Validation of the screening tool ApneaLink® in comparison to polysomnography for the diagnosis of sleep-disordered breathing in children and adolescents

Diagnostic accuracy of portable sleep monitors in pediatric sleep apnea: A systematic review

In recent years, a plethora of new type III and IV portable sleep monitors (PSM) have been developed, although evidence regarding their diagnostic accuracy for use in children remains heterogeneous. This study systematically reviews the literature addressing the diagnostic accuracies of type III and IV PSM for pediatric sleep apnea. Publications indexed in Medline, Embase, or Web of Science were reviewed using the PRISMA framework. Of 1054 studies, 62 fulfilled the inclusion criteria. Of the studies evaluating oximetry-based type IV PSM, one (6.25 %) demonstrated a balanced set of high (≥80 %) sensitivities and specificities for the diagnosis of any pediatric sleep apnea, while five studies (27.8 %) showed similar accuracies for moderate-to-severe sleep apnea. For non-oximetry-based type IV PSM, two studies (40 %) reported a balanced set of high diagnostic accuracies for moderate-to-severe sleep apnea. Type III PSM repeatedly demonstrated higher diagnostic accuracies, with six studies (66.7 %) reporting a balanced set of high diagnostic accuracies for moderate-to-severe sleep apnea. This review highlights the potential of type III PSM to detect moderate-to-severe pediatric sleep apnea, although current evidence is limited to support the stand-alone use of type IV PSM for the diagnosis of sleep apnea in most children.

Advancements in Home-Based Devices for Detecting Obstructive Sleep Apnea: A Comprehensive Study

Obstructive Sleep Apnea (OSA) is a respiratory disorder characterized by frequent breathing pauses during sleep. The apnea-hypopnea index is a measure used to assess the severity of sleep apnea and the hourly rate of respiratory events. Despite numerous commercial devices available for apnea diagnosis and early detection, accessibility remains challenging for the general population, leading to lengthy wait times in sleep clinics. Consequently, research on monitoring and predicting OSA has surged. This comprehensive paper reviews devices, emphasizing distinctions among representative apnea devices and technologies for home detection of OSA. The collected articles are analyzed to present a clear discussion. Each article is evaluated according to diagnostic elements, the implemented automation level, and the derived level of evidence and quality rating. The findings indicate that the critical variables for monitoring sleep behavior include oxygen saturation (oximetry), body position, respiratory effort, and respiratory flow. Also, the prevalent trend is the development of level IV devices, measuring one or two signals and supported by prediction software. Noteworthy methods showcasing optimal results involve neural networks, deep learning, and regression modeling, achieving an accuracy of approximately 99%.

The prevalence of sleep-disordered breathing and associated risk factors in patients with decompensated congestive heart failure in Mozambique

STUDY OBJECTIVES

Sleep-disordered breathing (SDB) is common in patients with congestive heart failure and has important implications regarding symptoms and prognosis. However, the burden of SDB on those with heart failure has not been well characterized in developing countries, including Mozambique in sub-Saharan Africa. Diagnosing SDB in individuals with congestive heart failure is important because treatment of SDB may improve outcomes.

METHODS

Between September 2014 and April 2017, patients hospitalized in a specialized cardiology unit in Maputo, Mozambique with decompensated congestive heart failure were recruited using convenience sampling. We determined the prevalence of SDB and associated risk factors.

RESULTS

A total of 165 patients were recruited, of which 145 had evaluable sleep study data. The overall prevalence of SDB in patients with decompensated congestive heart failure was 72%, and of these 46% had Cheyne-Stokes respirations. Male sex, higher body mass index, and lower left ventricular ejection fraction were all associated with a higher likelihood of SDB and more severe SDB. Cheyne-Stokes respirations were associated with male sex, lower ejection fraction, and larger left atrial size.

CONCLUSIONS

We conclude that in sub-Saharan Africa SDB is common in decompensated congestive heart failure and strongly predicted by demographic and echocardiographic parameters. This study highlights the need for the development of diagnostic tools and management strategies for patients with severe heart failure in resource-limited settings.

CITATION

Lo S, Mbanze I, Orr JE, et al. The prevalence of sleep-disordered breathing and associated risk factors in patients with decompensated congestive heart failure in Mozambique. J Clin Sleep Med. 2023;19(6):1103-1110.

