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de Terán TD, Boira I, Muñoz P, Chiner E, Esteban V, González M. Reliability of the Paediatric Sleep Questionnaire in Patients Referred for Suspected Obstructive Sleep Apnea. Arch Bronconeumol 2024:S0300-2896(24)00274-6. [PMID: 39095310 DOI: 10.1016/j.arbres.2024.07.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2024] [Revised: 07/15/2024] [Accepted: 07/17/2024] [Indexed: 08/04/2024]
Affiliation(s)
- Teresa Díaz de Terán
- Department of Pneumology, Sleep and Non-Invasive Ventilation Unit, 'Marqués de Valdecilla' University Hospital, Spain; University of Cantabria, Institute for Research 'Marqués de Valdecilla' (IDIVAL), Santander, Spain
| | - Ignacio Boira
- Department of Pneumology, Sleep and Non-Invasive Ventilation Unit, University Hospital of San Juan Alicante, Spain
| | - Pedro Muñoz
- Primary Care Management of Cantabria, Institute for Research 'Marqués de Valdecilla' (IDIVAL), Santander, Spain
| | - Eusebi Chiner
- Department of Pneumology, Sleep and Non-Invasive Ventilation Unit, University Hospital of San Juan Alicante, Spain
| | - Violeta Esteban
- Department of Pneumology, Sleep and Non-Invasive Ventilation Unit, University Hospital of San Juan Alicante, Spain
| | - Mónica González
- Department of Pneumology, Sleep and Non-Invasive Ventilation Unit, 'Marqués de Valdecilla' University Hospital, Spain; University of Cantabria, Institute for Research 'Marqués de Valdecilla' (IDIVAL), Santander, Spain.
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Ramamurthy MB, Jayaprakash S. Introduction to Pediatric Sleep Medicine. Indian J Pediatr 2023; 90:927-933. [PMID: 37378884 DOI: 10.1007/s12098-023-04697-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Accepted: 05/19/2023] [Indexed: 06/29/2023]
Abstract
Sleep is a key component of life to maintain our health, performance, safety and quality of life. In fact, sleep has been implicated in the optimal functioning of all organ systems - brain, heart, lung, metabolism, immune function, and hormonal balance too. One of the most common reasons for poor-quality sleep in children is a group of conditions termed sleep disordered breathing (SDB). Obstructive sleep apnea (OSA) is the most severe form of SDB. A good history and clinical examination is likely to reveal features of SDB including snoring, restless sleep, morning sleepiness, irritability or exhibit signs of hyperactivity. Examination may also reveal evidence of underlying pathology e.g., Craniofacial abnormalities, obesity and neuromuscular disorders that creates higher risk of developing SDB. Further investigation using polysomnography (PSG) is considered a gold-standard assessment of SDB and allows for scoring using Obstructive Apnoea-Hypopnea scale. Adenotonsillectomy is used as the first-line management in patients who otherwise have normal anatomy. Parents often approach their pediatricians with concerns regarding their child's sleeping habits and given the significant role sleep has on child development, it is essential that doctors are equipped to provide good care and advice for this population. This article aims to summarise presentation of SDB and common risk factors, investigations and management options to aid clinicians in managing SDB.
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Affiliation(s)
- Mahesh Babu Ramamurthy
- Department of Pediatrics, KTP-National University Children's Medical Institute, National University Hospital, Singapore, Singapore.
- Department of Pediatrics, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore.
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Borrelli M, Corcione A, Cimbalo C, Annunziata A, Basilicata S, Fiorentino G, Santamaria F. Diagnosis of Paediatric Obstructive Sleep-Disordered Breathing beyond Polysomnography. CHILDREN (BASEL, SWITZERLAND) 2023; 10:1331. [PMID: 37628330 PMCID: PMC10452996 DOI: 10.3390/children10081331] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/22/2023] [Revised: 07/24/2023] [Accepted: 07/26/2023] [Indexed: 08/27/2023]
Abstract
Obstructive sleep-disordered breathing (SDB) has significant impacts on health, and therefore, a timely and accurate diagnosis is crucial for effective management and intervention. This narrative review provides an overview of the current approaches utilised in the diagnosis of SDB in children. Diagnostic methods for SDB in children involve a combination of clinical assessment, medical history evaluation, questionnaires, and objective measurements. Polysomnography (PSG) is the diagnostic gold standard. It records activity of brain and tibial and submental muscles, heart rhythm, eye movements, oximetry, oronasal airflow, abdominal and chest movements, body position. Despite its accuracy, it is a time-consuming and expensive tool. Respiratory polygraphy instead monitors cardiorespiratory function without simultaneously assessing sleep and wakefulness; it is more affordable than PSG, but few paediatric studies compare these techniques and there is optional recommendation in children. Nocturnal oximetry is a simple and accessible exam that has high predictive value only for children at high risk. The daytime nap PSG, despite the advantage of shorter duration and lower costs, is not accurate for predicting SDB. Few paediatric data support the use of home testing during sleep. Finally, laboratory biomarkers and radiological findings are potentially useful hallmarks of SDB, but further investigations are needed to standardise their use in clinical practice.
