Pediatric OSAS: Oximetry can provide answers when polysomnography is not available

doi:10.1016/j.smrv.2015.05.008

Sleep Medicine Reviews

Volume 27, June 2016, Pages 96-105

https://doi.org/10.1016/j.smrv.2015.05.008 Get rights and content

Summary

Overnight polysomnography is the gold standard tool for the diagnosis of obstructive sleep apnea syndrome (OSAS) in habitually snoring children, but it is expensive and not always available. Nocturnal oximetry has been proposed as an abbreviated and low-cost testing modality for the diagnosis of OSAS. In this systematic review, 25 original articles were evaluated to: (i) summarize reference values of nocturnal oximetry parameters in healthy children; (ii) identify abnormal oximetry patterns that predict OSAS in habitually snoring children; (iii) delineate abnormalities in oximetry that can predict responses to treatment interventions for OSAS and potential complications. Nocturnal SpO₂ drops <90%, more than two clusters of desaturation events (≥4%) and oxyhemoglobin desaturation (≥4%) index (ODI₄) >2.2 episodes/h are unusual in children without OSAS. At least three clusters of desaturation events, and at least three SpO₂ drops below 90% in a nocturnal oximetry recording are indicative of moderate-to-severe OSAS. An ODI₄ >2 episodes/h combined with OSAS symptoms also exhibits high positive predictive value for apnea-hypopnea index >1 episode/h. Children without clusters of desaturation events have low risk of major respiratory complications following adenotonsillectomy. Thus, nocturnal oximetry emerges as a valuable tool that can facilitate treatment decisions when polysomnography is not available.

Section snippets

Introduction and aims

The term “obstructive sleep-disordered breathing (SDB)” describes a spectrum of abnormal breathing patterns during sleep characterized by snoring and increased respiratory effort [1]. A variety of factors, including adenotonsillar hypertrophy, obesity, craniofacial abnormalities and neuromuscular disorders, facilitate increases in upper airway resistance and pharyngeal collapsibility, and predispose to intermittent upper airway obstruction during sleep, especially during stages N2 and REM [2].

Methods and literature search

To identify studies relevant to the aims of the present systematic review, the PubMed database was searched for original studies, meta-analyses, or systematic reviews published in the English language with filters “humans” and “child: birth-18 years” using the terms “oximetry” and (“sleep apnea” or “sleep-disordered breathing” or “snoring”) from January 2000 until January 2015. Studies published earlier than 2000 were not taken under consideration because pulse oximetry technology has evolved

Search results

The initial search retrieved 176 titles, 141 of whom were irrelevant to the aims of the present systematic review and were excluded from further analysis (Fig. 1). We excluded three review articles with limited focus on pulse oximetry, one small case series, two letters to the editor and one original study in a Brazilian journal because it was also published in an American journal [15], [16]. Three other articles were not included because the OSA-18 quality of life questionnaire score, young

Studies reporting reference values for nocturnal pulse oximetry parameters

Original studies that were published after 2000 and reported reference values for nocturnal pulse oximetry parameters in children without symptoms of SDB or with no abnormalities predisposing to SDB are summarized in Table 1 ∗[20], [21], ∗[22], [23], [24]. Regarding baseline SpO₂ levels, the 2.5th percentile for the baseline SpO₂ in 1–15 year-old children without OSAS is approximately 95% [23], [24]. In a population-based study of children attending primary school by Urschitz and collaborators,

Discussion

Polysomnography is a valuable tool for the diagnosis of OSAS in children but is fraught with many practical limitations [40]. Only a small proportion of children who are subjected to adenotonsillectomy for SDB in the USA undergo preoperative polysomnography [41]. In a survey involving pediatric otolaryngology specialists, children with suspected OSAS were referred for polysomnography “most of the time” by only 4% of respondents and patients with Down syndrome or obesity by 20% and 8% of

Conclusion

Nocturnal pulse oximetry is a low-cost and easy to use diagnostic modality to identify OSAS among children with symptoms of SDB when polysomnography is not available. Results of oximetry can facilitate treatment decisions and also help predict immediate, major respiratory complications post-adenotonsillectomy.

