Hui-Leng Tan1, David Gozal2, Helena Molero Ramirez2, Hari P R Bandla2, Leila Kheirandish-Gozal2. 1. Section of Pediatric Sleep Medicine, Department of Pediatrics, Pritzker School of Medicine, Biological Sciences Division, The University of Chicago, Chicago, IL ; Department of Paediatric Respiratory Medicine, Royal Brompton Hospital, London, UK. 2. Section of Pediatric Sleep Medicine, Department of Pediatrics, Pritzker School of Medicine, Biological Sciences Division, The University of Chicago, Chicago, IL.
Abstract
BACKGROUND: Substantial discrepancies exist in the type of sleep studies performed to diagnose pediatric obstructive sleep apnea (OSA) in different countries. Respiratory polygraphic (RP) recordings are primarily performed in sleep laboratories in Europe, whereas polysomnography (PSG) constitutes the majority in the US and Australia. Home RP show consistent apnea-hypopnea index (AHI) underscoring, primarily because the total recording time is used as the denominator when calculating the AHI compared to total sleep time (TST). However, laboratory-based RP are less likely affected, since the presence of sleep technicians and video monitoring may enable more accurate TST estimates. We therefore examined differences in AHI in PSG and in-lab RP, and whether RP-based AHI may impact clinical decision making. METHODS: Of all the children assessed for possible OSA who underwent PSG evaluation, 100 were identified and divided into 4 groups: (A) those with AHI < 1/h TST (n = 20), (B) 1 ≤ AHI < 5/h TST (n = 40), (C) 5 ≤ AHI < 10/h TST (n = 20), and (D) AHI ≥ 10/h TST (n = 20). Electroencephalography, electrooculography, and electromyography channels were deleted from the original unscored recordings to transform them into RP, and then rescored in random sequence. AHI-RP were compared to AHI-PSG, and therapeutic decisions based on AHI-RP and AHI-PSG were formulated and analyzed using clinical details derived from the patient's clinic letter. RESULTS: Bland Altman analysis showed that in lab RP underestimated the AHI despite more accurate estimates of TST. This underestimation was due to missed hypopneas causing arousals without desaturation. Basing the therapeutic management decision on RP instead of PSG results changed the clinical management in 23% of all patients. The clinical management for patients in groups A and D was unaffected. However, 27.5% of patients in group B would have been given no treatment, as they would be diagnosed as having no OSA (AHI < 1/h TST) when they should have received a trial of anti-inflammatory therapy or been referred for ear, nose, and throat (ENT) review. Sixty percent of patients in group C would have received either a trial of medical treatment to treat mild OSA or no treatment, instead of referral to ENT services or commencement of continuous positive airway pressure. CONCLUSION: Apnea-hypopnea index (AHI) is underestimated in respiratory polygraphy (RP), and the disparity in AHI-RP and AHI-polysomnography can significantly affect clinical management decisions, particularly in children with mild and moderate obstructive sleep apnea (1 < AHI < 10/h total sleep time).
BACKGROUND: Substantial discrepancies exist in the type of sleep studies performed to diagnose pediatric obstructive sleep apnea (OSA) in different countries. Respiratory polygraphic (RP) recordings are primarily performed in sleep laboratories in Europe, whereas polysomnography (PSG) constitutes the majority in the US and Australia. Home RP show consistent apnea-hypopnea index (AHI) underscoring, primarily because the total recording time is used as the denominator when calculating the AHI compared to total sleep time (TST). However, laboratory-based RP are less likely affected, since the presence of sleep technicians and video monitoring may enable more accurate TST estimates. We therefore examined differences in AHI in PSG and in-lab RP, and whether RP-based AHI may impact clinical decision making. METHODS: Of all the children assessed for possible OSA who underwent PSG evaluation, 100 were identified and divided into 4 groups: (A) those with AHI < 1/h TST (n = 20), (B) 1 ≤ AHI < 5/h TST (n = 40), (C) 5 ≤ AHI < 10/h TST (n = 20), and (D) AHI ≥ 10/h TST (n = 20). Electroencephalography, electrooculography, and electromyography channels were deleted from the original unscored recordings to transform them into RP, and then rescored in random sequence. AHI-RP were compared to AHI-PSG, and therapeutic decisions based on AHI-RP and AHI-PSG were formulated and analyzed using clinical details derived from the patient's clinic letter. RESULTS: Bland Altman analysis showed that in lab RP underestimated the AHI despite more accurate estimates of TST. This underestimation was due to missed hypopneas causing arousals without desaturation. Basing the therapeutic management decision on RP instead of PSG results changed the clinical management in 23% of all patients. The clinical management for patients in groups A and D was unaffected. However, 27.5% of patients in group B would have been given no treatment, as they would be diagnosed as having no OSA (AHI < 1/h TST) when they should have received a trial of anti-inflammatory therapy or been referred for ear, nose, and throat (ENT) review. Sixty percent of patients in group C would have received either a trial of medical treatment to treat mild OSA or no treatment, instead of referral to ENT services or commencement of continuous positive airway pressure. CONCLUSION:Apnea-hypopnea index (AHI) is underestimated in respiratory polygraphy (RP), and the disparity in AHI-RP and AHI-polysomnography can significantly affect clinical management decisions, particularly in children with mild and moderate obstructive sleep apnea (1 < AHI < 10/h total sleep time).
Authors: Patricia Lloberes; Joaquín Durán-Cantolla; Miguel Ángel Martínez-García; José María Marín; Antoni Ferrer; Jaime Corral; Juan Fernando Masa; Olga Parra; Mari Luz Alonso-Álvarez; Joaquín Terán-Santos Journal: Arch Bronconeumol Date: 2011-03 Impact factor: 4.872
Authors: María Luz Alonso-Álvarez; Ana Isabel Navazo-Egüia; José Aurelio Cordero-Guevara; Estrella Ordax-Carbajo; Gregorio De La Mata; José Luis Barba-Cermeño; Joaquin Terán-Santos Journal: Sleep Med Date: 2012-03-24 Impact factor: 3.492
Authors: Juan F Masa; Jaime Corral; Ricardo Pereira; Joaquin Duran-Cantolla; Marta Cabello; Luis Hernández-Blasco; Carmen Monasterio; Alberto Alonso; Eusebi Chiner; Jose Zamorano; Felipe Aizpuru; Jose M Montserrat Journal: Am J Respir Crit Care Med Date: 2011-07-07 Impact factor: 21.405
Authors: R Nisha Aurora; Rochelle S Zak; Anoop Karippot; Carin I Lamm; Timothy I Morgenthaler; Sanford H Auerbach; Sabin R Bista; Kenneth R Casey; Susmita Chowdhuri; David A Kristo; Kannan Ramar Journal: Sleep Date: 2011-03-01 Impact factor: 5.849
Authors: Samuel T Kuna; Indira Gurubhagavatula; Greg Maislin; Sakhena Hin; Kathryn C Hartwig; Sue McCloskey; Robert Hachadoorian; Sharon Hurley; Rajesh Gupta; Bethany Staley; Charles W Atwood Journal: Am J Respir Crit Care Med Date: 2011-01-21 Impact factor: 21.405
Authors: Carole L Marcus; Lee Jay Brooks; Kari A Draper; David Gozal; Ann Carol Halbower; Jacqueline Jones; Michael S Schechter; Stephen Howard Sheldon; Karen Spruyt; Sally Davidson Ward; Christopher Lehmann; Richard N Shiffman Journal: Pediatrics Date: 2012-08-27 Impact factor: 7.124