The Correlation of Computerized Scoring in Home Sleep Apnea Tests with Technician Visual Scoring for Assessing the Severity of Obstructive Sleep Apnea.

Background: Obstructive sleep apnea (OSA) affects a significant proportion of the global population, with many having moderate or severe forms of the disease. Home Sleep Apnea Testing (HSAT) has become the most common method of diagnosing OSA, replacing in-lab polysomnography. Polysmith software Version 11 by Nihon Kohden allows for the automatic scoring of respiratory events. This study aimed to assess the validity of this technology. Study Objectives: The objective was to assess the accuracy of the Polysmith Software Automatic Scoring Algorithm of HSATs in comparison to that of sleep technicians. Methods: One hundred twenty HSATs were scored by both sleep technicians and Polysmith software. The measured values were the respiratory event index (REI), apneic events, and hypopneic events. Agreement between the two methods was reached by utilizing the Kruskal-Wallis test, Pearson correlation coefficient, and Bland-Altman plot, as well as sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV). Results: The correlation between the REI calculated by the software and technicians proved to be strong overall (r = 0.96, p < 0.0001). The mild OSA group had a moderate correlation (r = 0.45, p = 0.0129). The primary snoring, moderate OSA, and severe OSA groups showed stronger correlations (r = 0.69, p < 0.0001; r = 0.56, p = 0.012; r = 0.71, p < 0.0001). The analysis conducted across all groups demonstrated an average sensitivity of 81%, specificity of 94%, PPV of 82%, and NPV of 94%, with an overall accuracy of 81%. When combining the moderate and severe OSA groups into a single category, the sensitivity was 90%, specificity was 100%, PPV was 100%, and NPV was 91%. Conclusions: OSA can be reliably diagnosed from HSATs with the automated Polysmith software across all OSA disease severity groups, with higher levels of accuracy in moderate/severe OSA and lower levels of accuracy in mild OSA.

Performance evaluation of portable respiratory polygraphy for assessing sleep bruxism in adults.

BACKGROUND: Polysomnography (PSG) is the gold standard for sleep bruxism (SB) assessment, it is expensive, not widely accessible, and time-consuming. OBJECTIVE: Given the increasing prevalence of SB, there is a growing need for an alternative, readily available, reliable and cost-effective diagnostic method. This study aimed to evaluate the diagnostic validity of portable respiratory polygraphy (PRPG) compared with PSG for SB diagnosis. METHODS: One hundred and three subjects underwent simultaneous examinations using PRPG (NOX T3, NOX Medical) and PSG (NOX A1, NOX Medical) in a sleep laboratory. RESULTS: The mean Bruxism Episodes Index (BEI) measured by PRPG was 4.70 ± 3.98, whereas PSG yielded a mean BEI of 3.79 ± 3.08. The sensitivity for detecting sleep bruxism (BEI >2) by PRPG was 48.3%, with a specificity of 81.2%. The positive predictive value was estimated at 51.9%, and the negative predictive value at 78.9%. However, when distinguishing between mild bruxism (BEI >2 < 4) and severe bruxism (BEI >4), PRPG demonstrated a sensitivity of 77.8% and 68.3% and a specificity of 48.6% and 71.4%, respectively. CONCLUSION: Polysomnography continues to be the SB diagnostic gold standard tool, as the sensitivity and specificity of PRPG are significantly lower when compared with PSG. Nevertheless, PRPG could serve as an alternative tool for SB screening or diagnosis, despite its limitations. Furthermore, our data indicate that comorbidities such as sleep apnea and sleep quality do not influence the diagnostic accuracy of PSG, suggesting its potential as a screening instrument in individuals with other sleep disorders.

Telemedicine management of obstructive sleep apnea disorder in China: a randomized, controlled, non-inferiority trial.