Palatal hybrid surgery for obstructive sleep apnea-state-of-the-art annotation of uvulopalatopharyngoplasty

BACKGROUND

Surgery for obstructive sleep apnea (OSA) has changed in concept and technique that transformed from radical excision to functional reconstruction. The aim of this study was to investigate the safety and effectiveness of palatal hybrid surgery in OSA patients.

METHODS

Palatal hybrid surgery is a tissue-specific technique (mucosa-preservation, tonsil-excision, fat-ablation, muscle-relocation/suspension) used in treating OSA patients with velopharyngeal obstruction. The study included 46 consecutive adults OSA patients. The palatal hybrid surgery annotates uvulopalatopharyngoplasty in stereoscopic reconstruction of tonsillar fossa (pharyngoplasty), omni-suspension of the soft palate (palatoplasty) and advancement of uvula (uvuloplasty).

RESULTS

No patient experienced airway compromise, voice change or persistent nasal regurgitation following palatal hybrid surgery. One patient existed postoperative tonsillar fossa bleeding received conservative treatment. Postoperative pain in visual analogue scale (VAS) showed average score of 3, 3, 2, 0 at the 1st, 3rd, 7th, 14th day, respectively. Perioperative snoring severity (VAS) (8.7 vs 2.6) and daytime sleepiness (Epworth Sleepiness Scale) (11.3 vs 5.5) all improved significantly (p < 0.001). Posterior air space in retropalatal area increased from 8.4 to 11.1 mm (p < 0.001). Home sleep test showed that apnea-hypopnea index significantly reduced from 41.8 to 18.2 event/h and minimal oxygen saturation increased from 72.4 to 81.5% (p < 0.001). The success rate in individual Friedman stage was 100% (stage I), 63% (stage II) and 58% (stage III) with a total success rate of 63%.

CONCLUSION

Palatal hybrid surgery using tissue-specific maneuver annotates UPPP in concept and technique. The results show that palatal hybrid surgery is mini-invasive with low morbid and is effective in improving subjective clinic symptoms, objective sleep parameters and success rate of OSA.

Factors Associated With Undiagnosed Obstructive Sleep Apnea in Overweight and Obese High-Tech Employees: A Multisite Cross-Sectional Study

Background: Being overweight or obese is regarded as crucial risk factors for obstructive sleep apnea (OSA). Objectives: This study aimed to determine the influencing factors of overweight and obese employees with OSA in high-tech workplaces. Methods: A cross-sectional study design was employed. A total of 491 overweight and obese participants were recruited from a large-scale electronics industry. The Chinese version of Pittsburgh Sleep Quality Index, the Epworth Sleep Scale, and a portable sleep monitoring device were used for data collection. Logistic regression analysis was conducted to identify the factors affecting overweight and obese employees with OSA. This study was conducted from August 2019 to July 2020. Results: 60.5% of the overweight and obese participants were found to have OSA, of which 58.9% had mild and 18.5% had severe OSA, respectively. The results showed that age, neck circumference, snoring, and habitual drinking were the crucial factors affecting OSA. Remarkably, age and snoring times showed a significant correlation in predicting OSA of different severities. Neck circumference was an independent risk factor for moderate and severe OSA. Conclusion: More than 60% of the overweight and obese high-tech workplace employees were found to have OSA. We found that the older the age, the larger the neck circumference, a higher number of snoring instances, and drinking were important risk factors for predicting OSA in overweight high-tech employees. The healthcare providers should actively educate OSA-related information for employees in the workplace, and promote high-risk OSA groups to adopt screening based on at-home sleep apparatus.

Diagnostic approaches to respiratory abnormalities in craniofacial syndromes

Craniofacial syndromes are a complex cluster of genetic conditions characterized by embryonic perturbations in the developmental trajectory of the upper airway and related structures. The presence of reduced airway size and maladaptive neuromuscular responses, particularly during sleep, leads to significant alterations in sleep architecture and overall detrimental gas exchange abnormalities that can be life-threatening. The common need for multi-stage therapeutic interventions for these craniofacial problems requires careful titration of anatomy and function, and the latter is currently evaluated by overnight polysomnography in sleep laboratories. The cost, inconvenience, and scarcity of pediatric sleep laboratories preclude the frequent evaluations that could optimize the overall process of treatment and corresponding outcomes. Here, we critically examine reductionist approaches to polysomnography in children to establish the parallel approximation of such techniques to infant with craniofacial disorders. The need for prospective longitudinal multicenter studies with side-by-side comparisons aimed at identifying an optimal diagnostic and long-term monitoring paradigm for these potentially life-threatening conditions is emphasized.

