Night-to-night variability in obstructive sleep apnea using peripheral arterial tonometry: a case for multiple night testing

Influence of Sleep Stage on the Determination of Positional Dependency in Patients With Obstructive Sleep Apnea

OBJECTIVES

The supine sleep position and the rapid eye movement (REM) stage are widely recognized to exacerbate the severity of obstructive sleep apnea (OSA). Position-dependent OSA is generally characterized by an apnea-hypopnea index (AHI) that is at least twice as high in the supine position compared to other sleep positions. However, this condition can be misdiagnosed if a particular sleep stage-REM or non-REM (NREM)-predominates in a specific position. We explored the impact of the sleep stage on positional dependency in OSA.

METHODS

Polysomnographic data were retrospectively analyzed from 111 patients with OSA aged 18 years or older, all of whom had an AHI exceeding five events per hour and slept in both supine and non-supine positions for at least 5% of the total sleep time. The overall ratio of non-supine AHI to supine AHI (NS/S-AHI ratio) was compared between total, REM, and NREM sleep. Additionally, a weighted NS/S-AHI ratio, reflecting the proportion of time spent in each sleep stage, was calculated and compared to the original ratio.

RESULTS

The mean NS/S-AHI ratio was consistent between the entire sleep period and the specific sleep stages. However, the NS/S-AHI ratios for individual patients displayed poor agreement between total sleep and the specific stages. Additionally, the weighted NS/S-AHI ratio displayed poor agreement with the original NS/S-AHI ratio, primarily due to discrepancies in patients with mild to moderate OSA.

CONCLUSION

The weighted NS/S-AHI ratio may help precisely assess positional dependency.

Outcome Prediction Model for Radiofrequency Uvulopalatopharyngoplasty with Tonsillectomy in Adult Obstructive Sleep Apnea: Retrospective Cohort Study

Introduction

Knowing an individualized outcome prediction is essential when counseling patients before surgery. We aim to identify predictors and build a model for the outcome of radiofrequency uvulopalatopharyngoplasty with tonsillectomy (rfUPPP + TE).

Methods

All adult patients undergoing rfUPPP + TE for sleep-disordered breathing from 2015 to 2022 in our institution were included. Preoperative evaluations included detailed upper airway examinations and standardized questionnaires. Postoperative outcomes were measured through home sleep apnea testing and repeated questionnaires 3 months post-surgery. The primary endpoint was the postoperative apnea-hypopnea index (AHI) and the AHI responders using the Sher criteria.

Results

We analyzed 247 patients with a mean age of 46 ± 11 years, predominantly male (88.7%), and a mean BMI of 29.0 kg/m2. The mean AHI was reduced from 26.4 ± 18.6/h preoperatively to 16.2 ± 14.6/h postoperatively. Daytime sleepiness improved from 8.9 ± 48 to 4.0 ± 3.1 and snoring from 7.9 ± 2.1 to 3.3 ± 2.2. Multivariate analysis indicated that higher tonsil grades, preoperative AHI, and snoring levels were associated with a greater reduction in AHI. Age and body weight were negative predictors for AHI reduction. For AHI responders, according to Sher, tonsil grade was the only predictor in a multivariate analysis. The ROC curve of this simple model, with a corrected AUC of 0.625, compared favorably against two established models.

Conclusion

Our study highlights that tonsil grade, preoperative AHI, snoring, and, to a smaller extent, age and weight are key determinants of AHI reduction, emphasizing the importance of preoperative evaluation. Despite the multifactorial nature of obstructive sleep apnea, preoperative evaluation can predict the outcome of rfUPPP + TE and guide surgical planning.

Multi-night measurement for diagnosis and simplified monitoring of obstructive sleep apnoea

Substantial night-to-night variability in obstructive sleep apnoea (OSA) severity has raised misdiagnosis and misdirected treatment concerns with the current prevailing single-night diagnostic approach. In-home, multi-night sleep monitoring technology may provide a feasible complimentary diagnostic pathway to improve both the speed and accuracy of OSA diagnosis and monitor treatment efficacy. This review describes the latest evidence on night-to-night variability in OSA severity, and its impact on OSA diagnostic misclassification. Emerging evidence for the potential impact of night-to-night variability in OSA severity to influence important health risk outcomes associated with OSA is considered. This review also characterises emerging diagnostic applications of wearable and non-wearable technologies that may provide an alternative, or complimentary, approach to traditional OSA diagnostic pathways. The required evidence to translate these devices into clinical care is also discussed. Appropriately sized randomised controlled trials are needed to determine the most appropriate and effective technologies for OSA diagnosis, as well as the optimal number of nights needed for accurate diagnosis and management. Potential risks versus benefits, patient perspectives, and cost-effectiveness of these novel approaches should be carefully considered in future trials.

