Mild to Moderate Sleep Respiratory Events: One Negative Night May Not Be Enough

doi:10.1378/chest.118.2.353

Chest

Volume 118, Issue 2, August 2000, Pages 353-359

https://doi.org/10.1378/chest.118.2.353 Get rights and content

Study objectives

Reports on the reproducibility of apnea-hypopnea indexes (AHIs) across sequential polysomnography (PSG) sessions are conflicting, leading to a lack of clear recommendations on the optimal use of this technique: is one night of monitoring sufficient or is a second night required in order to safely reject the diagnosis?

Design

Retrospective comparison of two consecutive nights.

Setting

Sleep unit of a tertiary-care facility.

Patients

Two hundred forty-three subjects with suspected sleep apneas.

Interventions

Two sequential PSG sessions in a sleep unit.

Measurements and results

Using analysis of covariance for repeated measures, with age and body mass index as covariates and gender as a cofactor, a classic first-night effect was found for sleep variables. In addition, a night effect was demonstrated for sleep respiratory variables. Moreover, the high variability of AHIs showed that many patients had their condition diagnosed on only one of the two nights, and more often on the second night than on the first. The gain in detection by adding a second night when the results of testing on the first were negative was between 15% and 25%, according to the AHI obtained on night 1.

Conclusions

Considering the disability associated with sleep apnea/hypopnea syndrome, as well as its global cost for society, the present study shows that it is worth performing two consecutive PSG sessions or at least a second one when the result of the first one is negative in all patients admitted for apnea detection.

Section snippets

Patients

Two hundred forty-three patients were admitted to the Brugmann Hospital Sleep Unit between 1992 and 1998 for the exclusion of SAHS. They presented with excessive daytime sleepiness, fatigue, snoring, or a description by their spouse of respiratory interruptions during sleep. They were referred by pneumology, ear-nose-throat, or sleep disorders outpatient clinics or were self-referred. There were no exclusion criteria, since the object was to describe the sample in a natural way. Patients were

Results

Two hundred forty-three patients entered the study (mean[± SD] age, 48.4 ± 11.9; men, 179 [74%]; mean BMI, 28.7 ± 5.8). One hundred one patients had AHIs ≥ 20 on N1, and 74 of them tried an nCPAP device on N2. Unpaired t tests performed between patients with AHIs > 20 who underwent a nCPAP trial (n = 74) and those who did not (n = 27) showed no significant difference in AHIs on N1. Only the subgroup of 169 patients who did not use a nCPAP device on N2 (mean age, 47.2 ± 12.1; men, 113 [67%];

Discussion

In this comparison of two sequential nights of PSG recordings in patients suspected of SAHS, a typical FNE was found, including a reduction of NREMS and stage-shift values, which are less consistently observed in studies on FNEs. Though a partial FNE has been observed before in patients evaluated for possible SAHS, this is the first time that a full FNE clearly has been demonstrated, taking into account the potential influences of age, BMI, and AHI.

Similarly, sleep respiratory events, measured

ACKNOWLEDGMENTS

The authors thank Anita Bessemans and Marleen Bocken for their meticulous scoring of PSG sessions.

References (18)

RJ Dean et al.
Negative polysomnogram in patients with obstructive sleep apnea syndrome
Chest
(1992)
TJ Meyer et al.
One negative polysomnogram does not exclude obstructive sleep apnea
Chest
(1993)
DL Bliwise et al.
Factors associated with nightly variability in sleep-disordered breathing in the elderly
Chest
(1991)
WR Aber et al.
Consistency of respiratory measurements from night-to-night during the sleep of elderly men
Chest
(1989)
RM Wittig et al.
Night-to-night consistency of apneas during sleep
Am Rev Respir Dis
(1984)
S Lord et al.
Night-to-night variability of disturbed breathing during sleep in an elderly community sample
Sleep
(1991)
WB Mendelson
Use of the sleep laboratory in suspected sleep apnea syndrome: is one night enough?
Cleve Clin J Med
(1994)
AD Chediack et al.
Nightly variability in the indices of sleep-disordered breathing in men being evaluated for impotence with consecutive night polysomnograms
Sleep
(1996)
SS Mosko et al.
Night-to-night variability in sleep apnea and sleep-related periodic limb movements in the elderly
Sleep
(1988)

There are more references available in the full text version of this article.

Cited by (161)

