA Score, Sleep-Related Breathing Disorder [SRBD] scale, Severity Score, and OSA-18). The Pediatric Sleep Questionnaire SRBD scale, which is widely used, has a sensitivity of 71% to 84% in included studies, but specificity as low as 13% and a low AUC of 0.57-0.69, indicating poor diagnostic accuracy. None of the 15 scoring tools performed well enough to be considered accurate diagnostic tests for pediatric OSA.

CONCLUSIONS

A well-designed questionnaire can provide crucial information on the impact of sleep-disordered breathing on a child's physical and psychological health, which may not be adequately reflected in objective polysomnography outcomes measures. However, DTA results indicate that published clinical scoring tools do not accurately predict a diagnosis of pediatric OSA as defined by polysomnography outcome measures. Laryngoscope, 130:1034-1043, 2020.

The Accuracy of an Ambulatory Level III Sleep Study Compared to a Level I Sleep Study for the Diagnosis of Sleep-Disordered Breathing in Children With Neuromuscular Disease

STUDY OBJECTIVES

Polysomnography (PSG) surveillance recommendations are not being met for children with neuromuscular disease (NMD) because of limited diagnostic facilities. We evaluated the diagnostic accuracy of an ambulatory level III device as compared to a level I PSG.

METHODS

A cross-sectional study was conducted at a tertiary pediatric institution. Eligibility criteria included: (1) children with NMD; (2) age 6 to 18 years; (3) booked for a clinically indicated overnight level I PSG. Participants were randomized to an overnight level I PSG followed by an ambulatory level III study with end tidal carbon dioxide (etCO₂) or vice versa. Sensitivity and specificity of the ambulatory level III device to diagnose sleep-disordered breathing (SDB) at an apnea-hypopnea index (AHI) cutoff of > 1.0 events/h was the primary outcome.

RESULTS

Moderate to severe SDB was found in 46% of participants (13/28). The device's sensitivity and specificity to detect SDB was 61.5% and 86.7%, respectively. The positive predictive value of the level III study was 80.0% and the negative predictive value was 72.0%. Fifty percent of the cohort were either missing or had incomplete or falsely low ambulatory etCO₂ data.

CONCLUSIONS

A level III device with etCO₂ is not yet able to be implemented in clinical practice as a diagnostic tool for SDB in pediatric patients with NMD.

COMMENTARY

A commentary on this article appears in this issue on page 1973.

The utility of a portable sleep monitor to diagnose sleep-disordered breathing in a pediatric population

BACKGROUND

Central and⁄or obstructive sleep-disordered breathing (SDB) in children represents a spectrum of abnormal breathing during sleep. SDB is diagnosed using the gold standard, overnight polysomnography (PSG). The limited availability and access to PSG prevents its widespread use, resulting in significant delays in diagnosis and treatment of SDB. As such, portable sleep monitors are urgently needed.

OBJECTIVE

To evaluate the utility of a commercially available portable sleep study monitor (PSS-AL) (ApneaLink, ResMed, USA) to diagnose SDB in children.

METHODS

Children referred to a pediatric sleep facility were simultaneously monitored using the PSS-AL monitor and overnight PSG. The apnea-hypopnea index (AHI) was calculated using the manual and autoscoring function of the PSS-AL, and PSG. Sensitivity and specificity were compared with the manually scored PSS-AL and PSG. Pearson correlations and Bland-Altman plots were constructed.

RESULTS

Thirty-five children (13 female) completed the study. The median age was 11.0 years and the median body mass index z-score was 0.67 (range -2.3 to 3.8). SDB was diagnosed in 17 of 35 (49%) subjects using PSG. The AHI obtained by manually scored PSS-AL strongly correlated with the AHI obtained using PSG (r=0.89; P<0.001). Using the manually scored PSS-AL, a cut-off of AHI of >5 events⁄h had a sensitivity of 94% and a specificity of 61% to detect any SDB diagnosed by PSG.

CONCLUSIONS

Although PSG is still recommended for the diagnosis of SDB, the ApneaLink sleep monitor has a role for triaging children referred for evaluation of SDB, but has limited ability to determine the nature of the SDB.

Screening of pediatric sleep-disordered breathing: a proposed unbiased discriminative set of questions using clinical severity scales

BACKGROUND

Identification of sleep-disordered breathing (SDB) using questionnaires is critical from a clinical and research perspective. However, which questions to use and how well such questionnaires perform has thus far been fraught with substantial uncertainty. We aimed at delineating the usefulness of a set of questions for identifying pediatric SDB.