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Affiliation(s)
- Melissa Borrelli
- Department of Translational Medical Sciences, Paediatric Pulmonology, Federico II University, 80131 Naples, Italy; (A.C.); (C.C.); (S.B.); (F.S.)
| | - Adele Corcione
- Department of Translational Medical Sciences, Paediatric Pulmonology, Federico II University, 80131 Naples, Italy; (A.C.); (C.C.); (S.B.); (F.S.)
| | - Chiara Cimbalo
- Department of Translational Medical Sciences, Paediatric Pulmonology, Federico II University, 80131 Naples, Italy; (A.C.); (C.C.); (S.B.); (F.S.)
| | - Anna Annunziata
- Department of Intensive Cure, Unit of Respiratory Pathophysiology, Monaldi Hospital, 80131 Naples, Italy; (A.A.); (G.F.)
| | - Simona Basilicata
- Department of Translational Medical Sciences, Paediatric Pulmonology, Federico II University, 80131 Naples, Italy; (A.C.); (C.C.); (S.B.); (F.S.)
| | - Giuseppe Fiorentino
- Department of Intensive Cure, Unit of Respiratory Pathophysiology, Monaldi Hospital, 80131 Naples, Italy; (A.A.); (G.F.)
| | - Francesca Santamaria
- Department of Translational Medical Sciences, Paediatric Pulmonology, Federico II University, 80131 Naples, Italy; (A.C.); (C.C.); (S.B.); (F.S.)
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Chiner E, Sancho-Chust JN, Pastor E, Esteban V, Boira I, Castelló C, Celis C, Vañes S, Torba A. Features of Obstructive Sleep Apnea in Children with and without Comorbidities. J Clin Med 2023; 12:jcm12062418. [PMID: 36983418 PMCID: PMC10054579 DOI: 10.3390/jcm12062418] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2023] [Revised: 03/11/2023] [Accepted: 03/19/2023] [Indexed: 03/30/2023] Open
Abstract
BACKGROUND To compare the clinical and polysomnographic features of obstructive sleep apnea (OSA) in children with adenotonsillar hypertrophy (Group A) and comorbidities (Group B). METHODS A five-year prospective study using nocturnal polysomnography before and after treatment. RESULTS We included 168 patients: 121 in Group A and 47 in Group B, with differences in age (6.5 ± 3 vs. 8.6 ± 4 years; p < 0.001), body mass index (BMI) (18 ± 4 vs. 20 ± 7 kg/m2; p < 0.05), neck circumference (28 ± 4 vs. 30 ± 5 cm; p < 0.05), and obesity (17% vs. 30%; p < 0.05). Group B patients were more likely to have facial anomalies (p < 0.001), macroglossia (p < 0.01), dolichocephaly (p < 0.01), micrognathia (p < 0.001), and prognathism (p < 0.05). Adenotonsillectomy was performed in 103 Group A patients (85%) and 28 Group B patients (60%) (p < 0.001). In B, 13 children (28%) received treatment with continuous positive airway pressure (CPAP) and 2 (4%) with bilevel positive airway pressure (BiPAP), compared with 7 in Group A (6%) (p < 0.001). Maxillofacial surgery was more common in Group B (p < 0.01). Clinical and polysomnography parameters improved significantly in both groups after therapeutic intervention, though Group A showed better results. CONCLUSIONS Obesity and facial anomalies are more frequent in childhood OSA patients with comorbidities, who often require combination therapy, such as ventilation and surgery.
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Affiliation(s)
- Eusebi Chiner
- Pulmonology Department, Multidisciplinary Sleep Clinic, San Juan de Alicante University Hospital, 03550 Alicante, Spain
| | - Jose N Sancho-Chust
- Pulmonology Department, Multidisciplinary Sleep Clinic, San Juan de Alicante University Hospital, 03550 Alicante, Spain
| | - Esther Pastor
- Pulmonology Department, Multidisciplinary Sleep Clinic, San Juan de Alicante University Hospital, 03550 Alicante, Spain
| | - Violeta Esteban
- Pulmonology Department, Multidisciplinary Sleep Clinic, San Juan de Alicante University Hospital, 03550 Alicante, Spain
| | - Ignacio Boira
- Pulmonology Department, Multidisciplinary Sleep Clinic, San Juan de Alicante University Hospital, 03550 Alicante, Spain
| | - Carmen Castelló
- Pulmonology Department, Multidisciplinary Sleep Clinic, San Juan de Alicante University Hospital, 03550 Alicante, Spain
| | - Carly Celis
- Pulmonology Department, Multidisciplinary Sleep Clinic, San Juan de Alicante University Hospital, 03550 Alicante, Spain
| | - Sandra Vañes
- Pulmonology Department, Multidisciplinary Sleep Clinic, San Juan de Alicante University Hospital, 03550 Alicante, Spain
| | - Anastasiya Torba
- Pulmonology Department, Multidisciplinary Sleep Clinic, San Juan de Alicante University Hospital, 03550 Alicante, Spain
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Ioan I, Renard E, Da Mota S, Bonabel C, Tiotiu A, Franco P, Coutier L, Schweitzer C. Unattended home sleep studies for the diagnosis of obstructive sleep apnea in a population of French children. Sleep Med 2023; 102:117-122. [PMID: 36640557 DOI: 10.1016/j.sleep.2023.01.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2022] [Revised: 12/31/2022] [Accepted: 01/01/2023] [Indexed: 01/04/2023]
Abstract
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.