PURPOSE: Previous studies assessed different components of telemedicine management pathway for OSA instead of the whole pathway. This randomized, controlled, and non-inferiority trial aimed to assess whether telemedicine management is clinically inferior to in-person care in China. METHODS: Adults suspected of OSA were randomized to telemedicine (web-based questionnaires, self-administered home sleep apnea test [HSAT], automatically adjusting positive airway pressure [APAP], and video-conference visits) or in-person management (paper questionnaires, in-person HSAT set-up, APAP, and face-to-face visits). Participants with an apnea-hypopnea index (AHI) ≥ 15 events/hour received APAP for 3 months. The non-inferiority analysis was based on the change in Functional Outcomes of Sleep Questionnaire (FOSQ) score and APAP adherence. Cost-effectiveness analysis was performed. RESULTS: In the modified intent-to-treat analysis set (n = 111 telemedicine, 111 in-person), FOSQ scores improved 1.73 (95% confidence interval [CI], 1.31-2.14) points with telemedicine and 2.05 (1.64-2.46) points with in-person care. The lower bound of the one-sided 95% non-inferiority CI for the difference in change between groups of - 0.812 was larger than the non-inferiority threshold of - 1. APAP adherence at 3 months was 243.3 (223.1-263.5) minutes/night for telemedicine and 241.6 (221.3-261.8) minutes/night for in-person care. The lower bound of the one-sided 95% non-inferiority CI of - 22.2 min/night was higher than the non-inferiority delta of - 45 min/night. Telemedicine had lower total costs than in-person management (CNY 1482.7 ± 377.2 vs. 1912.6 ± 681.3; p < 0.0001), driven by patient costs, but no significant difference in QALYs. CONCLUSIONS: Functional outcomes and adherence were not clinically inferior in patients managed by a comprehensive telemedicine approach compared to those receiving in-person care in China. CLINICAL TRIAL REGISTRATION: https://www.chictr.org.cn , Registration number ChiCTR2000030546. Retrospectively registered on March 06, 2020.

Home sleep apnea tests: Conflicts of interest and funding.

OBJECTIVE: Pediatric otolaryngologists rely on HSAT literature to guide their diagnostic methods related to obstructive sleep apnea (OSA). Our objectives were to review the rates of presence of funding and/or potential conflict of interest (COI), as well as its relationship to the overall quality of HSAT publications in the literature over the last two decades. DATA SOURCES: Medline, Web of Science and Embase databases. REVIEW METHODS: A review was performed reviewing publications from January 2000 to December 2021. Oxford Level of Evidence (OLE) was used as a quality metric. COI and funding were recorded verbatim as self-declared in the text of the manuscript. RESULTS: Literature search yielded 4257 articles with 400 articles included in final analysis. The odds of higher quality studies (LOE 1 or 2) were higher in the last five years from 2016 to 2021 (OR, 3.6; 95% CI 1.4 to 6.9). Nearly half of all articles (43.0%) lacked a statement regarding funding or COI. There was a positive correlation between level of evidence and industry funding. The largest source of funding was from industry, comprising 39.6% of all studies that had a funding statement. Of these industry-funded studies, 37.5% reported no COI or lacked a COI statement. CONCLUSION: Despite a growing interest in HSATs for OSA evaluation, there is heterogeneity in reporting of COI and high prevalence of industry funding and COI. Re-evaluation and consensus amongst journals on guidelines for reporting disclosures are needed.

Autonomic arousal detection and cardio-respiratory sleep staging improve the accuracy of home sleep apnea tests.

Introduction: The apnea-hypopnea index (AHI), defined as the number of apneas and hypopneas per hour of sleep, is still used as an important index to assess sleep disordered breathing (SDB) severity, where hypopneas are confirmed by the presence of an oxygen desaturation or an arousal. Ambulatory polygraphy without neurological signals, often referred to as home sleep apnea testing (HSAT), can potentially underestimate the severity of sleep disordered breathing (SDB) as sleep and arousals are not assessed. We aim to improve the diagnostic accuracy of HSATs by extracting surrogate sleep and arousal information derived from autonomic nervous system activity with artificial intelligence. Methods: We used polysomnographic (PSG) recordings from 245 subjects (148 with simultaneously recorded HSATs) to develop and validate a new algorithm to detect autonomic arousals using artificial intelligence. A clinically validated auto-scoring algorithm (Somnolyzer) scored respiratory events, cortical arousals, and sleep stages in PSGs, and provided respiratory events and sleep stages from cardio-respiratory signals in HSATs. In a four-fold cross validation of the newly developed algorithm, we evaluated the accuracy of the estimated arousal index and HSAT-derived surrogates for the AHI. Results: The agreement between the autonomic and cortical arousal index was moderate to good with an intraclass correlation coefficient of 0.73. When using thresholds of 5, 15, and 30 to categorize SDB into none, mild, moderate, and severe, the addition of sleep and arousal information significantly improved the classification accuracy from 70.2% (Cohen's κ = 0.58) to 80.4% (κ = 0.72), with a significant reduction of patients where the severity category was underestimated from 18.8% to 7.3%. Discussion: Extracting sleep and arousal information from autonomic nervous system activity can improve the diagnostic accuracy of HSATs by significantly reducing the probability of underestimating SDB severity without compromising specificity.