Determinants of apnea-hypopnea index variability during home sleep testing

BACKGROUND

A single-night attended in-laboratory polysomnography or home sleep testing are common approaches for obstructive sleep apnea (OSA) diagnosis. However, internight variability in apnea-hypopnea index value is common, and may result in misclassification of OSA severity and inapropriate treatment decisions.

OBJECTIVE

To investigate factors determining short-term apnea-hypopnea index variability using multi-night automated home sleep testing, and to determine how this variability impacts clinical decisions.

PATIENTS/METHODS

Adults with suspected OSA who successfully performed three home sleep tests using measurements of mandibular jaw movements (Sunrise, Namur, Belgium) combined with automated machine learning analysis were enrolled. Data analysis included principal component analysis, generalized estimating equation regression and qualitative agreement analysis.

RESULTS

160 individuals who performed three sleep tests over a mean of 8.78 ± 8.48 days were included. The apnea-hypopnea index varied by -0.88 events/h (5th-95th percentile range: -14.33 to 9.72 events/h). Based on a single-night recording, rates of overtreatment and undertreatment would have been of 13.5% and 6.0%, respectively. Regression analysis adjusted for age, sex, body mass index, total sleep time, and time between home sleep tests showed that time spent in deep non-rapid eye movement sleep and with head in supine position were independent significant predictors of the apnea-hypopnea index variability.

CONCLUSIONS

At the individual level, short-term internight variability in the apnea-hypopnea index was significantly associated with time spent in deep non-rapid eye movement sleep and head in supine position. Clinical decisions based on a single-night testing may lead to errors in OSA severity classification and incorrect therapeutic decisions.

Evaluating an under-mattress sleep monitor compared to a peripheral arterial tonometry home sleep apnea test device in the diagnosis of obstructive sleep apnea

STUDY OBJECTIVES

To evaluate whether or not the apnea-hypopnea index (AHI) from a peripheral arterial tonometry (PAT) home sleep apnea test (HSAT) is equivalent to the AHI provided by the mean of one, three, or seven nights from the Withings Sleep Analyzer (WSA) under-mattress device.

METHODS

We prospectively enrolled patients with suspected OSA in whom a PAT-HSAT was ordered. Eligible patients used the WSA for seven to nine nights. PAT data were scored using the device's intrinsic machine learning algorithms to arrive at the AHI using both 3% and 4% desaturation criteria for hypopnea estimations (PAT3%-AHI and PAT4%-AHI, respectively). These were then compared with the WSA-estimated AHI (WSA-AHI).

RESULTS

Of 61 patients enrolled, 35 completed the study with valid PAT and WSA data. Of the 35 completers 16 (46%) had at least moderately severe OSA (PAT3%-AHI ≥ 15). The seven-night mean WSA-AHI was 2.13 (95%CI =  - 0.88, 5.14) less than the PAT3%-AHI, but 5.64 (95%CI = 2.54, 8.73) greater than the PAT4%-AHI. The accuracy and area under the receiver operating curve (AUC) using the PAT3%-AHI ≥ 15 were 77% and 0.87 and for PAT4%-AHI ≥ 15 were 77% and 0.85, respectively. The one-, three-, or seven-night WSA-AHI were not equivalent to either the 3% or 4% PAT-AHI (equivalency threshold of ± 2.5 using the two one-sided t-test method).

CONCLUSIONS

The WSA derives estimates of the AHI unobtrusively over many nights, which may prove to be a valuable clinical tool. However, the WSA-AHI over- or underestimates the PAT-AHI in clinical use, and the appropriate use of the WSA in clinical practice will require further evaluation.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT04778748.

