Home Sleep Testing in the Diagnosis and Treatment of Sleep Disordered Breathing

Comparison of home ambulatory type 2 polysomnography with a portable monitoring device and in-laboratory type 1 polysomnography for the diagnosis of obstructive sleep apnea in children

STUDY OBJECTIVES

To compare type 2 polysomnography (T2PSG) to the gold standard type 1 in-laboratory polysomnography (T1PSG) for diagnosing obstructive sleep apnea (OSA) in children; validate home T2PSG in children with suspected OSA.

METHODS

Eighty-one participants (ages 6-18) with suspected OSA had simultaneous T1PSG and T2PSG in the sleep laboratory, 47 participants (ages 5-16) had T1PSG in the sleep laboratory and T2PSG performed at home. Sleep scientists staged and scored polysomnography data, and pediatric sleep physicians assigned a diagnosis of normal or OSA. Participant demographics, polysomnography variables, and diagnoses were compared using chi-square and Fisher's exact tests for nominal variables, t test for continuous variables and Cohen's kappa to assess concordance.

RESULTS

Acceptable recordings were obtained for every home T2PSG. When T1PSG and T2PSG were simultaneous, correlation between the number of arousals, respiratory disturbance index, and sleep stages was excellent. T2PSG at home demonstrated less stage 2 sleep, more rapid eye movement sleep, and higher sleep efficiency. Comparison of home T2PSG to T1PSG for diagnosing OSA showed a false-positive rate of 6.6% and false-negative rate of 3% for those performed at home.

CONCLUSIONS

T2PSG in the home is feasible with excellent concordance with T1PSG for the purposes of diagnosing OSA in children aged 5-18 years. Home T2PSG may be more representative of a "normal" night for children and could benefit those suspected of having OSA by reducing waiting times for laboratory PSG, improving access to PSG and possibly reducing costs of investigating and treating OSA.

CITATION

Withers A, Maul J, Rosenheim E, O'Donnell A, Wilson A, Stick S. Comparison of home ambulatory type 2 polysomnography with a portable monitoring device and in-laboratory type 1 polysomnography for the diagnosis of obstructive sleep apnea in children. J Clin Sleep Med. 2022;18(2):393-402.

Guidelines for the recording and evaluation of pharmaco-sleep studies in man: the International Pharmaco-EEG Society (IPEG)

The International Pharmaco-EEG Society (IPEG) presents guidelines summarising the requirements for the recording and computerised evaluation of pharmaco-sleep data in man. Over the past years, technical and data-processing methods have advanced steadily, thus enhancing data quality and expanding the palette of sleep assessment tools that can be used to investigate the activity of drugs on the central nervous system (CNS), determine the time course of effects and pharmacodynamic properties of novel therapeutics, hence enabling the study of the pharmacokinetic/pharmacodynamic relationship, and evaluate the CNS penetration or toxicity of compounds. However, despite the presence of robust guidelines on the scoring of polysomnography -recordings, a review of the literature reveals inconsistent -aspects in the operating procedures from one study to another. While this fact does not invalidate results, the lack of standardisation constitutes a regrettable shortcoming, especially in the context of drug development programmes. The present guidelines are intended to assist investigators, who are using pharmaco-sleep measures in clinical research, in an effort to provide clear and concise recommendations and thereby to standardise methodology and facilitate comparability of data across laboratories.

Obstructive sleep apnea: preoperative assessment

Obstructive sleep apnea is the most prevalent breathing disturbance in sleep. It is linked to a host of preexisting medical conditions, and associated with poorer postoperative outcomes. Screening and vigilance during the preoperative assessment identifies patients at high risk of obstructive sleep apnea. Further diagnostic tests may be performed, and plans can be made for tailored intraoperative care. The STOP and the STOP-Bang questionnaires are useful screening tools. Patients with a known diagnosis of obstructive sleep apnea should be seen in the preoperative clinic, where risk stratification and optimization may be done before surgery. This review article presents functional algorithms for the perioperative management of obstructive sleep apnea based on limited clinical evidence, and a collation of expert knowledge and practices. These recommendations may be used to assist the anesthesiologist in decision-making when managing the patient with obstructive sleep apnea.

Computed tomographic evaluation of mouth breathers among paediatric patients

OBJECTIVES

Mouth breathing causes many serious problems in the paediatric population. It has been maintained that enlarged adenoids are principally responsible for mouth breathing. This study was designed to evaluate whether other mechanical obstacles might predispose the child to mouth breathing.

METHODS

67 children with ages ranging from 10 to 15 years were studied and grouped into mouth-breathers and nose-breathers. The children first underwent axial CT scans of the brain for which they were originally referred. In addition, they were subjected to a limited coronal CT examination of the paranasal sinuses. Congenital anatomical variations as well as inflammatory changes were assessed.

RESULTS

87% of mouth-breathing children had hypertrophied adenoids, 77% had maxillary sinusitis, 74% had pneumatized middle concha, 55% had a deviated nasal septum, 55% had hypertrophied inferior conchae, 45% had ethmoidal sinusitis and 23% showed frontal sinusitis. Such changes were significantly less prevalent in nose-breathers. 12.9% of mouth-breathing children did not have adenoids. Of these children, only 3.3% had one or more congenital or inflammatory change whereas the other 9.6% showed a completely normal CT scan signifying the incidence of habitual non-obstructive mouth breathing.

CONCLUSIONS

It is clear that adenoids have a dominant role in causing mouth breathing. Yet, we recommend that paediatricians should assess other mechanical obstacles if mouth breathing was not corrected after adenoidectomy. Further research should be performed to test the validity of correction of such factors in improving the quality of life of mouth-breathing children.

Clinical practice: diagnosis and treatment of childhood snoring

Obstructive sleep-disordered breathing in children is a relatively common problem, presenting in various ways, from primary snoring, without an apparent decrease in quality of life, to obstructive sleep apnea with cognitive, cardiac, and growth abnormalities. History, clinical examination, radiologic evaluations, sleep studies, and other diagnostic modalities are reviewed. Since application and interpretation of these methods are not consistent in studies of snoring, a consensus on optimal treatment options has not been established. Traditionally, adenotonsillectomy has long been the treatment of choice. Treatment failures or recurrences as well as the existence of causes and contributing factors other than adenotonsillar hypertrophy, like obesity, facial malformations, and Down syndrome, have changed the concept of adenotonsillectomy as the ultimate cure. Several other treatment options have been proposed on their own or in combination. Continuous positive airway pressure, anti-inflammatory medications, maxillofacial, and orthodontic treatments are reviewed suggesting the need of a multidisciplinary approach in some cases. Finally, at the end of the chapter, a diagnostic and treatment work up based on current evidence is proposed for otherwise normal children or children with specific conditions.