Sleep apnea severity in patients undergoing atrial fibrillation ablation: Home sleep apnea-test and polysomnography comparison.

Background: Sleep apnea (SA) is highly prevalent and should be treated in patients referred for catheter ablation (CA) of atrial fibrillation (AF). Watch-type peripheral arterial tonometry (WP) for home SA testing has demonstrated a high correlation of the apnea-hypopnea index (AHI) with Polysomnography (PSG), but the evidence of its accuracy in AF patients is not adequate. Methods: This study was conducted under a retrospective, single-center, observational design. We included 464 consecutive AF patients (age 65 ± 11 years, 76.5% male, 45.0% paroxysmal-AF) who received both WP and PSG during the periprocedural period of the CA. We compared the AHI using the WP (WP-AHI) to that using PSG (PSG-AHI). Results: The WP-AHI was 25.9 ± 12.7 and PSG-AHI 31.4 ± 18.9 (r = .48). Among 325 patients with a WP-AHI < 30, 116 (35.7%) exhibited a PSG-AHI ≥ 30. Only 12.5% of the patients were indicated for continuous positive airway pressure (CPAP) treatment only by the WP-AHI, while 70.9% were indicated for CPAP by the PSG-AHI according to the Japanese health insurance system. The best cut-off value of the WP-AHI was 18.1 to predict a PSG-AHI ≥ 20 with an area under the curve of 0.72 (95% confidence interval, 0.67-0.76). Conclusions: The WP-AHI and PSG-AHI were weakly correlated in AF patients receiving CA. About one-third of the patients with moderate SA using the WP was diagnosed with severe SA evaluated by PSG. The majority required PSG for the CPAP indication.

Economic evaluation of telemonitoring as a follow-up approach for patients with obstructive sleep apnea syndrome starting treatment with continuous positive airway pressure.

Telemonitoring of obstructive sleep apnea patients is increasingly being adopted though its cost-effectiveness evidence base is scanty. This study investigated whether telemonitoring is a cost-effective strategy compared with the standard follow-up in patients with obstructive sleep apnea who are starting continuous positive airway pressure treatment. In total, 167 obstructive sleep apnea patients were randomised into telemonitoring (n = 79) or standard follow-up (n = 88), initiated continuous positive airway pressure treatment, and were followed up for 6 months. The frequencies of healthcare contacts, related costs (in USD 2021 prices), treatment effect and compliance were compared between the follow-up approaches using generalised linear models. The cost effectiveness analysis was conducted from a healthcare perspective and the results presented as cost per avoided extra clinic visit. Additionally, patient satisfaction between the two approaches was explored. The analysis showed no baseline differences. At follow-up, there was no significant difference in treatment compliance, and the mean residual apnea-hypoapnea index. There was no difference in total visits, adjusted incidence rate ratio 0.87 (0.72-1.06). Participants in the telemonitoring arm made eight times more telephone visits, 8.10 (5.04-13.84), and about 73% fewer physical healthcare visits 0.27 (0.20-0.36). This translated into significantly lower total costs for the telemonitoring approach compared with standard follow-up, -192 USD (-346 to -41). The form of follow-up seemed to have no impact on the extent of patient satisfaction. These results demonstrate the telemonitoring of patients with obstructive sleep apnea initiating continuous positive airway pressure treatment as a cost saving strategy and can be argued as a potential worthy investment.

Positive airway pressure treatment for sleep-disordered breathing is rare during the first year after stroke: The BASIC project.