Does sleep promote adaptation to acute stress: An experimental study
2024, Neurobiology of Stress
Evidence of the impact of chronic stress on sleep is abundant, yet experimental sleep studies with a focus on acute stress are scarce and the results are mixed. Our study aimed to fill this gap by experimentally investigating the effects of pre-sleep social stress on sleep dynamics during the subsequent night, as measured with polysomnography (PSG).
Thirty-four healthy individuals (65% females, M_age = 25.76 years SD = 3.35) underwent a stress-inducing (SC) or neutral control condition (CC) in virtual reality (VR). We used overnight EEG measurements to analyze the basic sleep parameters and power spectral density (PSD) across the sleep cycles, and measured heart rate and its variability (HRV), skin electrodermal activity (EDA), and salivary cortisol to capture physiological arousal during the VR task and the pre-sleep period.
Following acute stress (SC), the amount of slow-wave sleep (SWS) was higher and N2 sleep lower relative to CC, specifically in the first sleep cycle. In SC, PSD was elevated in the beta-low (16–24 Hz) and beta-high (25–35 Hz) frequency ranges during both stages N2 and SWS over the entire night.
Sleep promoted adaptation to acute social stress by a longer duration of SWS in the subsequent sleep period, especially in early sleep. A similar homeostatic effect towards restorative sleep is well-evidenced in animal model stress studies but has not been previously reported in experimental human studies. Whether the high-frequency PSD activity during stages N2 and SWS also serves in the resolution of transient stress, remains open.
Multi-night measurement for diagnosis and simplified monitoring of obstructive sleep apnoea
2023, Sleep Medicine Reviews
Substantial night-to-night variability in obstructive sleep apnoea (OSA) severity has raised misdiagnosis and misdirected treatment concerns with the current prevailing single-night diagnostic approach. In-home, multi-night sleep monitoring technology may provide a feasible complimentary diagnostic pathway to improve both the speed and accuracy of OSA diagnosis and monitor treatment efficacy. This review describes the latest evidence on night-to-night variability in OSA severity, and its impact on OSA diagnostic misclassification. Emerging evidence for the potential impact of night-to-night variability in OSA severity to influence important health risk outcomes associated with OSA is considered. This review also characterises emerging diagnostic applications of wearable and non-wearable technologies that may provide an alternative, or complimentary, approach to traditional OSA diagnostic pathways. The required evidence to translate these devices into clinical care is also discussed. Appropriately sized randomised controlled trials are needed to determine the most appropriate and effective technologies for OSA diagnosis, as well as the optimal number of nights needed for accurate diagnosis and management. Potential risks versus benefits, patient perspectives, and cost-effectiveness of these novel approaches should be carefully considered in future trials.
Determinants of apnea-hypopnea index variability during home sleep testing
2023, Sleep Medicine
A single-night attended in-laboratory polysomnography or home sleep testing are common approaches for obstructive sleep apnea (OSA) diagnosis. However, internight variability in apnea-hypopnea index value is common, and may result in misclassification of OSA severity and inapropriate treatment decisions.
To investigate factors determining short-term apnea-hypopnea index variability using multi-night automated home sleep testing, and to determine how this variability impacts clinical decisions.
Adults with suspected OSA who successfully performed three home sleep tests using measurements of mandibular jaw movements (Sunrise, Namur, Belgium) combined with automated machine learning analysis were enrolled. Data analysis included principal component analysis, generalized estimating equation regression and qualitative agreement analysis.
160 individuals who performed three sleep tests over a mean of 8.78 ± 8.48 days were included. The apnea-hypopnea index varied by −0.88 events/h (5th-95th percentile range: −14.33 to 9.72 events/h). Based on a single-night recording, rates of overtreatment and undertreatment would have been of 13.5% and 6.0%, respectively. Regression analysis adjusted for age, sex, body mass index, total sleep time, and time between home sleep tests showed that time spent in deep non-rapid eye movement sleep and with head in supine position were independent significant predictors of the apnea-hypopnea index variability.
At the individual level, short-term internight variability in the apnea-hypopnea index was significantly associated with time spent in deep non-rapid eye movement sleep and head in supine position. Clinical decisions based on a single-night testing may lead to errors in OSA severity classification and incorrect therapeutic decisions.
Obstructive sleep apnea may reduce a diagnostic accuracy of video-polysomnography for idiopathic REM sleep behavior disorder
2023, Sleep Medicine
Citation Excerpt :
Based on a stepwise logistic regression analysis, we found that shorter REM sleep time was less likely related to a diagnosis of RBD. Insufficient REM sleep could result from disturbed sleep by severe OSA [3,9] or the first night effect of PSG on sleep architecture [3,9,27] especially in older patients who were suggested to have greater first night effect [27]. Thus, insufficient amount of REM sleep may have significant impact on video-PSG diagnostic accuracy for RBD.
Severe obstructive sleep apnea (OSA) in patients with rapid eye movement (REM) sleep behavior disorder (RBD) may result in frequent fragmentation of REM sleep and consequently lead to a false negative diagnosis of RBD on a video-polysomnography (video-PSG). Thus, we determined whether OSA has the negative impact on video-PSG diagnostic accuracy for RBD.