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Affiliation(s)
- Iulia Ioan
- Service d'Explorations Fonctionnelles Pédiatriques, Hôpital d'Enfants, Centre Hospitalier Universitaire de Nancy, France; EA3450-DevAH, Faculté de Médecine, Université de Lorraine, France.
| | - Emeline Renard
- Service de Médecine Infantile, Centre Hospitalier Universitaire de Nancy, France
| | - Sofia Da Mota
- Service d'Explorations Fonctionnelles Pédiatriques, Hôpital d'Enfants, Centre Hospitalier Universitaire de Nancy, France
| | - Claude Bonabel
- Service d'Explorations Fonctionnelles Pédiatriques, Hôpital d'Enfants, Centre Hospitalier Universitaire de Nancy, France; EA3450-DevAH, Faculté de Médecine, Université de Lorraine, France
| | - Angelica Tiotiu
- EA3450-DevAH, Faculté de Médecine, Université de Lorraine, France; Service de Pneumologie, Centre Hospitalier Universitaire de Nancy, France
| | - Patricia Franco
- Service Epilepsie, Sommeil, Explorations Fonctionnelles Neurologiques Pédiatriques, Hôpital Femme Mère Enfant, Hospices Civils de Lyon, Bron, France; U1028, CNRL, Université de Lyon 1, France
| | - Laurianne Coutier
- U1028, CNRL, Université de Lyon 1, France; Service de pneumologie infantile, Allergologie et centre de référence en mucoviscidose, Hôpital Femme Mère Enfant, Hospices Civils de Lyon, Bron, France
| | - Cyril Schweitzer
- EA3450-DevAH, Faculté de Médecine, Université de Lorraine, France; Service de Médecine Infantile, Centre Hospitalier Universitaire de Nancy, France
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Riha RL, Celmina M, Cooper B, Hamutcu-Ersu R, Kaditis A, Morley A, Pataka A, Penzel T, Roberti L, Ruehland W, Testelmans D, van Eyck A, Grundström G, Verbraecken J, Randerath W. ERS technical standards for using type III devices (limited channel studies) in the diagnosis of sleep disordered breathing in adults and children. Eur Respir J 2023; 61:13993003.00422-2022. [PMID: 36609518 DOI: 10.1183/13993003.00422-2022] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2022] [Accepted: 07/27/2022] [Indexed: 02/01/2023]
Abstract
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.
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Affiliation(s)
- Renata L Riha
- Department of Sleep Medicine, The Royal Infirmary Edinburgh, Edinburgh, UK
| | - Marta Celmina
- Epilepsy and Sleep Medicine Centre, Children's Clinical University Hospital, Riga, Latvia
| | - Brendan Cooper
- Lung Function and Sleep, University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital Birmingham, Edgbaston, UK
| | | | - Athanasios Kaditis
- Division of Paediatric Pulmonology and Sleep Disorders Laboratory, First Department of Pediatrics, National and Kapodistrian University of Athens School of Medicine and Agia Sofia Children's Hospital, Athens, Greece
| | | | - Athanasia Pataka
- Respiratory Failure Unit, G. Papanikolaou Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Thomas Penzel
- Department of Cardiology and Angiology, Interdisciplinary Center of Sleep Medicine, Charité Universitätsmedizin Berlin, Berlin, Germany
| | | | - Warren Ruehland
- Institute for Breathing and Sleep, Austin Health, Melbourne, Australia
| | - Dries Testelmans
- Department of Pneumology, University Hospitals Leuven, Leuven, Belgium
| | - Annelies van Eyck
- Laboratory of Experimental Medicine and Pediatrics, University of Antwerp, Antwerp (Edegem), Belgium
- Department of Pediatrics, Antwerp University Hospital, Antwerp (Edegem), Belgium
| | | | - Johan Verbraecken
- Antwerp University Hospital and University of Antwerp, Edegem (Antwerp), Belgium
| | - Winfried Randerath
- Bethanien Hospital, Clinic of Pneumology and Allergology, Center for Sleep Medicine and Respiratory Care, Institute of Pneumology at the University of Cologne, Solingen, Germany
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Jurado MJ, Sampol G, Quintana M, Romero O, Cambrodí R, Ferré A, Sampol J. Nasal cannula use during polysomnography in children aged under three with suspected sleep apnea. Sleep Med 2022; 99:41-48. [PMID: 35947888 DOI: 10.1016/j.sleep.2022.07.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
OBJECTIVE Early diagnosis of obstructive sleep apnea (OSA) in children is important. The use of a nasal cannula as an airflow sensor during polysomnography has not been evaluated in younger children. The study aims to evaluate the use of nasal cannula in detecting respiratory events in children under three with suspected OSA during daytime nap studies. METHODS A total of 185 patients were prospectively included. Respiratory events were scored using nasal cannula alone, thermistor alone, and both methods simultaneously as the airflow sensor. Agreement and diagnostic accuracy were assessed. RESULTS One hundred and seventy-two children were finally analyzed and 110 (64.0%) presented OSA. Total sleep time with an uninterpretable signal was longer with the nasal cannula than with the thermistor (17.8% vs 1.9%; p < 0.001), and was associated with poor sensor tolerance and adenotonsillar hypertrophy. In the estimation of the apnea-hypopnea index, the nasal cannula showed lower agreement than the thermistor with the joint use of the two sensors (intraclass correlation coefficient: 0.79 vs 0.996 with thermistor). Compared with the thermistor, the nasal cannula presented lower sensitivity for detecting OSA (82.7% vs 95.5%) and a lower negative predictive value (76.5% vs 92.4%). Overall, fewer children were diagnosed with severe OSA with the nasal cannula (19.8% vs 30.8% with the thermistor, and 32.6% with both). CONCLUSIONS In children under the age of three, the ability of the nasal cannula to detect obstructive events was relatively low. Therefore, other non-invasive measurements for identifying respiratory events during sleep may be of additional value.