Night-to-Night Variability of Polysomnography-Derived Physiologic Endotypic Traits in Patients With Moderate to Severe OSA

BACKGROUND

Emerging data suggest that determination of physiologic endotypic traits (eg, loop gain) may enable precision medicine in OSA.

RESEARCH QUESTION

Does a single-night assessment of polysomnography-derived endotypic traits provide reliable estimates in moderate to severe OSA?

STUDY DESIGN AND METHODS

Two consecutive in-lab polysomnography tests from a clinical trial (n = 67; male, 69%; mean ± SD age, 61 ± 10 years; apnea-hypopnea index [AHI] 53 ± 22 events/h) were used for the reliability analysis. Endotypic traits, reflecting upper airway collapsibility (ventilation at eupneic drive [Vpassive]), upper airway dilator muscle tone (ventilation at the arousal threshold [Vactive]), loop gain (stability of ventilatory control, LG1), and arousal threshold (ArTh) were determined. Reliability was expressed as an intraclass correlation coefficient (ICC). Minimal detectable differences (MDDs) were computed to provide an estimate of maximum spontaneous variability. Further assessment across four repeated polysomnography tests was performed in a subcohort (n = 22).

RESULTS

Reliability of endotypic traits between the two consecutive nights was moderate to good (ICC: Vpassive = 0.82, Vactive = 0.76, LG1 = 0.72, ArTh = 0.83). Variability in AHI, but not in body position or in sleep stages, was associated with fluctuations in Vpassive and Vactive (r = -0.49 and r = -0.41, respectively; P < .001 for both). MDDs for single-night assessments were: Vpassive = 22, Vactive = 34, LG1 = 0.17, and ArTh = 21. Multiple assessments (mean of two nights, n = 22) further reduced MDDs by approximately 20% to 30%.

INTERPRETATION

Endotypic trait analysis using a single standard polysomnography shows acceptable reliability and reproducibility in patients with moderate to severe OSA. The reported MDDs of endotypic traits may facilitate the quantification of relevant changes and may guide future evaluation of interventions in OSA.

A new wearable diagnostic home sleep testing platform: comparison with available systems and benefits of multinight assessments

STUDY OBJECTIVES

We assessed the real-world performance of the ANNE Sleep system against 2 Food and Drug Administration-cleared home sleep testing platforms and the intraindividual night-to-night variability of respiratory event index measured by ANNE Sleep.

METHODS

We evaluated the home performance of the ANNE Sleep system compared with 2 Food and Drug Administration-cleared home sleep testing platforms (WatchPAT: n = 29 and Alice NightOne: n = 46) during a synchronous night with unsupervised patient application. Additionally, we evaluated night-to-night variability of respiratory event index and total sleep time using the ANNE Sleep system (n = 30).

RESULTS

For the diagnosis of moderate and severe obstructive sleep apnea, the ANNE Sleep system had a positive percent agreement of 58% (95% confidence interval, 28-85%) and a negative percent agreement of 100% (95% confidence interval, 80-100%) compared to WatchPAT. The positive and negative percent agreement for ANNE Sleep vs Alice NightOne was 85% (95% confidence interval, 66-96%) and 95% (95% confidence interval, 74-100%). There were no differences in mean total sleep time or respiratory event index across multiple nights of monitoring with ANNE. There were no differences consistent with a first-night effect but testing multiple nights reclassified obstructive sleep apnea severity in 5 (17%) individuals and detected 3 additional cases of moderate disease, with only a 12% (standard deviation, 28%) mean fluctuation in respiratory event index from the first night of testing compared to a mean of multiple nights. Overall, 80% of users found ANNE comfortable and easy to use.

CONCLUSIONS

ANNE Sleep exhibited stronger concordance with Alice NightOne compared to WatchPAT. While we illustrated low night-to-night variability for ANNE Sleep, the results suggest multiple nights increased detection of moderate or severe obstructive sleep apnea.

CLINICAL TRIAL REGISTRATION

Registry: ClinicalTrials.gov; Name: ANNE Diagnostic Agreement With Home Sleep Testing; URL: https://clinicaltrials.gov/ct2/show/NCT05421754; Identifier: NCT05421754.

