Successful home respiratory polygraphy to investigate sleep-disordered breathing in children

Comparison of sleep quality between outpatient and hospitalized children with respiratory tract dysfunction

OBJECTIVES

The main objective of the study to compare the effect of hospitalized and outpatient settings on quality of sleep in children with respiratory tract dysfunction.

METHODOLOGY

A descriptive correlational study was carried out at Dhi-Qar Health Directorate pediatric hospitals. The period of the study was from the November 19, 2023 to March 10, 2024. Purposive sample (non-probability) of 250 children (male and female). A total of (125) children were chosen from the children whose admitted to the hospitals, and a total of (125) children were chosen from the outpatient settings. The study instrument consisted of three parts: the sociodemographic sheet, clinical diagnosis sheet, and sleep quality scale. The questionnaire was modified according to experts' recommendation to use it for children with respiratory tract dysfunction. The questionnaire was evaluated by a panel of 15 experts from diverse medical and nursing professions. Both descriptive and inferential statistics were used to analyze the data.

RESULTS

The study findings that effect outpatient settings have more effect from hospitalized settings on quality of sleep in children with respiratory tract dysfunction (M ± SD = 1.322 ± 0.1522).

CONCLUSION

A study showed that the quality of sleep in children with respiratory tract dysfunction was generally average, whether in hospitalized or outpatient settings, outpatient settings had greater difficulties falling asleep and waking than children in hospitalized.

Assessment of obstructive sleep apnoea in children: What are the challenges we face?

There is an increasing demand for the assessment of sleep-disordered breathing in children of all ages to prevent the deleterious neurocognitive and behaviour consequences of the under-diagnosis and under-treatment of obstructive sleep apnoea [OSA]. OSA can be considered in three broad categories based on predominating contributory features: OSA type 1 [enlarged tonsils and adenoids], type II [Obesity] and type III [craniofacial abnormalities, syndromal, storage diseases and neuromuscular conditions]. The reality is that sleep questionnaires or calculations of body mass index in isolation are poorly predictive of OSA in individuals. Globally, the access to testing in tertiary referral centres is comprehensively overwhelmed by the demand and financial cost. This has prompted the need for better awareness and focussed history taking, matched with simpler tools with acceptable accuracy used in the setting of likely OSA. Consequently, we present key indications for polysomnography and present scalable, existing alternatives for assessment of OSA in the hospital or home setting, using polygraphy, oximetry or contactless sleep monitoring.

Signal quality of home polygraphy in children and adolescents

AIM

The aims of the study were to examine the signal quality (SQ) of home polygraphy (PG) in children and adolescents and to compare automatic and manual scoring of the PGs.

METHODS

Clinical Trials Registration: NCT04964830. Participants and caregivers were instructed to set up the equipment and perform home PGs themselves. The PGs were analysed according to SQ and their interpretability and differences in automatic vs. manual scoring regarding apnoea-hypopnoea index (AHI), apnoea index (AI), hypopnoea index (HI) and oxygen desaturation index (ODI) were examined.

RESULTS

54 healthy children aged 9-14 years participated in the study. 86% of the PGs were interpretable with mean SQ of 79.1% (CI 95%: 73.5%; 84.8%). Significant differences between the automatic and manual scoring were found for AHI, AI, HI and ODI (p < 0.0001).

CONCLUSION

Home PGs of children and adolescents are feasible to be performed with good SQ. Significantly higher markers of sleep-disordered breathing were achieved in the automatic scoring in comparison with the manual scoring.

Unattended home sleep studies for the diagnosis of obstructive sleep apnea in a population of French children

BACKGROUND

Ambulatory exams were preferred in children during the COVID-19 pandemic. Polysomnography (PSG), the gold standard for obstructive sleep apnea (OSA) diagnosis, requires several leads and sensors to be attached to the child's body. Children are more comfortable with respiratory polygraphic (RP) recording, which needs fewer sensors.

OBJECTIVE

To compare respiratory parameters obtained by home RP with those obtained by home PSG with the device installed at the child's home by a trained sleep nurse from a national health care provider.

METHODS

Data from home PSGs performed in children aged 2-19 years were retrospectively included. The obstructive apnea-hypopnea index (OAHI) was computed in PSG and then in RP after removing the sleep signals. The two indexes were compared using non-parametric paired Wilcoxon rank test, Bland-Altman analysis and sensitivity-specificity analysis.

RESULTS

44 PSGs of 44 children were included with only 34 (77%) PSGs interpretable. Median (min-max) OAHI was significantly underestimated in RP than in PSG (2.2 (0-25) vs 4.0 (0.4-28), p < 0.0001), confirmed also by the Bland-Altman diagram, the magnitude of the difference being mean ± standard deviation -1.7 ± 1.7. The sensitivity and specificity of OAHI in RP to identify an OAHI ≥2/h in PSG was 0.91 for both.

CONCLUSION

Unattended ambulatory RP performed at child's house and installed under carefully controlled conditions is a useful exam for diagnosing OSA in children with or without comorbidities. However, RP must be installed in a supervised environment and interpreted with caution as it tends to underestimate OSA severity.