OBJECTIVE/BACKGROUND: Sleep-disordered breathing (SDB) is very common after ischemic stroke, and its treatment may have a positive impact on recovery from stroke and on secondary stroke prevention. This study sought to determine the prevalence of positive airway pressure (PAP) use after stroke. PATIENTS/METHODS: Participants in the Brain Attack Surveillance in Corpus Christi (BASIC) project underwent a home sleep apnea test shortly after ischemic stroke. Demographics and co-morbidities were ascertained from the medical record. Self-reported PAP use (present vs absent) was assessed at 3, 6, and 12 months after stroke. Fisher exact tests and t-tests were used to compare PAP users versus non-users. RESULTS: Of 328 participants who were found to have SDB after stroke, only 20 (6.1%) indicated using PAP at any point during the 12-month follow up period. High pre-stroke sleep apnea risk based on Berlin Questionnaire score, neck circumference, and co-morbid atrial fibrillation were associated with any self-reported PAP use; race/ethnicity, insurance status and other demographic variables were not associated with PAP use. CONCLUSIONS: Only a small proportion of individuals with ischemic stroke and SDB received treatment with PAP during the initial year after stroke among participants in this population-based cohort study in Nueces County, Texas. Closing the substantial treatment gap for SDB after stroke might improve sleepiness and neurologic recovery.

Diagnosis of obstructive sleep apnea using a bio-radar contact-free system compared with an established HST device in older adults.

GOAL AND AIMS: To compare a bio-radar contact-free monitoring device in diagnosing obstructive sleep apnea (OSA) in older people with an established home sleep apnea testing system (HST). FOCUS METHOD/TECHNOLOGY: A bio-radar contact-free monitoring device (OrbSense+). REFERENCE METHOD/TECHNOLOGY: An established HST, Alice NightOne. SAMPLE: Fifty-three out of 63 recruited subjects were included in the final analysis. Seventy-two percent were male (age 72 ± 9 years; body mass index 31.05 ± 5.56 kg/m2). DESIGN: An observational, prospective study. CORE ANALYTICS: Intraclass correlation coefficient (ICC), Bland-Altman analysis, and receiver operating characteristic analysis. ADDITIONAL ANALYTICS AND EXPLORATORY ANALYSES: None. CORE OUTCOMES: Both 45 (84.91%) were diagnosed with OSA by Alice NightOne (average respiratory event index = 21.23 events/h) and by OrbSense+ (average respiratory event index = 25.98 events/h). Respiratory event index and oxygen desaturation index obtained by Alice NightOne and OrbSense+ were highly correlated, with ICC of 0.93 and 0.88, respectively. The Bland-Altman plot comparing the means showed good agreement between the 2 diagnostic techniques. With more than 5 respiratory events per hour as the standard for OSA diagnosis, OrbSense+ had a sensitivity of 100% and a specificity of 100% in diagnosis of OSA (P < .0001). With more than 15 respiratory events per hour as the standard for OSA diagnosis, OrbSense+ was found to have a sensitivity of 100% and a specificity of 86.96% in diagnosis of OSA (P < .0001). IMPORTANT ADDITIONAL OUTCOMES: None. CORE CONCLUSION: The bio-radar sleep monitoring device is a reasonably accurate home sleep apnea test for use in older patients.

Interaction between alcohol consumption and use of peripheral arterial tone home sleep apnea tests for sleep apnea evaluation.

OBJECTIVE/BACKGROUND: Home sleep apnea tests utilizing peripheral arterial tone (PAT HSAT) detect sleep disordered breathing by measuring various physiologic measures including changes in arterial volume in the finger. Validation tests comparing PAT HSAT to simultaneous polysomnography (PSG) have demonstrated a high correlation. Alcohol increases peripheral vasodilation, which may alter arterial tone in the finger. Validation studies have not evaluated for an interaction between alcohol consumption and PAT HSAT measures. PATIENTS/METHODS: We describe an in-depth evaluation of a 53-year-old man who consumes alcohol on nightly basis. He underwent a series of 5 diagnostic studies under different conditions: three PAT HSATs (two nights with and another without alcohol) and two polysomnograms (one night with and another without alcohol). RESULTS: Obstructive sleep apnea (OSA) was found on both polysomnograms but only on the PAT HSAT without alcohol, raising the possibility of two false negative PAT HSAT results after alcohol consumption. CONCLUSIONS: This report demonstrates the need for further investigations into the performance of PAT HSATs with and without alcohol. In the meantime we recommend that testing be done without alcohol and over the course of multiple nights.

Moving toward standardization: physician reporting of sleep studies.