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Affiliation(s)
- María José Jurado
- Department of Clinical Neurophysiology, Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, Passeig Vall d'Hebron 119-129, 08035, Barcelona, Spain; Multidisciplinary Sleep Unit, Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, Passeig Vall d'Hebron 119-129, 08035, Barcelona, Spain; Centro de Investigación Biomédica en Red Enfermedades Respiratorias (CIBERES), Instituto de la Salud Carlos III (ISCIIII), Avenida de Monforte de Lemos, 3-5, 28029, Madrid, Spain.
| | - Gabriel Sampol
- Department of Respiratory Care, Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, Passeig Vall d'Hebron 119-129, 08035, Barcelona, Spain; Multidisciplinary Sleep Unit, Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, Passeig Vall d'Hebron 119-129, 08035, Barcelona, Spain; Centro de Investigación Biomédica en Red Enfermedades Respiratorias (CIBERES), Instituto de la Salud Carlos III (ISCIIII), Avenida de Monforte de Lemos, 3-5, 28029, Madrid, Spain.
| | - Manuel Quintana
- Department of Neurology, Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, Passeig Vall d'Hebron 119-129, 08035, Barcelona, Spain.
| | - Odile Romero
- Department of Clinical Neurophysiology, Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, Passeig Vall d'Hebron 119-129, 08035, Barcelona, Spain; Multidisciplinary Sleep Unit, Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, Passeig Vall d'Hebron 119-129, 08035, Barcelona, Spain; Centro de Investigación Biomédica en Red Enfermedades Respiratorias (CIBERES), Instituto de la Salud Carlos III (ISCIIII), Avenida de Monforte de Lemos, 3-5, 28029, Madrid, Spain.
| | - Roser Cambrodí
- Department of Clinical Neurophysiology, Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, Passeig Vall d'Hebron 119-129, 08035, Barcelona, Spain; Multidisciplinary Sleep Unit, Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, Passeig Vall d'Hebron 119-129, 08035, Barcelona, Spain; Centro de Investigación Biomédica en Red Enfermedades Respiratorias (CIBERES), Instituto de la Salud Carlos III (ISCIIII), Avenida de Monforte de Lemos, 3-5, 28029, Madrid, Spain.
| | - Alex Ferré
- Department of Clinical Neurophysiology, Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, Passeig Vall d'Hebron 119-129, 08035, Barcelona, Spain; Multidisciplinary Sleep Unit, Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, Passeig Vall d'Hebron 119-129, 08035, Barcelona, Spain.
| | - Júlia Sampol
- Department of Respiratory Care, Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, Passeig Vall d'Hebron 119-129, 08035, Barcelona, Spain; Multidisciplinary Sleep Unit, Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, Passeig Vall d'Hebron 119-129, 08035, Barcelona, Spain; Centro de Investigación Biomédica en Red Enfermedades Respiratorias (CIBERES), Instituto de la Salud Carlos III (ISCIIII), Avenida de Monforte de Lemos, 3-5, 28029, Madrid, Spain.
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Abstract
Sleep Apnoea (SA) is a common chronic illness that affects nearly 1 billion people around the world, and the number of patients is rising. SA causes a wide range of psychological and physiological ailments that have detrimental effects on a patient’s wellbeing. The high prevalence and negative health effects make SA a public health problem. Whilst the current gold standard diagnostic procedure, polysomnography (PSG), is reliable, it is resource-expensive and can have a negative impact on sleep quality, as well as the environment. With this study, we focus on the environmental impact that arises from resource utilisation during SA detection, and we propose remote monitoring (RM) as a potential solution that can improve the resource efficiency and reduce travel. By reusing infrastructure technology, such as mobile communication, cloud computing, and artificial intelligence (AI), RM establishes SA detection and diagnosis support services in the home environment. However, there are considerable barriers to a widespread adoption of this technology. To gain a better understanding of the available technology and its associated strength, as well as weaknesses, we reviewed scientific papers that used various strategies for RM-based SA detection. Our review focused on 113 studies that were conducted between 2018 and 2022 and that were listed in Google Scholar. We found that just over 50% of the proposed RM systems incorporated real time signal processing and around 20% of the studies did not report on this important aspect. From an environmental perspective, this is a significant shortcoming, because 30% of the studies were based on measurement devices that must travel whenever the internal buffer is full. The environmental impact of that travel might constitute an additional need for changing from offline to online SA detection in the home environment.