CITATION

Walter J, Lee JY, Blake S, et al. A new wearable diagnostic home sleep testing platform: comparison with available systems and benefits of multinight assessments. J Clin Sleep Med. 2023;19(5):865-872.

Tonsil volume and outcome of radiofrequency uvulopalatoplasty with or without tonsillectomy in adults with sleep-disordered breathing

PURPOSE

Predictors for the outcome of uvulopalatopharyngoplasty with and without tonsillectomy (UPPP ± TE) in sleep-disordered breathing have not been fully established. This study investigates tonsil grade, volume, and preoperative examination in predicting radiofrequency UPP ± TE outcomes.

METHODS

All patients undergoing radiofrequency UPP with tonsillectomy if tonsils were present between 2015 and 2021 were retrospectively analyzed. Patients underwent a standardized clinical examination, including Brodsky palatine tonsil grade from 0 to 4. Preoperatively and 3 months after surgery, sleep apnea testing was performed using respiratory polygraphy. Questionnaires were administered assessing daytime sleepiness using the Epworth Sleepiness Scale (ESS) and snoring intensity on a visual analog scale. Tonsil volume was measured intraoperatively using water displacement.

RESULTS

The baseline characteristics of 307 patients and the follow-up data of 228 patients were analyzed. Tonsil volume increased by 2.5 ml (95% CI 2.1-2.9 ml; P < 0.001) per tonsil grade. Higher tonsil volumes were measured in men, younger patients, and patients with higher body mass indices. The preoperative apnea-hypopnea index (AHI) and AHI reduction strongly correlated with tonsil volume and grade, whereas postoperative AHI did not. The responder rate increased from 14% to 83% from tonsil grade 0 to 4 (P < 0.01). ESS and snoring were significantly reduced after surgery (P < 0.01), but the reduction was not influenced by tonsil grade or volume. No other preoperative factor other than tonsil size could predict surgical outcomes.

CONCLUSIONS

Tonsil grade and intraoperatively measured volume correlate well and predict the reduction of AHI, while they are not predictive of ESS and snoring response after radiofrequency UPP ± TE.

Clinical impact of manual scoring of peripheral arterial tonometry in patients with sleep apnea

PURPOSE

The objective was to analyze the clinical implications of manual scoring of sleep studies using peripheral arterial tonometry (PAT) and to compare the manual and automated scoring algorithms.

METHODS

Patients with suspected sleep-disordered breathing underwent sleep studies using PAT. The recordings were analyzed using a validated automated computer-based scoring and a novel manual scoring algorithm. The two methods were compared regarding sleep stages and respiratory events.

RESULTS

Recordings of 130 patients were compared. The sleep stages and time were not significantly different between the scoring methods. PAT-derived apnea-hypopnea index (pAHI) was on average 8.4 events/h lower in the manually scored data (27.5±17.4/h vs.19.1±15.2/h, p<0.001). The OSA severity classification decreased in 66 (51%) of 130 recordings. A similar effect was found for the PAT-derived respiratory disturbance index with a reduction from 31.2±16.5/h to 21.7±14.4/h (p<0.001), for automated and manual scoring, respectively. A lower pAHI for manual scoring was found in all body positions and sleep stages and was independent of gender and body mass index. The absolute difference of pAHI increased with sleep apnea severity, while the relative difference decreased. Pearson's correlation coefficient between pAHI and oxygen desaturation index (ODI) significantly improved from 0.89 to 0.94 with manual scoring (p<0.001).

CONCLUSIONS

Manual scoring results in a lower pAHI while improving the correlation to ODI. With manual scoring, the OSA category decreases in a clinically relevant proportion of patients. Sleep stages and time do not change significantly with manual scoring. In the authors' opinion, manual oversight is recommended if clinical decisions are likely to change.