Detailed primary data collected from sleep studies should lead to specific and clear reports with evidence-based clinical recommendations that, when introduced by sleep medicine specialists, create a window of opportunity to support our non-sleep medicine referring teams and to engage patients and caregivers in their care as recipients of the reports. This is how sleep study reporting differs from other test reports; currently, there is wide variation in how the data collected are presented and summarized. The goal of this document is to offer recommendations for structured reporting of sleep studies. We offer a practical, complete, and relevant document and a structure that can be implemented across sleep centers nationwide and does not burden the interpreter. We anticipate some readers will opine that some of the content is beyond the scope of what the interpreter physician needs to include, while others will propose missing data that they feel should have been included. We feel that the flexibility of the proposal accommodates for this and allows for a "first step" toward standardization of physician reporting of sleep studies. High-quality structured reporting of sleep studies is becoming ever more important for patient care, benefiting patients, caregivers, clinicians, durable medical equipment companies, and payers. CITATION: Lastra AC, Ingram D, Park J, et al. Moving toward standardization: physician reporting of sleep studies. J Clin Sleep Med. 2023;19(3):595-603.

The mobile sleep medicine model in neurologic practice: Rationale and application.

Background: Undiagnosed obstructive sleep apnea (OSA) is prevalent in neurological practice and significantly contributes to morbidity and mortality. OSA is prevalent in US adults and causes poor quality sleep and significant neurocognitive, cardiovascular, and cerebrovascular impairments. Timely treatment of OSA reduces cardio-cerebrovascular risks and improves quality of life. However, most of the US population has limited systematic access to sleep medicine care despite its clinical significance. Focus: We discuss the importance of systematic screening, testing, and best-practice management of OSA and hypoventilation/hypoxemia syndromes (HHS) in patients with stroke, neurocognitive impairment, and neuromuscular conditions. This review aims to introduce and describe a novel integrated Mobile Sleep Medicine (iMSM) care model and provide the rationale for using an iMSM in general neurological practice to assist with systematic screening, testing and best-practice management of OSA, HHS, and potentially other sleep conditions. Key points: The iMSM is an innovative, patient-centered, clinical outcome-based program that uses a Mobile Sleep Medicine Unit-a "sleep lab on wheels"-designed to improve access to OSA management and sleep care at all levels of health care system. The protocol for the iMSM care model includes three levels of operations to provide effective and efficient OSA screening, timely testing/treatment plans, and coordination of further sleep medicine care follow-up. The iMSM care model prioritizes effective, efficient, and patient-centered sleep medicine care; therefore, all parties and segments of care that receive and provide clinical sleep medicine services may benefit from adopting this innovative approach.

In-person vs video hookup instructions: a comparison of home sleep apnea testing quality.

STUDY OBJECTIVES: The high prevalence of obstructive sleep apnea (OSA) in the general population makes diagnosing OSA a high priority. Typically, patients receive in-person instructions to hook up the home sleep apnea test devices. Using recorded video instructions would save health care personnel time and improve access to OSA diagnostics for patients in remote areas. The aim of this study was to compare the quality of home sleep apnea test recordings when using in-person and video hookup instructions in a randomized study. METHODS: A total of 100 patients aged 18 to 70 years with suspected OSA were randomized to receive either in-person or video hookup instructions for the Nox T3 device (Nox Medical, Reykjavik, Iceland). The overall quality of the resulting sleep studies was analyzed by determining the number of technically invalid studies. The recording quality of 4 sensors (pulse oximeter, nasal cannula, thorax and abdominal respiratory inductance plethysmography belts) was assessed by checking for signal artifacts. RESULTS: No significant difference was found between the 2 groups in any quality index. Only 1 (2%) and 2 (3.9%) sleep studies were technically invalid in the in-person and video instructions group, respectively. The average ± standard deviation recording quality of the 4 sensors combined was 94.8% ± 13.6% for the in-person and 96.0% ± 11.0% for the video instructions group. CONCLUSIONS: This study found no difference in home sleep apnea test recording quality between the 2 groups. Video hookup instructions are therefore viable and an important step toward a telemedicine-based way of diagnosing OSA. CITATION: Horne AF, Olafsdottir KA, Arnardottir ES. In-person vs video hookup instructions: a comparison of home sleep apnea testing quality. J Clin Sleep Med. 2022;18(8):2069-2074.

Detection of Common Arrhythmias by the Watch-PAT: Expression of Electrical Arrhythmias by Pulse Recording.