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Hu M, Duan A, Huang Z, Zhao Z, Zhao Q, Yan L, Zhang Y, Li X, Jin Q, An C, Luo Q, Liu Z. Development and Validation of a Nomogram for Predicting Obstructive Sleep Apnea in Patients with Pulmonary Arterial Hypertension. Nat Sci Sleep 2022; 14:1375-1386. [PMID: 35971464 PMCID: PMC9375580 DOI: 10.2147/nss.s372447] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2022] [Accepted: 07/22/2022] [Indexed: 11/30/2022] Open
Abstract
PURPOSE Patients with pulmonary arterial hypertension (PAH) are at high risk for obstructive sleep apnea (OSA), which may adversely affect pulmonary hemodynamics and long-term prognosis. However, there is no clinical prediction model to evaluate the probability of OSA among patients with PAH. Our study aimed to develop and validate a nomogram for predicting OSA in the setting of PAH. PATIENTS AND METHODS From May 2020 to November 2021, we retrospectively analyzed the medical records of 258 patients diagnosed with PAH via right-heart catheterization. All participants underwent overnight cardiorespiratory polygraphy for OSA assessment. General clinical materials and biochemical measurements were collected and compared between PAH patients with or without OSA. Lasso regression was performed to screen potential predictors. Multivariable logistic regression analysis was conducted to establish the nomogram. Concordance index, calibration curve, and decision curve analysis were used to determine the discrimination, calibration, and clinical usefulness of the nomogram. RESULTS OSA was present in 26.7% of the PAH patients, and the prevalence did not differ significantly between male (29.7%) and female (24.3%) patients. Six variables were selected to construct the nomogram, including age, body mass index, hypertension, uric acid, glycated hemoglobin, and interleukin-6 levels. Based on receiver operating characteristic analysis, the nomogram demonstrated favorable discrimination accuracy with an area under the curve (AUC) of 0.760 for predicting OSA, exhibiting a better predictive value in contrast to ESS (AUC = 0.528) (P < 0.001). Decision curve analysis and clinical impact curve analysis also indicated the clinical utility of the nomogram. CONCLUSION By establishing a comprehensive and practical nomogram, we were able to predict the presence of OSA in patients with PAH, which may facilitate the early identification of patients that benefit from further diagnostic confirmation and intervention.
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Affiliation(s)
- Meixi Hu
- Center for Respiratory and Pulmonary Vascular Disease, Department of Cardiology, Fuwai Hospital, National Clinical Research Center for Cardiovascular Diseases, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China
| | - Anqi Duan
- Center for Respiratory and Pulmonary Vascular Disease, Department of Cardiology, Fuwai Hospital, National Clinical Research Center for Cardiovascular Diseases, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China
| | - Zhihua Huang
- Center for Respiratory and Pulmonary Vascular Disease, Department of Cardiology, Fuwai Hospital, National Clinical Research Center for Cardiovascular Diseases, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China
| | - Zhihui Zhao
- Center for Respiratory and Pulmonary Vascular Disease, Department of Cardiology, Fuwai Hospital, National Clinical Research Center for Cardiovascular Diseases, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China
| | - Qing Zhao
- Center for Respiratory and Pulmonary Vascular Disease, Department of Cardiology, Fuwai Hospital, National Clinical Research Center for Cardiovascular Diseases, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China
| | - Lu Yan
- Center for Respiratory and Pulmonary Vascular Disease, Department of Cardiology, Fuwai Hospital, National Clinical Research Center for Cardiovascular Diseases, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China
| | - Yi Zhang
- Center for Respiratory and Pulmonary Vascular Disease, Department of Cardiology, Fuwai Hospital, National Clinical Research Center for Cardiovascular Diseases, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China
| | - Xin Li
- Center for Respiratory and Pulmonary Vascular Disease, Department of Cardiology, Fuwai Hospital, National Clinical Research Center for Cardiovascular Diseases, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China
| | - Qi Jin
- Department of Cardiology, Shanghai Institute of Cardiovascular Disease, Zhongshan Hospital, Fudan University, Shanghai, People's Republic of China
| | - Chenhong An
- Center for Respiratory and Pulmonary Vascular Disease, Department of Cardiology, Fuwai Hospital, National Clinical Research Center for Cardiovascular Diseases, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China
| | - Qin Luo
- Center for Respiratory and Pulmonary Vascular Disease, Department of Cardiology, Fuwai Hospital, National Clinical Research Center for Cardiovascular Diseases, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China
| | - Zhihong Liu
- Center for Respiratory and Pulmonary Vascular Disease, Department of Cardiology, Fuwai Hospital, National Clinical Research Center for Cardiovascular Diseases, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China
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10
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Donskoy I, Loghmanee D, Fields BG, Troester M, Martin W. Telemedicine-based sleep services for a complex child: optimizing care during a pandemic and beyond. J Clin Sleep Med 2022; 18:325-327. [PMID: 34402782 PMCID: PMC8807920 DOI: 10.5664/jcsm.9616] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
A 12-year-old male with nonverbal autism and morbid obesity was referred to a pediatric sleep center during the SARS-CoV-2 pandemic for complaints of snoring with tonsillar hypertrophy and difficulty falling asleep. Due to social challenges, the family had not sought in-person care in the past. Through telemedicine consultation and home sleep apnea testing, the patient was diagnosed with obstructive sleep apnea as well as an irregular sleep-wake disorder. This unique utilization of the health care system in the care of a complex patient with multiple sleep disorders demonstrates the utility of remote care and testing. There is a great benefit to continuing to provide pediatric sleep care in this way beyond the pandemic.