Home Respiratory Polygraphy and Spirometry in Normal Weight and Children with Obesity Suspected for Obstructive Sleep Apnea Syndrome: Are There Any Associations?

Aim

It is known that children and adolescents with obesity are more prone to obstructive sleep apnea syndrome (OSAS) and that their lung function may show some disturbance. Literature is scarce about potential associations; therefore, we aimed to study the relationship between OSAS, lung function, and adiposity in a population of children suspected of OSAS. Material and Methods. We performed home respiratory polygraphy and spirometry in all subjects. The relationships between body mass index z-score (zBMI), polygraphy, and spirometry data were analyzed.

Results

We recruited 81 subjects aged between 5 and 16 years, 63% being obese. 43.2% of subjects were diagnosed with OSAS (32.1% mild, 4.9% moderate, and 6.2% severe). We found no correlation between respiratory polygraphy and the zBMI. The mean spirometric value FEV₁, FVC, and FEV₁/FVC ratio z's were normal in all subjects, whereas FVC z's and FEV₁/FVC ratio z's were significantly positively related for obesity and negatively for normal weight (p < 0.05). FEV₁ z's was inversely correlated to the percentage of analyzed time passed below 90% of SpO₂ (r = -0.224, p = 0.044). All subjects with FEV₁ (n = 8) and/or FVC (n = 9) z's below the lower limit for normal (LLN) had an AHI ≥ 1 (FEV₁: p = 0.001; FVC: p < 0.001), especially subjects with normal weight (FEV₁: p = 0.003; FVC: p = 0.010).

Conclusion

When comparing normal-weight children and adolescents with obesity, the prevalence of OSAS but not spirometric values was strongly related to BMI z-score, probably because obesity engenders advanced puberty and an accelerated growth spurt. FEV₁ was more frequently <LLN in normal-weight children, while obese subjects presented low FEV₁/FVC ratio z's and FEF_25-75% z's. Moreover, all subjects with abnormal spirometric values were suffering from at least mild OSAS, again more frequently in normal-weight subjects.

ERS technical standards for using type III devices (limited channel studies) in the diagnosis of sleep disordered breathing in adults and children

For more than three decades, type III devices have been used in the diagnosis of sleep disordered breathing in supervised as well as unsupervised settings. They have satisfactory positive and negative predictive values for detecting obstructive and central sleep apnoea in populations with moderately high pre-test probability of symptoms associated with these events. However, standardisation of commercially available type III devices has never been undertaken and the technical specifications can vary widely. None have been subjected to the same rigorous processes as most other diagnostic modalities in the medical field. Although type III devices do not include acquisition of electroencephalographic signals overnight, the minimum number of physical sensors required to allow for respiratory event scoring using standards outlined by the American Academy of Sleep Medicine remains debatable. This technical standard summarises data on type III studies published since 2007 from multiple perspectives in both adult and paediatric sleep practice. Most importantly, it aims to provide a framework for considering current type III device limitations in the diagnosis of sleep disordered breathing while raising research- and practice-related questions aimed at improving our use of these devices in the present and future.

A Novel Portable Real-Time Low-Cost Sleep Apnea Monitoring System based on the Global System for Mobile Communications (GSM) Network

Background and objective

Continuous monitoring of breathing activity plays a vital role in the detection of respiratory-based diseases (SA, COPD, etc.). Sleep Apnea (SA) is characterized by recurrent upper airway obstruction during sleep associated with arterial blood desaturation, sympathetic nervous system activation, and cardiovascular impairment. Untreated patients with SA have increased mortality rates compared to the general population. This study aims to design a remote monitoring system for sleep apnea to ensure patient safety and ease the workload of doctors in the Covid-19 era.

Methods

This study aims to design a remote monitoring system for sleep apnea to ensure patient safety and ease the workload of doctors. Our study focuses on a novel portable real-time low-cost sleep apnea monitoring system utilizing the GSM network (GSM Shield Sim900a). Proposed system is a remote monitoring and patient tracking system to detect the apnea event in real time, and to provide information of the sleep position, pulse, and respiratory and oxygen saturation to the medical specialists (SpO₂) by establishing a direct contact. As soon as an abnormal condition is detected in the light of these parameters, the condition is reported (instant or in the form of short reports after sleep) to the patient relatives, the doctor’s mobile telephone or to the emergency medical centers (EMCs) through a GSM network to handle the case depending on the patient’s emergency condition.

Results

A study group was formed of six patients for monitoring apnea events (three males and three females) between the ages of 20 and 60. The patients in the study group have sleep apnea (SA) in different grades. All the apnea events were detected, and all the patients were successfully alerted. Also, the patient parameters were successfully sent to all patient relatives. Patients who could not get out of apnea were called through the CALL feature, and they were informed about their ongoing apnea event and told that intervention was necessary. The proposed system is tested on six patients. The beginning moment of apnea was successfully detected and the SMS/CALL feature was successfully activated without delay. During the testing, it has been observed that while some of the patients start breathing after the first SMS, some others needed the second or the third SMS. According to the measurement result, the maximum breathless time is 46 s among the patients, and a SMS is sent every 15 s. In addition, in cases where the patient was breathless for a long time, the CALL feature was actively sought from the relatives of the patient and enabled him to intervene. The proposed monitoring system could be used in both clinical and home settings.

