Portable evaluation of obstructive sleep apnea in adults: A systematic review

Obstructive sleep apnea (OSA) is a significant healthcare burden affecting approximately one billion people worldwide. The prevalence of OSA is rising with the ongoing obesity epidemic, a key risk factor for its development. While in-laboratory polysomnography (PSG) is the gold standard for diagnosing OSA, it has significant drawbacks that prevent widespread use. Portable devices with different levels of monitoring are available to allow remote assessment for OSA. To better inform clinical practice and research, this comprehensive systematic review evaluated diagnostic performances, study cost and patients' experience of different levels of portable sleep studies (type 2, 3, and 4), as well as wearable devices and non-contact systems, in adults. Despite varying study designs and devices used, portable diagnostic tests are found to be sufficient for initial screening of patients at risk of OSA. Future studies are needed to evaluate cost effectiveness with the incorporation of portable diagnostic tests into the diagnostic pathway for OSA, as well as their application in patients with chronic respiratory diseases and other comorbidities that may affect test performance.

Caregiver knowledge of obstructive sleep apnoea in Down syndrome

BACKGROUND

Down syndrome (DS) population has a very high prevalence of obstructive sleep apnoea (OSA), but this remains underdiagnosed. Hence, we aimed to evaluate caregiver's knowledge of OSA and related sociodemographic factors that could contribute to OSA screening patterns in this population.

METHODS

An online survey though the LuMind IDSC Foundation focused on OSA diagnosis, treatments and the number of sleep studies performed. Data were compared between subjects born before and after the American Academy of Pediatrics (AAP) recommendations for OSA screening.

RESULTS

Of the caregivers, 724 (parents 96.3%), responded to the survey. The median [interquartile (IQR)] age of the subjects with DS was 12 [20;7] years. The majority (84.3%) had sleep apnoea diagnosis, and half of them were initially referred for a sleep study due to disturbed sleep symptoms. Only 58.7% of the responders were aware of the AAP recommendations. This was linked to higher socioeconomic and/or educational level and to an earlier OSA diagnosis. The median (IQR) age of OSA diagnosis was lowered after the AAP guidelines publication compared with before its publication (3 [4;2] years vs. 10 [18;5] years, P < 0.000). Adenotonsillectomy (81.9%) and continuous positive airway pressure (61.5%) were the most commonly prescribed treatments. Few had discussed other new therapies such as hypoglossal nerve stimulation (16.0%). Only 16.0% of the subjects repeated the sleep study to monitor OSA with ageing, and 30.2% had to wait more than 4 years between studies.

CONCLUSIONS

This study reinforces the need to improve OSA knowledge of caregivers and clinicians of individuals with DS to promote an earlier diagnosis and optimal treatment of OSA in this population.

Comparison of polysomnographic characteristics between low birthweight and normal birthweight children in the Northern Territory of Australia: A case-control study

OBJECTIVES

To describe the sleep architecture of pediatric patients according to whether they were born low birthweight (birthweight <2500 g, LBW) or normal birthweight (birthweight >2500 g).

DESIGN

Case control study.

SETTING

Pediatric sleep laboratory in the Northern Territory of Australia during a 5-year study period (2015- 2020).

PARTICIPANTS

Pediatric patients (aged <18 years) referred to the specialist sleep service for assessment of clinically suspected sleep disorders.

MEASUREMENTS

Sleep onset latency, rapid eye movement (REM) sleep latency, wake time after sleep onset, total sleep time, sleep efficiency, non-rapid eye movement stages N1/N2/N3, and REM sleep duration, total/spontaneous/respiratory/limb related arousal indexes, total/non-rapid eye movement/REM obstructive apnea-hypopnea index and oxygen saturation.

RESULTS

One hundred and seventy-two pediatric patients had birthweight data available of whom 19 were LBW. LBW patients showed significantly greater sleep disruption and higher prevalence of poor sleepers (<80% efficiency). In multivariate regression models, increasing birthweight was associated with significantly greater sleep efficiency and total sleep time. After accounting for gestational age LBW was associated with increased odds of obstructive sleep apnea.

CONCLUSIONS

Among pediatric patients LBW is associated with increased sleep disruption and reduced sleep efficiency. This is attenuated by gestational age, though both gestational age and LBW significantly influence odds of obstructive sleep apnea. This sleep health deficit may contribute to development of chronic disease in this vulnerable population, and should be monitored to provide avenues for early intervention.