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Affiliation(s)
- Innessa Donskoy
- Advocate Children’s Hospital, Park Ridge, Illinois;,Address correspondence to: Innessa Donskoy, MD, FAAP, FAASM, 1675 Dempster Street, Park Ridge, IL 60068;
| | | | - Barry G. Fields
- Emory University School of Medicine, Atlanta, Georgia;,Atlanta VA Medical Center, North Druid Hills, Georgia
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11
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Abel F, Wallis C. The role of the nasopharyngeal prong in craniofacial disorders in particular the Pierre Robin sequence. Semin Fetal Neonatal Med 2021; 26:101285. [PMID: 34602353 DOI: 10.1016/j.siny.2021.101285] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
There are a wide range of surgical and maxillofacial options to alleviate upper airway obstruction in children with craniofacial disorders. The nasopharyngeal prong (NPP) is a simple idea where the airway obstruction arising from the posteriorly placed tongue secondary to a small mandible can be overcome quickly and without resorting to more invasive surgical procedures. The role of the NPP is of particular interest in Robin sequence (RS). RS describes a congenital anomaly with retrognathia (often with associated U-shaped cleft palate) where in some children the tongue and small jaw can significantly impact on airway patency with upper airway obstruction. The NPP is a modified endotracheal tube, of ideal diameter and cut to a desired length that can bypass the airway obstruction and regain patency to the upper airway. RS has a natural history of mandibular growth and resolution of the symptoms with time and thus the NPP presents a medium term solution precluding the need in selected children of more permanent and potentially unnecessary surgical procedures. The role of the NPP in other craniofacial disorders (either as a temporary solution or longer term option) requires further research.
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Affiliation(s)
- Francois Abel
- Respiratory Unit, Great Ormond Street Hospital for Children NHS Foundation Trust, London, WC1N 3JH, UK.
| | - Colin Wallis
- Respiratory Unit, Great Ormond Street Hospital for Children NHS Foundation Trust, London, WC1N 3JH, UK
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12
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Martín-Montero A, Gutiérrez-Tobal GC, Kheirandish-Gozal L, Vaquerizo-Villar F, Álvarez D, Del Campo F, Gozal D, Hornero R. Heart Rate Variability as a Potential Biomarker of Pediatric Obstructive Sleep Apnea Resolution. Sleep 2021; 45:6366352. [PMID: 34498074 DOI: 10.1093/sleep/zsab214] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2021] [Revised: 05/26/2021] [Indexed: 12/23/2022] Open
Abstract
STUDY OBJECTIVES Pediatric obstructive sleep apnea (OSA) affects cardiac autonomic regulation, altering heart rate variability (HRV). Although changes in classical HRV parameters occur after OSA treatment, they have not been evaluated as reporters of OSA resolution. Specific frequency bands (named BW1, BW2 and BWRes) have been recently identified in OSA. We hypothesized that changes with treatment in these spectral bands can reliably identify changes in OSA severity and reflect OSA resolution. METHODS 404 OSA children (5-9.9 years) from the prospective Childhood Adenotonsillectomy Trial (CHAT) were included; 206 underwent early adenotonsillectomy (eAT), while 198 underwent watchful waiting with supportive care (WWSC). HRV changes from baseline to follow-up were computed for classical and OSA-related frequency bands. Causal mediation analysis was conducted to evaluate how treatment influences HRV through mediators such as OSA resolution and changes in disease severity. Disease resolution was initially assessed by considering only obstructive events, and was followed by adding central apneas to the analyses. RESULTS Treatment, regardless of eAT or WWSC, affects HRV activity, mainly in the specific frequency band BW2 (0.028-0.074 Hz). Furthermore, only changes in BW2 were specifically attributable to all OSA resolution mediators. HRV activity in BW2 also showed statistically significant differences between resolved and non-resolved OSA. CONCLUSIONS OSA treatment affects HRV activity in terms of change in severity and disease resolution, especially in OSA-related BW2 frequency band. This band allowed to differentiate HRV activity between children with and without resolution, so we propose BW2 as potential biomarker of pediatric OSA resolution.