Background: The WatchPAT (WP) device was shown to be accurate for the diagnosis of sleep apnea and is widely used worldwide as an ambulatory diagnostic tool. While it records peripheral arterial tone (PAT) and not electrocardiogram (ECG), the ability of it to detect arrhythmias is unknown and was not studied previously. Common arrhythmias such as atrial fibrillation (AF) or premature beats may be uniquely presented while recording PAT/pulse wave. Purpose: To examine the potential detection of common arrhythmias by analyzing the PAT amplitude and pulse rate/volume changes. Patients and Methods: Patients with suspected sleep disordered breathing (SDB) were recruited with preference for patients with previously diagnosed AF or congestive heart failure (CHF). They underwent simultaneous WP and PSG studies in 11 sleep centers. A novel algorithm was developed to detect arrhythmias while measuring PAT and was tested on these patients. Manual scoring of ECG channel (recorded as part of the PSG) was blinded to the automatically analyzed WP data. Results: A total of 84 patients aged 57±16 (54 males) participated in this study. Their BMI was 30±5.7Kg/m2. Of them, 41 had heart failure (49%) and 17 (20%) had AF. The sensitivity and specificity of the WP to detect AF segments (of at least 60 seconds) were 0.77 and 0.99, respectively. The correlation between the WP derived detection of premature beats (events/min) to that of the PSG one was 0.98 (p<0.001). Conclusion: The novel automatic algorithm of the WP can reasonably detect AF and premature beats. We suggest that when the algorithm raises a flag for arrhythmia, the patients should shortly undergo ECG and/or Holter ECG study.

Continuous Positive Airway Pressure Adherence and Treatment Cost in Patients With Obstructive Sleep Apnea and Cardiovascular Disease.

Objective: To determine whether continuous positive airway pressure (CPAP) adherence reduces health care-related costs or use in patients with obstructive sleep apnea (OSA) and comorbid cardiovascular disease (CVD). Patients: A total of 23 million patients with CVD were identified in the Medicare fee-for-service database. Of the 65,198 who completed a sleep study between January 2016 and September 2018, 55,125 were diagnosed as having OSA and 1758 were identified in the 5% Medicare durable medical equipment (DME) database. Methods: Patients with DME claims were categorized as adherent (AD, treatment evidenced ≥91 days after CPAP initiation; n=614) or nonadherent (nAD, n=242) to CPAP therapy. In addition, 9881 individuals with CVD who were not diagnosed as having OSA after sleep testing and without CPAP initiation were included as control patients. Propensity score matching balanced the groups for age, sex, and comorbidities (eg, diabetes mellitus), resulting in 241 participants per cohort. Dependent variables included total episode-of-care, inpatient, outpatient, skilled nursing, home health, and DME costs across 12 months. Results: Total episode-of-care costs of AD participants ($6825) were lower than those of nAD ($11,312; P<.05) and control ($8102) participants. This difference (Δ) was attributable to fewer outpatient expenses (Δ$2290; P<.05) relative to the nAD group and fewer inpatient expenses (Δ$745) relative to the control group because skilled nursing costs were comparable between groups (P=.73). Conclusion: Adherence to CPAP treatment reduces annual health care-related expenses by 40% in Medicare patients with CVD and OSA.

A new tool to screen patients with severe obstructive sleep apnea in the primary care setting: a prospective multicenter study.

BACKGROUND: The coordination between different levels of care is essential for the management of obstructive sleep apnea (OSA). The objective of this multicenter project was to develop a screening model for OSA in the primary care setting. METHODS: Anthropometric data, clinical history, and symptoms of OSA were recorded in randomly selected primary care patients, who also underwent a home sleep apnea test (HSAT). Respiratory polygraphy or polysomnography were performed at the sleep unit to establish definite indication for continuous positive airway pressure (CPAP). By means of cross-validation, a logistic regression model (CPAP yes/no) was designed, and with the clinical variables included in the model, a scoring system was established using the ß coefficients (PASHOS Test). In a second stage, results of HSAT were added, and the final accuracy of the model was assessed. RESULTS: 194 patients completed the study. The clinical test included the body mass index, neck circumference and observed apneas during sleep (AUC 0.824, 95% CI 0.763-0.886, P < 0.001). In a second stage, the oxygen desaturation index (ODI) of 3% (ODI3% ≥ 15%) from the HSAT was added (AUC 0.911, 95% CI 0.863-0.960, P < 0.001), with a sensitivity of 85.5% (95% CI 74.7-92.1) and specificity of 67.8% (95% CI 55.1-78.3). CONCLUSIONS: The use of this model would prevent referral to the sleep unit for 55.1% of the patients. The two-stage PASHOS model is a useful and practical screening tool for OSA in primary care for detecting candidates for CPAP treatment. Clinical Trial Registration Registry: ClinicalTrials.gov; Name: PASHOS Project: Advanced Platform for Sleep Apnea Syndrome Assessment; URL: https://clinicaltrials.gov/ct2/show/NCT02591979 ; Identifier: NCT02591979. Date of registration: October 30, 2015.

