Comparison of polysomnography, sleep apnea screening test and cardiopulmonary coupling in the diagnosis of pediatric obstructive sleep apnea syndrome
Introduction
Pediatric obstructive sleep apnea (OSA) is defined as disordered breathing during sleep characterized by prolonged partial upper airway obstruction and/or intermittent complete obstruction that disrupts normal ventilation during sleep and normal sleep patterns [1]. It is one of the most common diagnoses among pediatric ENT outpatients and the prevalence are reported to range from 1.2 to 5.7% due to wide variations in sample size and populations [[2], [3], [4]]. In China, as Li et al. reported, the OSA prevalence for boys and girls (n = 6447) was 5.8% and 3.8%, respectively [3].
Pediatric OSA features a history of habitual snoring, gasping, and pauses in breathing that may result in sudden arousals during sleep, which is often accompanied with excessive daytime sleepiness and fatigue [5]. As it usually starts with snoring and pauses in breathing, it is easily neglected by the parents and effective intervention may well be delayed. If left untreated, these patients are very likely to have behavioral, cognitive and cardiovascular consequences, including hyperactivity, attention-deficit disorder, anxiety/depression, poor school performance, nocturnal enuresis, pulmonary hypertension, etc. Maxillofacial abnormalities, such as retrognathia, high-arched palate and narrow intermolar distance might also be noted [6].
At present, the gold standard for the diagnosis of OSA is Polysomnography (PSG). The severity of OSA is assessed based on a summary of the number of apneas and hypopneas (AHI) and lowest oxygen saturation (LsO2) [7]. However, patients always have to join a long waiting list for the comparatively expensive examination, which can be stressful for our medical system and parents in China. In correspondence to these great demands for time-efficient sleep analyses, sleep medicine practitioners have come up with various alternative methods to objectively assess sleep stability, sleep quality and severity of OSA.
Portable sleep monitoring device, such as sleep apnea screening test (SAST) in the form of wristband and cardiopulmonary coupling (CPC) which measures sleep stability, are gaining in their popularity in recent years. The wristband, as a modified overnight pulse-oximetry, could measure and record heart rate, blood oxygen saturation and body position changes. It has been suggested that nocturnal pulse oximetry could provide screening for OSA and with the specificity and sensitivity insufficient for OSA diagnosis but still acceptable for OSA screening [8,9]. One potential reason is that children tend to move a lot during sleep, resulting in movement artifact [7]. The wristband we use could record body position changes, which would be taken into account by the algorithm.
Electrocardiogram (ECG)-based CPC analysis represents the stability of the sleep by measuring coupling between cardiac regulation and respiratory variation. As previously reported, overnight pulse-oximetry alone may aid in OSA diagnosis, which is less effective at ruling it out [10]. The validity of the CPC device has already been evaluated in adult OSA patients in several studies and inconsistent results were noted [11,12]. Its application in evaluating sleep quality among pediatric OSA patients has been previously reported [13]. Specifically, Lee et al. used both conventional sleep staging and CPC analysis to demonstrate postoperative changes in sleep quality in children with OSA and found that postoperative improvement of sleep quality was more readily discernible by CPC analysis than EEG-based sleep staging [13]. But its use in evaluating the severity of pediatric OSA has not been reported yet.
We hypothesized that the ODI3 recorded by SAST and AHI obtained by CPC are comparable with results of an overnight polysomnography. In this study, all patients had PSG, SAST and CPC simultaneously, and the results of three examinations and their correlations with patients’ clinical features were analyzed to further predict their diagnostic values for pediatric OSA patients.
Section snippets
Materials and methods
This was a prospective study approved by the Institutional Ethics Committee of Shanghai Children's Medical Center (SCMCIRB-K2017040).
Comparison between PSG and SAST in blood saturation monitoring
No statistically difference was noted in ODI3 between PSG and SAST through Wilcoxon matched-pairs signed-ranks test (Z = 1.384, P = 0.1664) nor in LsO2 through paired t-test (t = 0.5411, P = 0.589).However Bland-Altman analysis yielded insufficient consistency of ODI3 (P = 0.029) (Fig. 1A) and LsO2 (P = 0.001) (Fig. 1B) between PSG and SAST.
Comparison between AHI from PSG and CPC
The AHI obtained from CPC was significantly lower than that from PSG Wilcoxon matched-pairs signed-ranks test (Z = 6.902, P = 0.0000). Among the patients
Discussion
At present, it is widely acknowledged that nocturnal, attended, laboratory PSG is the gold standard for diagnosis of OSA because it provides an objective, quantitative evaluation of disturbances in respiratory and sleep patterns. It allows patients to be stratified in terms of severity by the indices of AHI and LsO2, which helps determine which children are at risk for sequelae, postoperative complications and persistence of OSA postoperatively [20,21]. But PSG requires a large amount of
Conclusion
SAST and CPC were both convenient and cost-effective for pediatric OSA screening. SAST is an acceptable fast tool in the assessments of blood oxygen desaturation and further in pediatric OSA screening. CPC is capable to screen severe pediatric OSA, but its results should be interpreted with caution for pediatric patients with non-severe OSA. The degree of adenoid and tonsillar hypertrophy may not be highly related to the severity of OSA.
Source of funding
This study was supported by National Natural Science Foundation (Grant No. NSFC81900939, to F. Z.) and Shanghai Science and Technology Committee (Grant No. 16411960700, to J.C.).
Declaration of competing interest
The authors have no conflicts of interest to declare.
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