Can Sleep and Wakefulness Be Distinguished in Children by Cardiorespiratory and Videotape Recordings?

doi:10.1378/chest.109.3.680

Chest

Volume 109, Issue 3, March 1996, Pages 680-687

https://doi.org/10.1378/chest.109.3.680 Get rights and content

Polysomnography, including EEG recording, is the standard method to diagnose obstructive sleep apnea (OSA) in children and adults. Diagnosis of OSA would be considerably simplified if it was shown that sleep could be distinguished from wakefulness without EEG recordings. Therefore, we compared sleep/wakefulness classification using a simplified cardiorespiratoryvideo (CRV) method with standard polysomnography in 20 children undergoing in-hospital evaluation for OSA. The channels for the simplified montage were chosen because they (1) were suitable for unattended, home recordings, (2) allowed the diagnosis of apneas, hypopneas, desaturation, and movement/arousals, and (3) did not require attachment to the head or face that might disturb the child's sleep. Sleep staging by the two methods was blinded to results of the other method. We evaluated 21,832 30-s epochs—1,092 ± 111 (SD) per child. Across 20 subjects, 79.7 ± 7.1% of the epochs were sleep. The simplified montage agreed with polysomnographic classification of sleep/wakefulness for 93.8 ± 2.5% of the epochs. Of all sleep epochs, 97.7 (96.4, 98.1%) median (interquartile range), were correctly classified; sleep predictive value of the CRV method was 95.2 ± 2.8%. Of all epochs classified as wakefulness by polysomnography, 80.1 ± 12.8% were correctly classified by the CRV method. The wakeful predictive value was 88.7 ± 2.6%. Kappa values averaged 0.8 ± 0.1, indicating that agreement between the CRV method and polysomnography did not occur by chance and that the level of agreement was excellent. Thus, sleep can be distinguished from wakefulness in children being evaluated for OSA using a combination of cardiorespiratory and videotape recordings. These results suggest that the CRV method would be useful in a pediatric laboratory setting where EEG recordings are not always possible. They also suggest that overnight, unattended CRV recordings in a child's own home could correctly distinguish sleep from wakefulness.

Section snippets

Subjects

The study population consisted of 20 pediatric patients referred to the Montreal Children's Hospital Sleep Laboratory to rule out OSA due to adenotonsillar hypertrophy. The first 12 children were consecutive patients who came to the laboratory for testing. The last eight children were selected because they had an apnea/hypopnea index greater than or equal to 5. None of the children had neuromuscular or craniofacial disorders that predispose to OSA. The mean (±SD) age was 5.6 ± 3.1 years with a

Results

A total of 21,832 30-s epochs were analyzed for S/W (1,092 ± 111 [SD] epochs per subject). Within the group, measures of OSA severity (apnea/hypopnea and desaturation indexes) varied widely. Likewise, there was marked variability in the movement/arousal index, a measure of sleep disturbance.²² Across 20 subjects, 79.7 ± 7.1 % of the epochs were polysomnographically staged as sleep.

Discussion

The present study demonstrates that S can accurately be distinguished from W in children being evaluated for OSA using a CRV method. The total concordance of 93.8% indicates an excellent agreement between the CRV method and polysomnography. The high level of agreement between the two CRV scorers with different levels of experience suggests that the scoring rules are reproducible. The kappa values, which account for agreement beyond chance, confirm this excellent agreement.²⁷ Our results

Conclusions

In summary, a CRV method for distinguishing S and W showed excellent agreement with standard polysomnography. Similar cardiorespiratory and videotape equipment is widely available. The recordings are easier to obtain and to score than polysomnography and do not require, but could use, specialized computerized processing.17, 33 Because there are no electrodes attached to the face or head, sleep and breathing may be more representative of the child's usual patterns.¹⁷

ACKNOWLEDGMENTS

The authors thank Lois Earle, Victoria Lafontaine, and Melodee A. Mograss for data collection and analysis; Rosanna Barrafato for assistance in preparing the manuscript; and Jennifer Morrison for preparation of the figures.