The accuracy of a portable sleep monitor to diagnose obstructive sleep apnea in adolescent patients

STUDY OBJECTIVES

The efficacy of portable-monitor (PM) sleep testing in children is not well understood. While most studies have evaluated PM in a lab setting, the utility of PM in the home environment is relatively unknown. We sought to determine whether home PM accurately diagnoses obstructive sleep apnea in adolescents and to assess patient satisfaction with home PM sleep testing.

METHODS

We evaluated adolescents (age 12-18 years) with suspected obstructive sleep apnea using a PM device. In addition to in-laboratory polysomnography (PSG), all participants had PM testing performed twice, once in their home and once concurrent to in-laboratory PSG. PM was compared to PSG using 2 primary outcomes: the apnea-hypopnea index and oxygen desaturation index. All participants were approached for interview to evaluate their experience with PM sleep testing.

RESULTS

Twenty adolescents participated. Bland-Altman analysis comparing the apnea-hypopnea index and oxygen desaturation index determined by home or in-laboratory PM to in-laboratory PSG revealed mostly agreement; however, some deviations were observed when either parameter was markedly increased. While PM testing tended to underestimate the apnea-hypopnea index, the diagnostic agreement between home PM and PSG was 80% (by the White-Westbrook method). Most preferred PM to PSG and found PM easy to very easy to set up.

CONCLUSIONS

In a small cohort of adolescents, our study supports the application of home PM in the diagnosis of suspected obstructive sleep apnea. Until studies implementing PM using larger cohorts become readily available, the findings from this preliminary study could contribute to adolescents receiving sleep apnea therapy more promptly.

CLINICAL TRIAL REGISTRATION

Registry: ClinicalTrials.gov; Identifier: NCT03748771. At the time of issue publication, this registration is not publicly available because the trial includes a device that is not approved or cleared for use in pediatric populations. Once the device is FDA cleared, the registration will become public.

Bispectral analysis of overnight airflow to improve the pediatric sleep apnea diagnosis

Pediatric Obstructive Sleep Apnea (OSA) is a respiratory disease whose diagnosis is performed through overnight polysomnography (PSG). Since it is a complex, time-consuming, expensive, and labor-intensive test, simpler alternatives are being intensively sought. In this study, bispectral analysis of overnight airflow (AF) signal is proposed as a potential approach to replace PSG when indicated. Thus, our objective was to characterize AF through bispectrum, and assess its performance to diagnose pediatric OSA. This characterization was conducted using 13 bispectral features from 946 AF signals. The oxygen desaturation index ≥3% (ODI3), a common clinical measure of OSA severity, was also obtained to evaluate its complementarity to the AF bispectral analysis. The fast correlation-based filter (FCBF) and a multi-layer perceptron (MLP) were used for subsequent automatic feature selection and pattern recognition stages. FCBF selected 3 bispectral features and ODI3, which were used to train a MLP model with ability to estimate apnea-hypopnea index (AHI). The model reached 82.16%, 82.49%, and 90.15% accuracies for the common AHI cut-offs 1, 5, and 10 events/h, respectively. The different bispectral approaches used to characterize AF in children provided complementary information. Accordingly, bispectral analysis showed that the occurrence of apneic events decreases the non-gaussianity and non-linear interaction of the AF harmonic components, as well as the regularity of the respiratory patterns. Moreover, the bispectral information from AF also showed complementarity with ODI3. Our findings suggest that AF bispectral analysis may serve as a useful tool to simplify the diagnosis of pediatric OSA, particularly for children with moderate-to-severe OSA.

Toward standardizing the clinical testing protocols of point-of-care devices for obstructive sleep apnea diagnosis

PURPOSE

In recent years, point-of-care (POC) devices, especially smart wearables, have been introduced to provide a cost-effective, comfortable, and accessible alternative to polysomnography (PSG)-the current gold standard-for the monitoring, screening, and diagnosis of obstructive sleep apnea (OSA). Thorough validation and human subject testing are essential steps in the translation of these device technologies to the market. However, every device development group tests their device in their own way. No standard guidelines exist for assessing the performance of these POC devices. The purpose of this paper is to critically distill the key aspects of the various protocols reported in the literature and present a protocol that unifies the best practices for testing wearable and other POC devices for OSA.