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Affiliation(s)
| | - Gonzalo C Gutiérrez-Tobal
- Biomedical Engineering Group, University of Valladolid, Valladolid, Spain
- CIBER-BBN, Centro de Investigación Biomédica en Red en Bioingeniería, Biomateriales y Nanomedicina, Valladolid, Spain
| | - Leila Kheirandish-Gozal
- Department of Child Health and The Child Health Research Institute, University of Missouri School of Medicine, Columbia, MO, USA
| | - Fernando Vaquerizo-Villar
- Biomedical Engineering Group, University of Valladolid, Valladolid, Spain
- CIBER-BBN, Centro de Investigación Biomédica en Red en Bioingeniería, Biomateriales y Nanomedicina, Valladolid, Spain
| | - Daniel Álvarez
- Biomedical Engineering Group, University of Valladolid, Valladolid, Spain
- CIBER-BBN, Centro de Investigación Biomédica en Red en Bioingeniería, Biomateriales y Nanomedicina, Valladolid, Spain
- Sleep-Ventilation Unit, Pneumology Department, Río Hortega University Hospital, Valladolid, Spain
| | - Félix Del Campo
- Biomedical Engineering Group, University of Valladolid, Valladolid, Spain
- CIBER-BBN, Centro de Investigación Biomédica en Red en Bioingeniería, Biomateriales y Nanomedicina, Valladolid, Spain
- Sleep-Ventilation Unit, Pneumology Department, Río Hortega University Hospital, Valladolid, Spain
| | - David Gozal
- Department of Child Health and The Child Health Research Institute, University of Missouri School of Medicine, Columbia, MO, USA
| | - Roberto Hornero
- Biomedical Engineering Group, University of Valladolid, Valladolid, Spain
- CIBER-BBN, Centro de Investigación Biomédica en Red en Bioingeniería, Biomateriales y Nanomedicina, Valladolid, Spain
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13
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Martín-Montero A, Gutiérrez-Tobal GC, Gozal D, Barroso-García V, Álvarez D, del Campo F, Kheirandish-Gozal L, Hornero R. Bispectral Analysis of Heart Rate Variability to Characterize and Help Diagnose Pediatric Sleep Apnea. ENTROPY (BASEL, SWITZERLAND) 2021; 23:1016. [PMID: 34441156 PMCID: PMC8394544 DOI: 10.3390/e23081016] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/05/2021] [Revised: 07/28/2021] [Accepted: 08/03/2021] [Indexed: 12/28/2022]
Abstract
Pediatric obstructive sleep apnea (OSA) is a breathing disorder that alters heart rate variability (HRV) dynamics during sleep. HRV in children is commonly assessed through conventional spectral analysis. However, bispectral analysis provides both linearity and stationarity information and has not been applied to the assessment of HRV in pediatric OSA. Here, this work aimed to assess HRV using bispectral analysis in children with OSA for signal characterization and diagnostic purposes in two large pediatric databases (0-13 years). The first database (training set) was composed of 981 overnight ECG recordings obtained during polysomnography. The second database (test set) was a subset of the Childhood Adenotonsillectomy Trial database (757 children). We characterized three bispectral regions based on the classic HRV frequency ranges (very low frequency: 0-0.04 Hz; low frequency: 0.04-0.15 Hz; and high frequency: 0.15-0.40 Hz), as well as three OSA-specific frequency ranges obtained in recent studies (BW1: 0.001-0.005 Hz; BW2: 0.028-0.074 Hz; BWRes: a subject-adaptive respiratory region). In each region, up to 14 bispectral features were computed. The fast correlation-based filter was applied to the features obtained from the classic and OSA-specific regions, showing complementary information regarding OSA alterations in HRV. This information was then used to train multi-layer perceptron (MLP) neural networks aimed at automatically detecting pediatric OSA using three clinically defined severity classifiers. Both classic and OSA-specific MLP models showed high and similar accuracy (Acc) and areas under the receiver operating characteristic curve (AUCs) for moderate (classic regions: Acc = 81.0%, AUC = 0.774; OSA-specific regions: Acc = 81.0%, AUC = 0.791) and severe (classic regions: Acc = 91.7%, AUC = 0.847; OSA-specific regions: Acc = 89.3%, AUC = 0.841) OSA levels. Thus, the current findings highlight the usefulness of bispectral analysis on HRV to characterize and diagnose pediatric OSA.
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Affiliation(s)
- Adrián Martín-Montero
- Biomedical Engineering Group, University of Valladolid, 47002 Valladolid, Spain; (G.C.G.-T.); (V.B.-G.); (D.Á.); (F.d.C.); (R.H.)
| | - Gonzalo C. Gutiérrez-Tobal
- Biomedical Engineering Group, University of Valladolid, 47002 Valladolid, Spain; (G.C.G.-T.); (V.B.-G.); (D.Á.); (F.d.C.); (R.H.)
- CIBER-BBN, Centro de Investigación Biomédica en Red en Bioingeniería, Biomateriales y Nanomedicina, 28029 Madrid, Spain
| | - David Gozal
- Department of Child Health and the Child Health Research Institute, The University of Missouri School of Medicine, Columbia, MO 65212, USA; (D.G.); (L.K.-G.)
| | - Verónica Barroso-García
- Biomedical Engineering Group, University of Valladolid, 47002 Valladolid, Spain; (G.C.G.-T.); (V.B.-G.); (D.Á.); (F.d.C.); (R.H.)