Annual review of selected scientific literature: A report of the Committee on Scientific Investigation of the American Academy of Restorative Dentistry

The Scientific Investigation Committee of the American Academy of Restorative Dentistry offers this review of the 2021 dental literature in restorative dentistry to inform busy dentists regarding noteworthy scientific and clinical progress over the past year. Each member of the committee brings discipline-specific expertise to coverage of this broad topical area. Specific subject areas addressed, in order of the appearance in this report, include COVID-19 and the dental profession (new); prosthodontics; periodontics, alveolar bone, and peri-implant tissues; implant dentistry; dental materials and therapeutics; occlusion and temporomandibular disorders; sleep-related breathing disorders; oral medicine and oral and maxillofacial surgery; and dental caries and cariology. The authors focused their efforts on reporting information likely to influence daily dental treatment decisions with an emphasis on future trends in dentistry. With the tremendous volume of dentistry and related literature being published daily, this review cannot possibly be comprehensive. Rather, its purpose is to update interested readers and provide important resource material for those interested in pursuing greater details on their own. It remains our intent to assist colleagues in negotiating the extensive volume of important information being published annually. It is our hope that readers find this work useful in successfully managing the patients and dental problems they encounter.

Home sleep apnea testing with peripheral arterial tonometry to assess outcome in upper airway stimulation

STUDY OBJECTIVES

To determine whether home sleep apnea testing with peripheral arterial tonometry (HSAT-PAT) can be used in upper airway stimulation to evaluate therapy success.

METHODS

Data analysis from 50 consecutive patients receiving upper airway stimulation was performed. Baseline values were measured by polysomnography and HSAT-PAT. Follow-up was performed during and after titration (3-6 months) by polysomnography and HSAT-PAT and after 1 year by HSAT-PAT only. Primary outcome measures were reduction in the apnea-hypopnea index and oxygen desaturation index. In addition, an analysis of night-to-night variability for HSAT-PAT was performed.

RESULTS

All 50 patients completed their posttitration visit (3-6 months) and 41 patients completed the 1-year follow-up. In HSAT-PAT after 1 year, the mean apnea-hypopnea index (desaturation 3%) was reduced from 29.5 ± 17.1 events/h to 19.9 ± 13.1 events/h (P < .01) and the oxygen desaturation index (desaturation 4%) was reduced from 17.8 ± 12.6 events/h to 10.2 ± 8.3 events/h (P < .01). Therapy adherence after 1 year was high (6.6 ± 1.9 hours per night) and led to improvement in daytime sleepiness, meaning a reduction in the Epworth Sleepiness Scale score from 12.8 ± 5.4 to 5.9 ± 4.0 (P < .01). Analysis of night-to-night variability showed similar apnea-hypopnea index values between the 2 nights.

CONCLUSIONS

Upper airway stimulation was able to reduce the apnea-hypopnea index and oxygen desaturation index after 1 year, as assessed by full-night efficacy studies with HSAT-PAT. In addition, improvements in self-reported outcome parameters were observed. The importance of publishing the scoring criteria is highlighted and whether data are based on full-night efficacy studies or a selected period of time from a sleep study. This is a prerequisite for comparing data with other trials in the emerging field of upper airway stimulation.

CITATION

Hinder D, Schams SC, Knaus C, Tschopp K. Home sleep apnea testing with peripheral arterial tonometry to assess outcome in upper airway stimulation. J Clin Sleep Med. 2022;18(9):2197-2205.

Dynamic models of obstructive sleep apnea provide robust prediction of respiratory event timing and a statistical framework for phenotype exploration

Obstructive sleep apnea (OSA), in which breathing is reduced or ceased during sleep, affects at least 10% of the population and is associated with numerous comorbidities. Current clinical diagnostic approaches characterize severity and treatment eligibility using the average respiratory event rate over total sleep time (apnea-hypopnea index). This approach, however, does not characterize the time-varying and dynamic properties of respiratory events that can change as a function of body position, sleep stage, and previous respiratory event activity. Here, we develop a statistical model framework based on point process theory that characterizes the relative influences of all these factors on the moment-to-moment rate of event occurrence. Our results provide new insights into the temporal dynamics of respiratory events, suggesting that most adults have a characteristic event pattern that involves a period of normal breathing followed by a period of increased probability of respiratory event occurrence, while significant differences in event patterns are observed among gender, age, and race/ethnicity groups. Statistical goodness-of-fit analysis suggests consistent and substantial improvements in our ability to capture the timing of individual respiratory events using our modeling framework. Overall, we demonstrate a more statistically robust approach to characterizing sleep disordered breathing that can also serve as a basis for identifying future patient-specific respiratory phenotypes, providing an improved pathway towards developing individualized treatments.