Prevalence and effects of sleep-disordered breathing on middle-aged patients with sedative-free generalized anxiety disorder: A prospective case-control study.

Objective: Generalized anxiety disorder (GAD) and sleep-disordered breathing (SDB) share similar symptoms, such as poor sleep quality, irritability, and poor concentration during daily activities. This study aims to investigate the proportion of undiagnosed SDB and its impacts on anxiety severity and autonomic function in newly diagnosed, sedative-free GAD patients. Methods: This prospective case-control study included newly diagnosed GAD patients and control participants with matched age, sex, and body mass index (BMI) in Taiwan. All participants completed questionnaires for sleep and mood symptoms and a resting 5-min heart rate variability (HRV) examination during enrollment. The participants also used a home sleep apnea test to detect SDB. An oxygen desaturation index (ODI) ≥ 5 was considered indicative of SDB. Results: In total, 56 controls and 47 newly diagnosed GAD participants (mean age 55.31 ± 12.36 years, mean BMI 23.41 ± 3.42 kg/m2) were included. There was no significant difference in the proportion of undiagnosed SDB in the control and sedative-free GAD groups (46.43 vs. 51.06%). Sedative-free GAD patients with SDB scored significantly higher on Beck Anxiety Inventory (23.83 ± 11.54) than those without SDB (16.52 ± 10.61) (p < 0.001). Both control and sedative-free GAD groups with SDB had worse global autonomic function than the control group without SDB, as evidenced by the HRV results (p < 0.05 for all). Conclusion: Average age 55 years and mean BMI 23 kg/m2 patients with GAD and matched controls had an undiagnosed SDB prevalence of approximately 50%. SDB correlated with worsening anxiety severity and reduced cardiac autonomic function. Moreover, age and BMI were considered major risk factors for predicting undiagnosed SDB.

Clinical application of home sleep apnea testing in children: a prospective pilot study.

STUDY OBJECTIVES: (1) To determine the sensitivity and specificity of the home sleep apnea test (HSAT) performed in typically developing children who were diagnosed with moderate to severe obstructive sleep apnea during overnight attended laboratory polysomnography (LPSG). (2) To determine the utility of a screening questionnaire to identify children at increased risk for obstructive sleep apnea. METHODS: Participants completed 2 consecutive study nights, the first night with the HSAT followed by LPSG on the second night. The SHOOTS questionnaire, composed of 6 questions (snoring, hyperactivity, obesity, observed apnea, tonsillar hypertrophy, and sleepiness) concerning sleep-disordered breathing, was administered by the clinician before the first study night. RESULTS: Thirty-eight participants completed both studies. The mean age was 13.8 ± 3.0 years. Twenty (53%) were male. Most participants were obese. The mean LPSG total sleep time was 7.34 ± 1.19 hours; the mean HSAT total recording time was 8.86 ± 1.73 hours (P < .001). The median obstructive apnea-hypopnea index for LPSG and HSAT was 6.6 and 0.8 events/h, respectively. For an obstructive apnea-hypopnea index ≥ 3.1 events/h by HSAT, the sensitivity was 71.43% (95% confidence interval, 41.9-91.6) and the specificity was 95.83% (95% confidence interval, 78.9-99.9) for identifying those with an LPSG obstructive apnea-hypopnea index of ≥ 10 events/h. For a SHOOTS score with ≥ 4 "yes" responses, the sensitivity and specificity were 85.7% (95% confidence interval, 57.2-98.2) and 54.2% (95% confidence interval, 32.8-74.4), respectively, for identifying those with an LPSG obstructive apnea-hypopnea index ≥ 10 events/h. CONCLUSIONS: Using HSAT, we clinically applied cutoff values to identify moderate to severe obstructive sleep apnea in typically developing children. The SHOOTS questionnaire may aid in identifying children at risk for obstructive sleep apnea and who are candidates for HSAT. CITATION: Revana A, Vecchio J, Guffey D, Minard CG, Glaze DG. Clinical application of home sleep apnea testing in children: a prospective pilot study. J Clin Sleep Med. 2022;18(2):533-540.