- CIBER-BBN, Centro de Investigación Biomédica en Red en Bioingeniería, Biomateriales y Nanomedicina, 28029 Madrid, Spain
| | - Daniel Álvarez
- Biomedical Engineering Group, University of Valladolid, 47002 Valladolid, Spain; (G.C.G.-T.); (V.B.-G.); (D.Á.); (F.d.C.); (R.H.)
- CIBER-BBN, Centro de Investigación Biomédica en Red en Bioingeniería, Biomateriales y Nanomedicina, 28029 Madrid, Spain
| | - Félix del Campo
- Biomedical Engineering Group, University of Valladolid, 47002 Valladolid, Spain; (G.C.G.-T.); (V.B.-G.); (D.Á.); (F.d.C.); (R.H.)
- CIBER-BBN, Centro de Investigación Biomédica en Red en Bioingeniería, Biomateriales y Nanomedicina, 28029 Madrid, Spain
- Sleep-Ventilation Unit, Pneumology Service, Río Hortega University Hospital, 47012 Valladolid, Spain
| | - Leila Kheirandish-Gozal
- Department of Child Health and the Child Health Research Institute, The University of Missouri School of Medicine, Columbia, MO 65212, USA; (D.G.); (L.K.-G.)
| | - Roberto Hornero
- Biomedical Engineering Group, University of Valladolid, 47002 Valladolid, Spain; (G.C.G.-T.); (V.B.-G.); (D.Á.); (F.d.C.); (R.H.)
- CIBER-BBN, Centro de Investigación Biomédica en Red en Bioingeniería, Biomateriales y Nanomedicina, 28029 Madrid, Spain
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14
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Lildal TK, Bertelsen JB, Ovesen T. Feasibility of conducting type III home sleep apnoea test in children. Acta Otolaryngol 2021; 141:707-713. [PMID: 34182882 DOI: 10.1080/00016489.2021.1930152] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
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.
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Affiliation(s)
- Tina Kissow Lildal
- Department of ORL-HN Surgery, Region Hospital West Jutland, University Clinic for Flavour, Balance and Sleep, Holstebro, Denmark
| | - Jannik Buus Bertelsen
- Department of ORL-HN Surgery, Region Hospital West Jutland, University Clinic for Flavour, Balance and Sleep, Holstebro, Denmark
| | - Therese Ovesen
- Department of ORL-HN Surgery, Region Hospital West Jutland, University Clinic for Flavour, Balance and Sleep, Holstebro, Denmark
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15
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Barroso-García V, Gutiérrez-Tobal GC, Kheirandish-Gozal L, Vaquerizo-Villar F, Álvarez D, Del Campo F, Gozal D, Hornero R. Bispectral analysis of overnight airflow to improve the pediatric sleep apnea diagnosis. Comput Biol Med 2020; 129:104167. [PMID: 33385706 DOI: 10.1016/j.compbiomed.2020.104167] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2020] [Revised: 11/19/2020] [Accepted: 12/04/2020] [Indexed: 12/15/2022]
Abstract
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.
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Affiliation(s)
- Verónica Barroso-García
- Biomedical Engineering Group, University of Valladolid, Valladolid, Spain; CIBER-BBN, Centro de Investigación Biomédica en Red en Bioingeniería, Biomateriales y Nanomedicina, Valladolid, Spain.
| | - Gonzalo C Gutiérrez-Tobal
- Biomedical Engineering Group, University of Valladolid, Valladolid, Spain; CIBER-BBN, Centro de Investigación Biomédica en Red en Bioingeniería, Biomateriales y Nanomedicina, Valladolid, Spain
| | - Leila Kheirandish-Gozal
- Department of Child Health, The University of Missouri School of Medicine, Columbia, MO, USA
| | - Fernando Vaquerizo-Villar
- Biomedical Engineering Group, University of Valladolid, Valladolid, Spain; CIBER-BBN, Centro de Investigación Biomédica en Red en Bioingeniería, Biomateriales y Nanomedicina, Valladolid, Spain
| | - Daniel Álvarez
- Biomedical Engineering Group, University of Valladolid, Valladolid, Spain; CIBER-BBN, Centro de Investigación Biomédica en Red en Bioingeniería, Biomateriales y Nanomedicina, Valladolid, Spain; Sleep-Ventilation Unit, Pneumology Department, Río Hortega University Hospital, Valladolid, Spain
| | - Félix Del Campo
- Biomedical Engineering Group, University of Valladolid, Valladolid, Spain; CIBER-BBN, Centro de Investigación Biomédica en Red en Bioingeniería, Biomateriales y Nanomedicina, Valladolid, Spain; Sleep-Ventilation Unit, Pneumology Department, Río Hortega University Hospital, Valladolid, Spain
| | - David Gozal
- Department of Child Health, The University of Missouri School of Medicine, Columbia, MO, USA
| | - Roberto Hornero
- Biomedical Engineering Group, University of Valladolid, Valladolid, Spain; CIBER-BBN, Centro de Investigación Biomédica en Red en Bioingeniería, Biomateriales y Nanomedicina, Valladolid, Spain
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