Performance comparison of peripheral arterial tonometry-based testing and polysomnography to diagnose obstructive sleep apnea in military personnel

STUDY OBJECTIVES

Obstructive sleep apnea (OSA) is increasingly common among military personnel, but diagnostic capabilities are challenged by limited capability for polysomnography (PSG). We sought to evaluate the diagnostic properties of peripheral arterial tonometry (PAT)-based home sleep apnea testing (HSAT) to accurately identify and classify OSA among active-duty military personnel.

METHODS

This study was a retrospective review of all patients suspected of having OSA who completed an initial PAT-based HSAT followed by confirmatory PSG within 120 days. The diagnostic properties of a PAT-based, HSAT-derived apnea-hypopnea index (AHI) vs a PSG-derived AHI were assessed.

RESULTS

Two hundred eight matched pairs of asynchronous studies were analyzed. The prevalence of OSA was 63.5%. PAT-based HSAT overdiagnosed 27.4% of patients with OSA and underdiagnosed 46.6% of patients with OSA. The majority (n = 116, 55.8%) of patients changed OSA severity classification (absent, mild, moderate, severe) after PSG. OSA severity classification concordance between PAT-based HSAT and PSG was observed in 53.4%, 40.5%, 28.6%, and 40.0% of patients with absent, mild, moderate, and severe OSA, respectively. Receiver operating characteristic curve analysis showed an area under the curve of 0.715 and a proposed PAT-based, HSAT-derived AHI cutoff score for OSA diagnosis of 9.0 events/h. This PAT-based, HSAT-derived AHI provided a 52% sensitivity, 83% specificity, 84% positive predictive value, and 50% negative predictive value. Bland-Altman plots showed an unacceptable degree of agreement between PAT-based, HSAT-derived AHI and AHI.

CONCLUSIONS

There is significant discordance between PAT-based HSAT and PSG among active-duty military personnel evaluated for OSA. PAT-based HSAT may have limited utility for diagnosing OSA and grading severity in this unique patient population.

CITATION

O'Reilly BM, Wang Q, Collen J, Matsangas P, Colombo CJ, Mysliwiec V. Performance comparison of peripheral arterial tonometry-based testing and polysomnography to diagnose obstructive sleep apnea in military personnel. J Clin Sleep Med. 2022;18(6):1523-1530.

Effect of Different Maxillary Oral Appliance Designs on Respiratory Variables during Sleep

This study aimed to analyze the efficacy of maxillary oral appliance (MOA) designs on respiratory variables during sleep. At baseline, 23 participants underwent a sleep test with a portable device for two nights and were categorized as participants with mild obstructive sleep apnea (mild-OSA) (n = 13) and without OSA (w/o-OSA) (n = 10). Three types of MOAs, standard-OA (S-OA), palatal covering-OA (PC-OA), and vertically increasing-OA (VI-OA), were each worn for three nights, and sleep tests with each MOA were performed with a portable device for two nights. Based on the average of the respiratory event index (REI) values for the two nights for each MOA, w/o-OSA participants with an REI ≥ 5.0 were defined as the exacerbation group and those with an REI < 5.0 as the non-exacerbation group. In mild-OSA participants, an REI ≥ 15.0 or REI ≥ baseline REI × 1.5 were defined as the exacerbation group and those with an REI < 15.0 and REI < baseline REI × 1.5 were defined as the non-exacerbation group. The percentage of the exacerbation and non-exacerbation groups with MOA was evaluated in the w/o-OSA and mild-OSA participants. The maxillary and mandibular dental-arch dimension was compared by dentition model analysis. The exacerbation group in w/o-OSA participants (n = 10) comprised 10.0% participants (n = 1) with S-OA, 40.0% (n = 4) with PC-OA, and 30.0% (n = 3) with VI-OA. The exacerbation group in the mild-OSA participants (n = 13) comprised 15.4% subjects (n = 2) with S-OA, 23.1% (n = 3) with PC-OA, and 23.1% (n = 3) in VI-OA. In the model analysis for w/o-OSA, the posterior dental arch width was significantly greater in the exacerbation group than in the non-exacerbation group wearing S-OA (p < 0.05). In addition, the ratio of the maxillary to mandibular dental arch width (anterior dental arch width) was significantly greater in the exacerbation group than in the non-exacerbation group for both PC-OA and VI-OA (p < 0.05). In mild-OSA, the maxillary and mandibular dental arch lengths and the ratio of maxillary to mandibular dental arch width (posterior dental arch width) were significantly smaller in the exacerbation group than in the non-exacerbation group for S-OA (p < 0.05). This study confirmed that wearing an MOA by w/o-OSA and mild-OSA participants may increase the REI during sleep and that PC-OA and VI-OA may increase the REI more than S-OA. The maxillary and mandibular dental-arch dimensions may affect the REI when using an MOA.