METHODS

Random prospective sampling of urban 5- to 9-year-old children from the community and enriched for habitual snoring underwent overnight sleep study. Subjective indicators or questions were evaluated to further characterize and discriminate SDB.

RESULTS

Of 1,133 subjects, 52.8% were habitual snorers. This sample was analyzed based on a clinical grouping (ie, established apnea-hypopnea index cutoffs). Several statistical steps were performed and indicated that complaints can be ranked according to a severity hierarchy: shake child to breathe, apnea during sleep, struggle breathing when asleep, and breathing concerns while asleep, followed by loudness of snoring and snoring while asleep. With a posteriori cutoff, a predictive score &gt; 2.72 on the severity scale was found (ie, area under the curve, 0.79 ± 0.03; sensitivity, 59.03%; specificity, 82.85%; positive predictive value, 35.4; negative predictive value, 92.7), making this cutoff applicable for confirmatory purposes.

CONCLUSIONS

As a result, the set of six hierarchically arranged questions will aid the screening of children at high risk for SDB but cannot be used as the sole diagnostic approach.

Executive summary of respiratory indications for polysomnography in children: an evidence-based review

OBJECTIVE

This comprehensive, evidence-based review provides a systematic analysis of the literature regarding the validity, reliability, and clinical utility of polysomnography for characterizing breathing during sleep in children. Findings serve as the foundation of practice parameters regarding respiratory indications for polysomnography in children.

METHODS

A task force of content experts performed a systematic review of the relevant literature and graded the evidence using a standardized grading system. Two hundred forty-three evidentiary papers were reviewed, summarized, and graded. The analysis addressed the operating characteristics of polysomnography as a diagnostic procedure in children and identified strengths and limitations of polysomnography for evaluation of respiratory function during sleep.

RESULTS

The analysis documents strong face validity and content validity, moderately strong convergent validity when comparing respiratory findings with a variety of relevant independent measures, moderate-to-strong test-retest validity, and limited data supporting discriminant validity for characterizing breathing during sleep in children. The analysis documents moderate-to-strong test-retest reliability and interscorer reliability based on limited data. The data indicate particularly strong clinical utility in children with suspected sleep related breathing disorders and obesity, evolving metabolic syndrome, neurological, neurodevelopmental, or genetic disorders, and children with craniofacial syndromes. Specific consideration was given to clinical utility of polysomnography prior to adenotonsillectomy (AT) for confirmation of obstructive sleep apnea syndrome. The most relevant findings include: (1) recognition that clinical history and examination are often poor predictors of respiratory polygraphic findings, (2) preoperative polysomnography is helpful in predicting risk for perioperative complications, and (3) preoperative polysomnography is often helpful in predicting persistence of obstructive sleep apnea syndrome in patients after AT. No prospective studies were identified that address whether clinical outcome following AT for treatment of obstructive sleep apnea is improved in association with routine performance of polysomnography before surgery in otherwise healthy children. A small group of papers confirm the clinical utility of polysomnography for initiation and titration of positive airway pressure support.

CONCLUSIONS

Pediatric polysomnography shows validity, reliability, and clinical utility that is commensurate with most other routinely employed diagnostic clinical tools or procedures. Findings indicate that the "gold standard" for diagnosis of sleep related breathing disorders in children is not polysomnography alone, but rather the skillful integration of clinical and polygraphic findings by a knowledgeable sleep specialist. Future developments will provide more sophisticated methods for data collection and analysis, but integration of polysomnographic findings with the clinical evaluation will represent the fundamental diagnostic challenge for the sleep specialist.

Practice parameters for the respiratory indications for polysomnography in children

BACKGROUND

There has been marked expansion in the literature and practice of pediatric sleep medicine; however, no recent evidence-based practice parameters have been reported. These practice parameters are the first of 2 papers that assess indications for polysomnography in children. This paper addresses indications for polysomnography in children with suspected sleep related breathing disorders. These recommendations were reviewed and approved by the Board of Directors of the American Academy of Sleep Medicine.