Should obstructive hypopneas be included when analyzing sleep studies in infants with Robin Sequence?

OBJECTIVE

We have used an obstructive apnea index of ≥3 as treatment indication for infants with Robin sequence (RS), while the obstructive apnea-hypopnea index (OAHI) and a threshold of ≥5 is often used internationally. We wanted to know whether these two result in similar indications, and what the interobserver variability is with either asessement.

METHODS

Twenty lab-based overnight sleep recordings from infants with isolated RS (median age: 7 days, range 2-38) were scored based on the 2020 American Academy of Sleep Medicine guidelines, including or excluding obstructive hypopneas.

RESULTS

Median obstructive apnea index (OAI) was 18 (interquartile range: 7.6-38) including only apneas, and 35 (18-54) if obstructive hypopneas were also considered as respiratory events (OAHI). Obstructive sleep apnea (OSA) severity was re-classified from moderate to severe for two infants when obstructive hypopneas were also considered, but this did not lead to a change in clinical treatment decisions for either infant. Median interobserver agreement was 0.86 (95% CI 0.70-0.94) for the OAI, and 0.60 (0.05-0.84) for the OAHI.

CONCLUSION

Inclusion of obstructive hypopneas when assessing OSA severity in RS infants doubled the obstructive event rate, but impaired interobserver agreement and would not have changed clinical management.

Role of sleep study in children with Chiari malformation and sleep disordered breathing

PURPOSE

Chiari malformation incorporate numerous forms of congenital or acquired cerebellar herniation through the foramen magnum. This may lead to brain stem, high spinal cord and cranial nerve compression resulting in obstructive and central apneas. This review highlights he high prevalence of sleep-disordered breathing in this population and the importance of refering these patients for sleep studies as part of their workup.

METHODS

A review of the literature was performed through a PubMed and EMBASE search of original articles and reviews using the key words "chiari" "chiari malformation" "hindbrain herniation" "sleep disordered breathing" "obstructive sleep apnea" "central sleep apnea" "sleep study" and "foramen magnum decompression".

DISCUSSION

We highlight the pathophysiology of sleep disordered breathing in patients with Chiari malformation, how it can be diagnosed and what the treatment options are.

CONCLUSIONS

Sleep-disordered breathing is highly prevalent in patients with CM1. Clinicians caring for these patients should be aware of this and prioritise sleep diagnostic testing to allow for early diagnosis and management particularly in the presence of neurological symptoms and specific brain MRI pointers.

Sleep disturbances in Wolfram syndrome

Background

Wolfram syndrome is a rare disorder associated with diabetes mellitus, diabetes insipidus, optic nerve atrophy, hearing and vision loss, and neurodegeneration. Sleep complaints are common but have not been studied with objective measures. Our goal was to assess rates of sleep apnea and objective and self-reported measures of sleep quality, and to determine the relationship of sleep pathology to other clinical variables in Wolfram syndrome patients.

Methods

Genetically confirmed Wolfram syndrome patients were evaluated at the 2015 and 2016 Washington University Wolfram Syndrome Research Clinics. Patients wore an actigraphy device and a type III ambulatory sleep study device and completed the Epworth Sleepiness Scale (ESS), the Pittsburgh Sleep Quality Index (PSQI) and/or the Pediatric Sleep Questionnaire (PSQ). PSQI and PSQ questionnaire data were compared to a previously collected group of controls. Patients were characterized clinically with the Wolfram Unified Rating Scale (WURS) and a subset underwent magnetic resonance imaging (MRI) for brain volume measurements.

Results

Twenty-one patients were evaluated ranging from age 8.9–29.7 years. Five of 17 (29%) adult patients fit the criteria for obstructive sleep apnea (OSA; apnea-hypopnea index [AHI] ≥ 5) and all 4 of 4 (100%) children aged 12 years or younger fit the criteria for obstructive sleep apnea (AHI’s ≥ 1). Higher AHI was related to greater disease severity (higher WURS Physical scores). Higher mixed apnea scores were related to lower brainstem and cerebellar volumes. Patients’ scores on the PSQ were higher than those of controls, indicating greater severity of childhood obstructive sleep-related breathing disorders.

Conclusions

Wolfram syndrome patients had a high rate of OSA. Further study would be needed to assess how these symptoms change over time. Addressing sleep disorders in Wolfram syndrome patients would likely improve their overall health and quality of life.