Analysis of nocturnal desaturation waveforms using algorithms in patients with idiopathic pulmonary fibrosis.

PURPOSE: Sleep-disordered breathing is recognized as a comorbidity in patients with idiopathic pulmonary fibrosis (IPF). Among them, nocturnal hypoxemia has been reported to be associated with poor prognosis and disease progression. We developed a diagnostic algorithm to classify nocturnal desaturation from percutaneous oxygen saturation (SpO2) waveform patterns: sustained pattern, periodic pattern, and intermittent pattern. We then investigated the prevalence of nocturnal desaturation and the association between the waveform patterns of nocturnal desaturation and clinical findings of patients with IPF. METHODS: We prospectively enrolled patients with IPF from seven general hospitals between April 2017 and March 2020 and measured nocturnal SpO2 and nasal airflow by using a home sleep apnea test. An algorithm was used to classify the types of nocturnal desaturation. We evaluated the association between sleep or clinical parameters and each waveform pattern of nocturnal desaturation. RESULTS: Among 60 patients (47 men) who met the eligibility criteria, there were 3 cases with the sustained pattern, 49 cases with the periodic pattern, and 41 cases with the intermittent pattern. Lowest SpO2 during sleep and total sleep time spent with SpO2 < 90% were associated with the sustained pattern, and apnea-hypopnea index was associated with the intermittent pattern. CONCLUSION: We demonstrated the prevalence of each waveform and association between each waveform and sleep parameters in patients with IPF. This classification algorithm may be useful to predict the degree of hypoxemia or the complication of obstructive sleep apnea.

A Single-Center Validation of the Accuracy of a Photoplethysmography-Based Smartwatch for Screening Obstructive Sleep Apnea.

BACKGROUND: Obstructive sleep apnea (OSA), the most common upper-airway disease, is closely associated with the risk of cardiovascular diseases. However, the early screening of OSA is a main challenge, relying on polysomnography (PSG) or home sleep apnea test (HSAT) in hospitals. Photoplethysmography (PPG) has been developed as a novel technology for screening of OSA, while the validation of PPG-based smart devices is limited compared to that for PSG or HSAT devices. OBJECTIVE: This study aimed to investigate the feasibility and validity of a PPG-based smartwatch in the screening of OSA. METHODS: A total of 119 patients were recruited from the Chinese People's Liberty Army General Hospital (Beijing, China). Among them, 20 patients were assessed for a whole-night sleep study by a smartwatch and PSG simultaneously, as well as 82 cases by a smartwatch and HSAT simultaneously. Using PSG or HSAT as the "gold standard", we compared the accuracy, sensitivity, specificity, negative predictive value (NPV), positive predictive value (PPV), and positive likelihood ratio (+LR) or negative likelihood ratio (-LR) at three apnea hypopnea index (AHI) levels: AHI≥5, AHI≥15, and AHI≥30. RESULTS: A total of 17/119 patients were excluded from the study due to the poor quality of PPG signals. Among the remaining cases, 83 patients were diagnosed with OSA. Compared to HSAT device, the accuracy, sensitivity, and specificity of the PPG-based smartwatch in predicting moderate-to-severe OSA patients (AHI≥15) were 87.9%, 89.7%, and 86.0%, respectively. Compared to PSG device, the accuracy, sensitivity, and specificity of the PPG-based smartwatch in predicting OSA in patients (AHI≥5) were 81.1%, 76.5%, and 100%, respectively. CONCLUSION: The PPG-based smartwatch outperformed in terms of detecting OSA; nevertheless, validation in a large-scale population is imperative. TRIAL REGISTRATION: Chinese Clinical Trial Registry of the International Clinical Trials Registry Platform of the World Health Organization ChiCTR-OOC-17014138; http://www.chictr.org.cn/showprojen.aspx?proj=24191.