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To highlight Canada's contributions to the assessment and treatment of pediatric obstructive sleep apnea as well as outline the current state of pediatric obstructive sleep apnea in Canada.
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2018, Anales de Pediatria
El síndrome de apneas-hipopneas del sueño (SAHS) es altamente prevalente en la edad pediátrica y un problema importante de salud pública. Se pretende conocer la presentación clínica y polisomnográfica del SAHS infantil en nuestro medio.
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La mayoría de los niños estudiados tenían un IAH patológico. Casi la mitad presentaban sobrepeso/obesidad y un alto porcentaje tenía SAHS moderado-grave. El tratamiento más indicado fue la cirugía. La evolución clínica fue favorable en casi el 70%. Menos de un tercio con SAHS y sobrepeso/obesidad mejoraron el peso.
Obstructive sleep apnoea (OSA) is highly prevalent in children and a major public health problem. An attempt is made to determine the clinical and polysomnographic presentation of paediatric OSA in our area.
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The study included 234 children. OSA was found in 71.8%, with 42.3% moderate and 44.6% severe. The majority were male (60.7%) and the mean age 5 was years, of whom 78% were pre-school or school age. There was overweight/obesity in 44%, with 93.4% snoring, apnoea 84.5%, and 5.4% daytime sleepiness. There were 23 polysomnographies and 145 polygraphies, with a median apnoea/hypopnoea index (AHI) of 10, Sat.O2 minimum 84%, desaturation index 8, and mean sleep supine 53.65% and supine events 57.61%. Treatment was lifestyle modifications 29.2%, CPAP 6%, and surgery 42.9%. Improved snoring and/or apnoea 69.4%, and weight 32.4% of overweight/obesity children.
Most of the studied children had a pathological AHI. Almost half were overweight/obese, and a high percentage had moderate-severe OSA. Most frequent treatment was surgery. The clinical outcome was favourable in almost 70%. Less than a third with OSA and overweight/obesity improved weight.
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Citation Excerpt :
The finding that all of these children had at least partial obstruction is consistent with the belief that children more commonly have persistent partial upper airway obstruction (hypopneas) rather than discrete obstructive apneas [7]. In children, obstructive apneas are observed more frequently during rapid eye movement sleep [8], suggesting that DISE may not detect these completely, and this may also account for the absence of complete obstruction in 30% of these patients. We were able to compare overweight/obese children to those who were normal/underweight children, and found that the overweight/obese group was more likely to have obstruction at the tongue base.
Describe the patterns of obstruction in persistent pediatric OSA and their relationship with patient weight.
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All pediatric DISE procedures performed at a tertiary care hospital between October 2010 and October 2015 were reviewed. Patients had polysomnography after adenotonsillectomy that confirmed persistent obstructive sleep apnea (OSA). Variables included age, gender, co-morbidities, and AHI. DISE findings focused on inferior turbinates, adenoid, tongue base, epiglottis, aryepiglottic (AE) folds, arytenoids, lingual tonsil and their contributions to obstruction.
34 patients were included with mean age of 7.85 (2–16) years, mean BMI of 23.15 (13.6–44.8) and mean AHI of 6.34 (1.5–25.2) events per hour. Obstruction occurred at the level of the epiglottis in 97%, with retropositioning by tongue base (73.6%) or lingual tonsil enlargement (70.5%). Obstruction occurred at the inferior turbinates in 76.5%, the adenoid in 64.7% and the palate in 58.8%. Shortened AE folds were less often identified (15%). Multiple sites of partial or complete obstruction were found in 97% of patients. Overweight or obese patients had a mean of 3 sites of complete obstruction and 4.69 sites of partial or complete obstruction as compared to 2.33 and 4.52 in underweight or normal weight children. Overweight or obese children were more likely to have obstruction at the lingual tonsil or adenoid than normal/underweight children.
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Correlations between pediatric obstructive sleep apnea and longitudinal growth
2018, International Journal of Pediatric Otorhinolaryngology
Citation Excerpt :
Moreover, there are no previous studies on the effects of pediatric obstructive sleep apnea to growth in direct, not after upper-airway surgery. However, it seems paradoxical that growth-hormone secretion is affected, since children with OSA have normal amounts of slow-wave sleep (the sleep stage in which this hormone is secreted) [18,19]; moreover, episodes of airway obstruction usually predominate during rapid eye movement [20], which could bias this study's results. The first report correlating pediatric OSA and growth disturbance by Guilleminault et al. described a negative influence in eight patients [6].
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745 pediatric subjects with obstructive sleep apnea diagnosed by in-lab polysomnography were enrolled, after excluding ineligible subjects with abnormal growth related factors. Height, weight, and BMI of enrolled patients were measured and statistically converted to z-scores, and the converted data were analyzed statistically with the polysomnographic results. Multiple linear regression were used to analyze the relationships between age, gender, z-score for weight, polysomnography results, and z-score for height.
Patients with higher respiratory related index or lower mean/lowest oxygen saturation of PSG showed smaller z-score for height. Mean apnea hypopnea index and standard deviation of enrolled patients was 7.46 ± 12.92, with moderate severity. And mean z-score for height and standard deviation was 0.21 ± 1.15. Apnea hypopnea index, respiratory disturbance index, obstructive apnea index, and hypopnea index, respiratory related results of polysomnography, were statistically negative correlated with a z-score for height. And mean oxygen saturation and lowest oxygen saturation, oxygen saturation results of polysomnography, were statistically positive correlated with a z-score for height.
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Polysomnography (PSG) is the gold standard for the scoring of residual respiratory events during continuous positive airway pressure (CPAP). Studies comparing PSG scoring with automatic scoring by the built-in software of CPAP devices have reported acceptable agreements except for the hypopnea index (HI) in adult patients, but no study has yet been conducted in children. The aim of the present study was to compare the automatic scoring by CPAP device and manual scoring using the software tracings of the CPAP device integrating pulse oximetry (SpO₂) with in-lab polygraphy (PG).
Consecutive clinically stable children treated with constant CPAP (ResMed) for at least one month and scheduled for a nocturnal PG were recruited. A pulse oximeter was connected to the CPAP device. The PG apnea-hypopnea index (AHI_PG), scored according to modified AASM guidelines, was compared with the automatic AHI reported by the CPAP device (AHI_{A CPAP}) and the manual scoring of the AHI on the CPAP software (AHI_{M CPAP}).
Fifteen children (1.5–18.6 years) were included. Mean residual AHI_PG was 0.9 ± 1.2/hour (0.0–4.6/hour) vs. AHI_{A CPAP} of 3.6 ± 3.6/hour (0.5–14.7/hour) (p < 0.001), and AHI_{M CPAP} of 1.2 ± 1.6/hour (0.0–5.1/hour) (p = 0.01). Correlation between AHI_PG and AHI_{A CPAP} was good (r = 0.667; p = 0.007), and improved when considering AHI_{M CPAP} (r = 0.933; p < 0.001). Strong correlations were also observed between the PG apnea index (AI) and HI, and the manually scored AI and HI on CPAP, respectively.
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RP has been shown to underestimate the apnea–hypopnea index (AHI) in children when compared to PSG [6], mainly because of an incorrect estimation of total sleep time (TST). However, sleep and wakefulness can be accurately determined in children by using cardiorespiratory and videotape recordings [7], which reduce this discrepancy between PSG and RP. A second major problem when scoring obstructive respiratory events with RP is the absence of EEG, which precludes the detection of respiratory-related cortical arousals (RRCA) for the scoring of obstructive hypopneas.
The accuracy of respiratory polygraphy (RP) is limited because of the absence of electroencephalography (EEG). Pulse wave amplitude (PWA) reduction has been shown to be a marker of autonomic activation during arousal, and may represent a substitute for obstructive respiratory-related cortical arousal (RRCA). This study tested the hypothesis that PWA could be a surrogate for RRCA in detecting obstructive hypopnea (OH) in a pediatric population.
Two experienced readers scored 30 consecutive polysomnographies (PSG) using standard scoring rules. Automatic software detected every 20–90% reduction in PWA. A second scoring of respiratory events using PWA reduction as a surrogate for RRCA was performed (RP with PWA) for each percentage of PWA reduction. The final analysis consisted of determining the concordance between the two methods of detecting OH.
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Pulse wave amplitude reduction lacks sensitivity and specificity to be used as a surrogate for RRCA to detect OH in children. Polysomnography remains the gold standard for the diagnosis of sleep disordered breathing in children.