HLA-DQB1*06:02 allele frequency and clinic-polysomnographic features in Saudi Arabian patients with narcolepsy

BACKGROUND

Narcolepsy is an uncommon neurological disorder characterised by irresistible spells of sleep associated with abnormal rapid eye movement (REM) sleep. The association between narcolepsy and human leukocyte antigen HLA- DQB1*06:02 has been established elsewhere but remains to be investigated among Saudi Arabian patients with narcolepsy.

METHODS

A total of 29 Saudi patients with type I or type 2 narcolepsy comprising of 23 (79%) males and 6 (21%) females with a mean age of 17.2 ± 9.6 years were included in this study. Type 1 or type 2 narcolepsy was diagnosed by full polysomnography followed by a multiple sleep latency test in accordance with International Classifications of Sleep Disorders-3 criteria. HLA typing for DQB1 alleles was performed by polymerase chain reaction and hybridization with sequence-specific oligonucleotide probes. Differences in clinical and sleep parameters were compared by univariable analyses. HLA-DQB1*06:02 frequency was systematically compared with the published literature.

RESULTS

Type 1 narcolepsy was diagnosed in 19/29 (65.5%) patients, whereas 10/29 (34.5%) patients had type 2 narcolepsy. DQB1*06:02 was present in 25/29 (86.2%) patients; 15/19 (78.9%) narcolepsy type 1 patients and 10/10 (100%) narcolepsy type 2 patients harboured the DQB1*06:02 allele. REM latency was significantly lower in DQB1*06:02-positive patients compared to DQB1*06:02-negative patients (17.6 ± 32.3 min vs. 106.0 ± 86.0 min; p = 0.025). Epworth Sleepiness Scale scores were significantly higher among type 1 than type 2 narcolepsy patients (19.7 ± 3.2 vs 15.3 ± 3.6; p = 0.02).

CONCLUSIONS

DQB1*06:02 allele frequencies among Saudi patients with narcolepsy were consistent with previously published data.

A simple and robust method for the automatic scoring of EEG arousals in polysomnographic recordings

BACKGROUND

Clinical diagnosis of sleep disorders relies on the polysomnographic test to examine the neurophysiological markers of the sleep process. In this test, the recording of the electroencephalographic activity and the submental electromyogram is the source of the analysis for the detection of electroencephalographic arousals. The identification of these events is important for the evaluation of the sleep continuity because they cause the fragmentation of the normal sleep process. This work proposes a new technique for the automatic detection of arousals in polysomnographic recordings, presenting a non-computationally complex method with the idea of providing an easy integration with other algorithms.

METHODS

The proposed algorithm combines different well-known signal analysis solutions to identify relevant arousal patterns with special emphasis on robustness and artifacts tolerance. It is a multistage method that after obtaining an initial set of events, improves the detection finding common EEG arousal patterns. Finally, false positives are discarded after examining each candidate within the context of clinical definitions.

RESULTS

22 polysomnographic recordings from real patients were used to validate the method. The results obtained were encouraging, achieving a precision value of 0.86 and a F₁ score value of 0.79. When compared with the gold standard, the method achieves a substantial agreement (Kappa coefficient of 0.78), with an almost perfect agreement with ten recordings.

CONCLUSIONS

The algorithm designed achieved encouraging results and shows robust behavior in presence of signal artifacts. Its low-coupled design allows its implementation on different development platforms, and an easy combination with other methods.

Complementary home mechanical ventilation techniques. SEPAR Year 2014

This is a review of the different complementary techniques that are useful for optimizing home mechanical ventilation (HMV). Airway clearance is very important in patients with HMV and many patients, particularly those with reduced peak cough flow, require airway clearance (manual or assisted) or assisted cough techniques (manual or mechanical) and suctioning procedures, in addition to ventilation. In the case of invasive HMV, good tracheostomy cannula management is essential for success. HMV patients may have sleep disturbances that must be taken into account. Sleep studies including complete polysomnography or respiratory polygraphy are helpful for identifying patient-ventilator asynchrony. Other techniques, such as bronchoscopy or nutritional support, may be required in patients on HMV, particularly if percutaneous gastrostomy is required. Information on treatment efficacy can be obtained from HMV monitoring, using methods such as pulse oximetry, capnography or the internal programs of the ventilators themselves. Finally, the importance of the patient's subjective perception is reviewed, as this may potentially affect the success of the HMV.