Multi-night Prevalence, Variability, and Diagnostic Misclassification of Obstructive Sleep Apnea

Rationale Recent studies suggest that obstructive sleep apnea (OSA) severity can vary markedly from night to night which may have important implications for diagnosis and management. Objectives This study aimed to assess OSA prevalence from multi-night in-home recordings and the impact of night-to-night variability in OSA severity on diagnostic classification in a large, global, non-randomly selected community sample from a consumer database of people that purchased a novel, validated, under-mattress sleep analyzer. Methods 67,278 individuals aged between 18 and 90 years underwent in-home nightly monitoring over an average of ~170 nights per participant between July 2020 to March 2021. OSA was defined as a nightly mean apnea-hypopnea index (AHI) >15 events/h. Outcomes were multi-night global prevalence and likelihood of OSA misclassification from a single night AHI value. Measurements and Main Results Over 11.6 million nights of data were collected and analyzed. OSA global prevalence was 22.6% (95% CI: 20.9-24.3%). The likelihood of misdiagnosis in people with OSA based on a single night ranged between ~20% and 50%. Misdiagnosis error rates decreased with increased monitoring nights (e.g. 1-night F1-score=0.77 vs. 0.94 for 14-nights); and remained stable after 14-nights of monitoring. Conclusions Multi-night in-home monitoring using novel non-invasive under mattress sensor technology indicates a global prevalence of moderate to severe OSA of ~20%, and that ~20% of people diagnosed with a single night study may be misclassified. These findings highlight the need to consider night-to-night variation on OSA diagnosis and management. This article is open access and distributed under the terms of the Creative Commons Attribution Non-Commercial No Derivatives License 4.0 (http://creativecommons.org/licenses/by-nc-nd/4.0/).

A meta-analysis of diagnostic test performance of peripheral arterial tonometry studies

STUDY OBJECTIVES

The objective of this meta-analysis was to analyze agreement in apnea-hypopnea index (AHI) determination between peripheral arterial tonometry (PAT) and polysomnography (PSG) studies.

METHODS

Mean AHI bias and standard deviation (SD) extracted from Bland-Altman plots reported in studies was pooled in a meta-analysis, which was then used to calculate percentage errors of limit agreement (PE) in AHI determination by PAT using PSG AHI as the reference. Individual participant data (where reported in studies) was used to compute Cohen's kappa to assess agreement between PSG and PAT on sleep apnea severity and also for computing sensitivity and specificity of PAT at different AHI thresholds using PSG AHI as the reference.

RESULTS

From 17 studies and 1318 participants (all underwent simultaneous PSG and WatchPAT), a pooled mean AHI bias of 0.30 (standard error (SE) 0.74) and a WatchPAT AHI PE of 230% was calculated. Meta-analysis of Cohen's kappa for agreement between PSG and WatchPAT studies for classifying patients with no sleep apnea, mild, moderate or severe sleep apnea severity was 0.45 (SE 0.06), 0.29 (SE 0.05), 0.25 (SE 0.07) and 0.64 (SE 0.05), respectively. At AHI thresholds 5, 15 and 30, WatchPAT studies showed pooled sensitivities and specificities of 94.11% and 43.47%, 92.21% and 72.39% and 74.11% and 87.10%, respectively. Likelihood ratios were not significant at any AHI threshold.

CONCLUSIONS

The results of this meta-analysis suggest clinically significant discordance between WatchPAT and PSG measurements of AHI, significant sleep apnea severity misclassification by PAT studies and also poor diagnostic test performance.