Conclusions

The monitoring of a patient in real time allows to intervene in any unexpected circumstances about the patient. The proposed work uses an acceleration sensor as a reliable method of the sleep apnea for monitoring and prevention. The developed device is more economical, comfortable, and convenient than existing systems not only for the patients but also for the doctors. The patients can easily use this device in their home environment, so which could yield a more comfortable, easy to use, cost-effective, and long-term breathing monitoring system for healthcare applications.

Graphical abstract

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.

Alternatives to surgery in children with mild OSA

Precision medicine requires coordinated and integrated evidence-based combinatorial approaches so that diagnosis and treatment can be tailored to the individual patient. In this context, the treatment approach to mild obstructive sleep apnea (OSA) is fraught with substantial debate as to what is mild OSA, and as to what constitutes appropriate treatment. As such, it is necessary to first establish a proposed consensus of what criteria need to be employed to reach the diagnosis of mild OSA, and then examine the circumstances under which treatment is indicated, and if so, whether and when anti-inflammatory therapy (AIT), rapid maxillary expansion (RME), and/or myofunctional therapy (MFT) may be indicated.

Feasibility of conducting type III home sleep apnoea test in children

OBJECTIVES

To test the feasibility of conducting unattended paediatric type III HSAT and to identify issues for improvements to optimize signal quality.

MATERIAL AND METHODS

Parents were instructed in setting up the unattended HSAT and reported their experiences. Signal quality and causes of signal failure of recordings were assessed.

RESULTS

Forty children were included. Mean age was 5.2 years. Predefined success criteria were met in 53% of recordings. Main causes of signal failure were nasal cannula, pulse-oximetry and battery failure. Sensor fixation techniques were developed and implemented during the study and hence signal quality improved. Seventeen (94%) parents reported HSAT to be either easy or medium hard to use.Conclusions and significance: Unattended paediatric type III HSAT can be conducted at home with acceptable signal quality. Signal quality improved considerably using simple sensor fixation techniques.

Home respiratory polygraphy in obstructive sleep apnea syndrome in children: Comparison with a screening questionnaire

OBJECTIVES

The prevalence of obstructive sleep apnea syndrome (OSAS) in children referred for sleep-disordered breathing reaches up to 59%. We aimed to test the adequacy of a questionnaire compared to home respiratory polygraphy (HRP), in 45 subjects (5-16 years-old), without maxillofacial malformations nor other comorbidities, presenting with symptoms compatible with OSAS.

METHODS

All children passed a 12-items questionnaire (Obstructive Airway Child test: OACT) and the HRP. OSAS was classified in severity according to the apnea-hypopnea index (AHI).

RESULTS

With HRP, 60% and 15% children were detected to have at least mild (AHI ≥1) and moderate (AHI >5) OSAS, respectively. The sensitivity of the questionnaire to detect mild and moderate OSAS was good (93% and 71%, respectively) but the specificity was very low (11% and 34%). However, an OACT score under 61 showed a very good negative predictive value for moderate and severe OSAS (87%). With the questionnaire, we could have avoided a complementary PSG or HRP in 25/45 (56%) of our subjects as in children with mild OSAS and without comorbidities only clinical observation is usually advised.

CONCLUSIONS

The OACT questionnaire has shown to be a good and quick instrument to exclude moderate and severe OSAS in our population of children without maxillofacial malformations. Indeed children scoring under 61 could avoid a constraining and expensive sleep exam. However, if the score is above this cut-off, the performance to recognize OSAS is low and the child's evaluation must be completed by a HRP or PSG.

Respiratory polygraphy data of children investigated for sleep-disordered breathing with different congenital or respiratory diseases

This short report describes respiratory indices of polygraphies (PG) performed to investigate several sleep-related disorders of breathing in children. It refers to the work of Michelet et al., Successful home respiratory polygraphy to investigate sleep-disordered breathing in children, Sleep Medicine [1]. Indications for PGs were grouped according to 6 categories: craniofacial malformation, neuromuscular disease, obesity, suspected obstructive sleep apnea (OSA), prematurity, and other. The reported data concern the initial interpretable PGs (N = 289); initial was defined as performed for the first time in any subject. Non-interpretability was defined as absent or unreliable oxygen saturation by pulse oximetry (SpO₂), and/or airflow and respiratory inductance plethysmography (RIP) flow trace signals during time analyzed. Analyzed time is reported. In a subset of patients, transcutaneous carbon dioxide partial pressure (p_tcCO₂) was also measured. Data may be re-used for comparison in future validating research for PGs in children [2].