Tan Hui-Leng, Gozal David, Ramirez Helena Molero, Bandla Hari P R, Kheirandish-Gozal Leila
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.
Section of Pediatric Sleep Medicine, Department of Pediatrics, Pritzker School of Medicine, Biological Sciences Division, The University of Chicago, Chicago, IL.
Sleep. 2014 Feb 1;37(2):255-60. doi: 10.5665/sleep.3392.
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.
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.
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.
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).
不同国家用于诊断儿童阻塞性睡眠呼吸暂停（OSA）的睡眠研究类型存在显著差异。呼吸多导睡眠图（RP）记录主要在欧洲的睡眠实验室进行，而多导睡眠监测（PSG）在美国和澳大利亚占大多数。家庭RP显示一致的呼吸暂停低通气指数（AHI）偏低，主要是因为在计算AHI时，总记录时间用作分母，而不是总睡眠时间（TST）。然而，基于实验室的RP受影响较小，因为睡眠技术人员的存在和视频监测可能使TST估计更准确。因此，我们研究了PSG和实验室RP中AHI的差异，以及基于RP的AHI是否会影响临床决策。
在所有接受PSG评估的疑似OSA儿童中，确定了100名并分为4组：（A）AHI < 1/h TST的儿童（n = 20），（B）1≤AHI < 5/h TST的儿童（n = 40），（C）5≤AHI < 10/h TST的儿童（n = 20），以及（D）AHI≥10/h TST的儿童（n = 20）。从原始未评分记录中删除脑电图、眼电图和肌电图通道，将其转换为RP，然后随机重新评分。将AHI-RP与AHI-PSG进行比较，并根据AHI-RP和AHI-PSG制定治疗决策，并使用患者临床信件中的临床细节进行分析。
Bland Altman分析表明，尽管实验室RP对TST的估计更准确，但仍低估了AHI。这种低估是由于漏诊了导致觉醒但无血氧饱和度下降的低通气。基于RP而非PSG结果做出治疗管理决策，在所有患者中有23%改变了临床管理。A组和D组患者的临床管理未受影响。然而，B组中有27.5%的患者本不应接受治疗，因为他们会被诊断为无OSA（AHI < 1/h TST），而此时他们应该接受抗炎治疗试验或转诊至耳鼻喉科（ENT）进行检查。C组中有60%的患者本应接受治疗轻度OSA的药物试验或不接受治疗，而不是转诊至ENT服务或开始持续气道正压通气治疗。
呼吸多导睡眠图（RP）低估了呼吸暂停低通气指数（AHI），AHI-RP与AHI-多导睡眠监测之间的差异会显著影响临床管理决策，尤其是在轻度和中度阻塞性睡眠呼吸暂停（总睡眠时间1 < AHI < 10/h）的儿童中。