Patients with clinically diagnosed idiopathic RBD were included. RBD was confirmed if a video-PSG demonstrated complex motor behavior during REM sleep or REM sleep without atonia (RWA). Motor behavior was measured using the RBD Severity Scale. Cohen's kappa coefficient was calculated for qualitative assessment of RWA. A stepwise logistic regression analysis was performed.
Of a total 254 patients included, a diagnosis of RBD was confirmed by a video-PSG in 221 patients (87.0%). RWA, vocalization, and axial or proximal muscle movements in REM sleep were noted in 86.6%, 58.3%, and 35.9%, respectively. A video-PSG diagnosis of RBD was less likely associated with severe OSA (odds ratio [OR] 0.284, p = 0.010) and moderate OSA (OR 0.404, p = 0.071) whereas was more likely associated with longer REM sleep time (OR 1.036, p < 0.001). In 43 patients who underwent a continuous positive airway pressure (CPAP) titration study, a diagnosis of RBD was more common on a CPAP titration study (88.4%) than on a first video-PSG (65.1%) (p = 0.013). Twelve (27.9%) of 43 CPAP patients were diagnosed with RBD according only to CPAP titration study.
OSA that requires CPAP may reduce a diagnostic accuracy for RBD by a video-PSG. False negative results were probably due to frequent electromyographic artifacts and/or severe sleep disruption from apneic events during REM sleep.
Night-to-night variability in respiratory sleep parameters to diagnose obstructive sleep apnea in children: A systematic review and meta-analysis
2022, International Journal of Pediatric Otorhinolaryngology
This systematic review aims to assess the night-to-night variability (NtNV) in respiratory sleep parameters in children and the accuracy of diagnosing obstructive sleep apnea (OSA) in children based on a single-night sleep study.
The PubMed, EMBASE, and Cochrane Library databases were searched until March 8, 2021. This study was registered in the International Prospective Register of Systematic Reviews (PROSPERO) database (CRD42021239838).
Our study included 395 patients from 5 articles. The mean (SD) age of all included patients was 11.78 (4.05) years. AHI was reported for 325 participants in 4 studies, and the mean change between two consecutive nights was −0.13 [95% CI: −0.40, 0.14] events per hour. The mean change in OAI was −0.07 [95% CI: −0.27, 0.12] events per hour in 187 participants across 3 studies. Based on the diagnostic criteria used, three studies reported that the diagnostic rates of OSA patients in a single-night sleep study were 83%, 84.6%, and 91%. The NtNV in AHI in children with severe and moderate OSA was greater than that in children with mild OSA (3.35 [95% CI: 0.07, 6.62] events per hour vs −0.15 [95% CI: −0.42, 0.12] events per hour), and these children with more severe OSA may have shown a higher AHI on the first night.
The NtNV in AHI was not statistically significant in the group sample of children. However, there were significant differences in NtNV in AHI between children with mild and moderate-to-severe OSA. Individual NtNV in respiratory sleep parameters may cause children to be misdiagnosed by single-night diagnostic sleep studies.
A meta-analysis of the first-night effect in healthy individuals for the full age spectrum
2022, Sleep Medicine
Citation Excerpt :
Second, different medical conditions might influence the magnitude of the FNE [6]. For example, it has been reported that patients with sleep apnea [17] and idiopathic nightmares [18] manifest a stronger FNE, while patients with depression [3], insomnia [12,19], or post-traumatic stress disorder [20] manifest a less-pronounced FNE. Third, the magnitude of the FNE could be associated with age.
The first-night effect (FNE) affects the accuracy of polysomnography (PSG) findings. However, the levels of FNE in different ages are unclear.
We searched PubMed, Cochrane Library, Embase and Web of Science. The studies that reported sleep parameters by PSG for at least 2 consecutive nights from healthy individuals were included. The weighted mean differences were used to assess the effect size of differences in each sleep parameters between the first and second nights, as well as between the second and the third.
A total of 53 studies from 1422 subjects with mean age of 9.2–85.5 years were included. Meta-analyses showed that prolonged sleep onset latency, wake time after sleep onset and rapid eye movement sleep (REM) latency, accompanied by decreased total sleep time, sleep efficiency, and REM and increased non-rapid eye movement sleep stage 1 (N1) during the first night compared to the second (all P-value ≤ 0.001). No significant differences were observed in N2 and slow wave sleep, apnea–hypopnea index or periodic limb movement index (all P-value > 0.5). A non-linear association between FNE and age was observed: young adults (age 20–29 years) had the lowest level of FNE compared to other age ranges. Moreover, no significant differences were observed in most sleep parameters between the second and third night except more N2 and less REM in the second night (both P-value < 0.05).
The FNE exists in most cases but only in the first night of PSG recording and is less pronounced among young adults.

View all citing articles on Scopus

: This work was entirely funded by SOMALCPE (Brussels), a private association dedicated to the scientific study of sleep.

View full text

Chest

Clinical Investigations: Sleep and BreathingMild to Moderate Sleep Respiratory Events: One Negative Night May Not Be Enough

Study objectives

Design

Setting

Patients

Interventions

Measurements and results

Conclusions

Section snippets

Patients

Results

Discussion

ACKNOWLEDGMENTS

Chest

Chest

Chest

Chest

Night-to-night consistency of apneas during sleep

Am Rev Respir Dis

Night-to-night variability of disturbed breathing during sleep in an elderly community sample

Sleep

Use of the sleep laboratory in suspected sleep apnea syndrome: is one night enough?

Cleve Clin J Med

Nightly variability in the indices of sleep-disordered breathing in men being evaluated for impotence with consecutive night polysomnograms

Sleep

Night-to-night variability in sleep apnea and sleep-related periodic limb movements in the elderly

Sleep

Clinical Investigations: Sleep and Breathing
Mild to Moderate Sleep Respiratory Events: One Negative Night May Not Be Enough