METHODS

A limited review and graphical descriptive analytics of literature-including journal articles, web sources, and clinical manuscripts by authoritative agencies in sleep medicine-are performed to glean the testing and validation methods employed for POC devices, specifically for OSA.

RESULTS

The analysis suggests that the extent of heterogeneity of the demographics, the performance metrics, subject survey, hypotheses, and statistical analyses need to be carefully considered in a systematic protocol for testing POC devices for OSA.

CONCLUSION

We provide a systematic method and list specific recommendations to extensively assess various performance criteria for human subject testing of POC devices. A rating scale of 1-3 is provided to encourage studies to put a focus on addressing the key elements of a testing protocol.

Assessment of Airflow and Oximetry Signals to Detect Pediatric Sleep Apnea-Hypopnea Syndrome Using AdaBoost

The reference standard to diagnose pediatric Obstructive Sleep Apnea (OSA) syndrome is an overnight polysomnographic evaluation. When polysomnography is either unavailable or has limited availability, OSA screening may comprise the automatic analysis of a minimum number of signals. The primary objective of this study was to evaluate the complementarity of airflow (AF) and oximetry (SpO₂) signals to automatically detect pediatric OSA. Additionally, a secondary goal was to assess the utility of a multiclass AdaBoost classifier to predict OSA severity in children. We extracted the same features from AF and SpO₂ signals from 974 pediatric subjects. We also obtained the 3% Oxygen Desaturation Index (ODI) as a common clinically used variable. Then, feature selection was conducted using the Fast Correlation-Based Filter method and AdaBoost classifiers were evaluated. Models combining ODI 3% and AF features outperformed the diagnostic performance of each signal alone, reaching 0.39 Cohens's kappa in the four-class classification task. OSA vs. No OSA accuracies reached 81.28%, 82.05% and 90.26% in the apnea-hypopnea index cutoffs 1, 5 and 10 events/h, respectively. The most relevant information from SpO₂ was redundant with ODI 3%, and AF was complementary to them. Thus, the joint analysis of AF and SpO₂ enhanced the diagnostic performance of each signal alone using AdaBoost, thereby enabling a potential screening alternative for OSA in children.

OSA and Neurocognitive Impairment in Children With Congenital Heart Disease

BACKGROUND

Children with congenital heart disease (CHD) have an increased risk of neurocognitive impairment. No prior studies have evaluated the role of OSA, which is associated with neurocognitive impairment in children without CHD.

RESEARCH QUESTION

Is OSA is associated with neurocognitive impairment in children with CHD?

STUDY DESIGN AND METHODS

Children aged 6 to 17 years with corrected moderate to complex CHD without syndromes that may affect neurocognition were recruited from the pediatric cardiology clinic. Participants underwent home sleep testing and neurocognitive testing, including a validated Intellectual Quotient (IQ) test as well as validated tests of memory (Paired Associates Learning test), executive function (Intra-Extra Dimensional set shift test), and attention (Simple Reaction Test) from the CANTAB neurocognitive testing battery.

RESULTS

Complete results were available for 30 children. Seventeen children (57%) were found to have OSA. Total IQ was markedly lower in children with CHD and comorbid OSA compared with children with CHD without comorbid OSA (mean, 86 ± 12 vs 98 ± 11; P = .01). Children with CHD and OSA did significantly worse on the Paired Associates Learning test, with a median of eight total errors (interquartile range [IQR], 2.25-15) compared with children with CHD without OSA (median total errors, 2, IQR, 1-8; P = .02).

INTERPRETATION

Children with CHD and comorbid OSA have impaired neurocognition compared with children with CHD without comorbid OSA. OSA may be a reversible cause of neurocognitive impairment in children with CHD. Further research is needed to evaluate the effects of OSA treatment on neurocognitive impairment in children with CHD.

Pediatric pulmonology year in review 2017: Part 4 (Sleep medicine)

Pediatric Pulmonology publishes original research, case reports and review articles on topics related to a wide range of children's respiratory disorders. In this article (Part 4 of a 5-part series), we summarize the past year's publications in sleep medicine, in the context of selected literature in this area from other journals. Articles are highlighted on topics including diagnosis and treatment of OSAS, sleep duration and position, and sleep disorders in chronic disease.