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Supported by the Canadian Foundation for the Study of Infant Deaths, McGill University/Montreal Children's Hospital Research Institute, and L'Association Pulmonaire du Québec.

revision accepted September 15.

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Chest

Clinical Investigations: Sleep and BreathingCan Sleep and Wakefulness Be Distinguished in Children by Cardiorespiratory and Videotape Recordings?

Section snippets

Subjects

Results

Discussion

Conclusions

ACKNOWLEDGMENTS

Electroencephalogr Clin Neurophysiol

Electroencephalogr Clin Neurophysiol

J Pediatr

Chest

Lancet

Lancet

Baseline sleep and recall studies in children

Psychophysiology

The differential laboratory adaptation of sleep parameters

Biol Psychiatry

Determination of sleep state in infants using respiratory variability

Pediatr Res

Definition of sleep state in the newborn infant by heart rate analysis

Am J Obstet Gynecol

Polygraphic studies of normal infants during the first 6 months of life: I Heart rate and variability as a function of state

Pediatr Res

Comparisons of home sleep recordings and polysomnograms in older adults with sleep disorders

Sleep

Ambulatory evaluation of sleep disturbance and therapeutic effects in sleep apnea syndrome by wrist activity monitoring

Am Rev Respir Dis

Wrist-actigraphic estimation of sleep time

Sleep

Actigraphically based automatic bedtime sleep-wake scoring: validity and clinical application

J Ambulatory Monitor

Actigraphic home-monitoring sleep-disturbed and control infants and young children: a new method for pediatric assessment of sleep/wake patterns

Pediatrics

Clinical Investigations: Sleep and Breathing
Can Sleep and Wakefulness Be Distinguished in Children by Cardiorespiratory and Videotape Recordings?