METHODS

A systematic review of the literature was performed, and the American Academy of Neurology grading system was used to assess the quality of evidence. RECOMMENDATIONS FOR PSG USE: 1. Polysomnography in children should be performed and interpreted in accordance with the recommendations of the AASM Manual for the Scoring of Sleep and Associated Events. (Standard) 2. Polysomnography is indicated when the clinical assessment suggests the diagnosis of obstructive sleep apnea syndrome (OSAS) in children. (Standard) 3. Children with mild OSAS preoperatively should have clinical evaluation following adenotonsillectomy to assess for residual symptoms. If there are residual symptoms of OSAS, polysomnography should be performed. (Standard) 4. Polysomnography is indicated following adenotonsillectomy to assess for residual OSAS in children with preoperative evidence for moderate to severe OSAS, obesity, craniofacial anomalies that obstruct the upper airway, and neurologic disorders (e.g., Down syndrome, Prader-Willi syndrome, and myelomeningocele). (Standard) 5. Polysomnography is indicated for positive airway pressure (PAP) titration in children with obstructive sleep apnea syndrome. (Standard) 6. Polysomnography is indicated when the clinical assessment suggests the diagnosis of congenital central alveolar hypoventilation syndrome or sleep related hypoventilation due to neuromuscular disorders or chest wall deformities. It is indicated in selected cases of primary sleep apnea of infancy. (Guideline) 7. Polysomnography is indicated when there is clinical evidence of a sleep related breathing disorder in infants who have experienced an apparent life-threatening event (ALTE). (Guideline) 8. Polysomnography is indicated in children being considered for adenotonsillectomy to treat obstructive sleep apnea syndrome. (Guideline) 9. Follow-up PSG in children on chronic PAP support is indicated to determine whether pressure requirements have changed as a result of the child's growth and development, if symptoms recur while on PAP, or if additional or alternate treatment is instituted. (Guideline) 10. Polysomnography is indicated after treatment of children for OSAS with rapid maxillary expansion to assess for the level of residual disease and to determine whether additional treatment is necessary. (Option) 11. Children with OSAS treated with an oral appliance should have clinical follow-up and polysomnography to assess response to treatment. (Option) 12. Polysomnography is indicated for noninvasive positive pressure ventilation (NIPPV) titration in children with other sleep related breathing disorders. (Option) 13. Children treated with mechanical ventilation may benefit from periodic evaluation with polysomnography to adjust ventilator settings. (Option) 14. Children treated with tracheostomy for sleep related breathing disorders benefit from polysomnography as part of the evaluation prior to decannulation. These children should be followed clinically after decannulation to assess for recurrence of symptoms of sleep related breathing disorders. (Option) 15. Polysomnography is indicated in the following respiratory disorders only if there is a clinical suspicion for an accompanying sleep related breathing disorder: chronic asthma, cystic fibrosis, pulmonary hypertension, bronchopulmonary dysplasia, or chest wall abnormality such as kyphoscoliosis. (Option) RECOMMENDATIONS AGAINST PSG USE: 16. Nap (abbreviated) polysomnography is not recommended for the evaluation of obstructive sleep apnea syndrome in children. (Option) 17. Children considered for treatment with supplemental oxygen do not routinely require polysomnography for management of oxygen therapy. (Option)

CONCLUSIONS

Current evidence in the field of pediatric sleep medicine indicates that PSG has clinical utility in the diagnosis and management of sleep related breathing disorders. The accurate diagnosis of SRBD in the pediatric population is best accomplished by integration of polysomnographic findings with clinical evaluation.

The multiple challenges of obstructive sleep apnea in children: diagnosis

PURPOSE OF REVIEW

To review some of the inherent problems in defining the diagnosis of pediatric obstructive sleep apnea (OSA) and propose a novel approach to clinical evaluation and referral of habitually snoring children.

RECENT FINDINGS

OSA has emerged in the last 30 years as a highly prevalent condition in children. However, the diagnostic uncertainties associated with the clinical presentation and physical examination, and changes in the clinical phenotype over time dictated by the escalation of obesity in children, along with the objective difficulties in accessing appropriately equipped sleep laboratories, have led to substantial underrecognition and to implementation of empirically driven treatment interventions for which scientific validity and efficacy remain undefined.

SUMMARY

Current tools for the diagnosis of OSA in children are labor-intensive, and onerous, and remain unvalidated. Novel diagnostic approaches linking objective physiological, biological, or both, measures to defined outcomes of pediatric OSA need to be developed and validated to enable wider and earlier recognition of this condition.