Practice points

In otherwise healthy children without symptoms of OSAS, the following are infrequent:

1.
Nocturnal baseline SpO₂ <95%;
2.
More than one nocturnal SpO₂ drop <90% and more than two

Funding source

LKG and DG are supported by National institutes of Health grant HL-65270.

Financial disclosures

None of the authors has any financial relationships relevant to this article to disclose.

Conflicts of interest

None of the authors has any conflicts of interest to disclose.

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Central Sleep Apnea (CSA) is characterized by respiratory pauses during sleep, posing risks like cardiovascular diseases, stroke and sudden death. The challenges in managing it arise from the current monitoring tools, which are often complicated and inaccurate. Furthermore, respiratory pauses leading to decreased blood oxygen can induce profuse sweating, further affecting accuracy. Herein, we have synthesized a bio-based, biocompatible and sweat-resistant polyurethane. By utilizing it as the matrix, we incorporated [BMIM]⁺[PF₆]⁻ to fabricate a markedly sensitive dielectric material, termed i-DFPU. The fluorine groups in i-DFPU contributed to a trap-release effect for migratable ions, while the alkyl side chains provided smooth ion migration channels, endowing i-DFPU with exceptional sensitivity. In combination with a stress concentration layer and serpentine-shaped electrodes, the resultant iontronic skin exhibited a remarkable sensitivity up to 132.2 kPa⁻¹, operational stability and portability. Consequently, it could accurately monitor various respiratory states in CSA, potentially preventing complications such as sudden death.
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Obstructive sleep apnea (OSA) is a common problem in children and can result in developmental and cognitive complications if untreated. The gold-standard tool for diagnosis is polysomnography (PSG); however, it is an expensive and time-consuming test to undertake. Overnight oximetry has been suggested as a faster and cheaper initial test in comparison to PSG as it can be performed at home using limited, reusable equipment.
This retrospective case control study aims to evaluate the effectiveness of a home oximetry service (implemented in response to extended waiting times for routine PSG) in reducing the time between patient referral and treatment.
Patients undergoing diagnostic sleep evaluation for suspected OSA who utilized the Queensland Children's Hospital screening home oximetry service in the first year since its inception in 2021 (n = 163) were compared to a historical group of patients who underwent PSG in 2018 (n = 311). Parameters compared between the two groups included time from sleep physician review to sleep test, ENT review, and definitive treatment in the form of adenotonsillectomy surgery (or CPAP initiation for those who had already undergone surgery).
The time from sleep physician review and request of the sleep-related study to ENT surgical treatment was significantly reduced (187 days for the HITH oximetry group vs 359 days for the comparable PSG group; p-value <0.05), and time from sleep study request to the report of results was significantly lower for patients in the oximetry group compared to those in the PSG group (11 days vs 105 days; p-value <0.05).
These results suggest that for children referred to a tertiary sleep center for possible obstructive sleep disordered breathing, a home oximetry service can be effective in assisting sleep evaluation and reducing the time to OSA treatment.
An explainable deep-learning architecture for pediatric sleep apnea identification from overnight airflow and oximetry signals
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Deep-learning algorithms have been proposed to analyze overnight airflow (AF) and oximetry (SpO₂) signals to simplify the diagnosis of pediatric obstructive sleep apnea (OSA), but current algorithms are hardly interpretable. Explainable artificial intelligence (XAI) algorithms can clarify the models-derived predictions on these signals, enhancing their diagnostic trustworthiness. Here, we assess an explainable architecture that combines convolutional and recurrent neural networks (CNN + RNN) to detect pediatric OSA and its severity. AF and SpO₂ were obtained from the Childhood Adenotonsillectomy Trial (CHAT) public database (n = 1,638) and a proprietary database (n = 974). These signals were arranged in 30-min segments and processed by the CNN + RNN architecture to derive the number of apneic events per segment. The apnea-hypopnea index (AHI) was computed from the CNN + RNN-derived estimates and grouped into four OSA severity levels. The Gradient-weighted Class Activation Mapping (Grad-CAM) XAI algorithm was used to identify and interpret novel OSA-related patterns of interest. The AHI regression reached very high agreement (intraclass correlation coefficient > 0.9), while OSA severity classification achieved 4-class accuracies 74.51% and 62.31%, and 4-class Cohen’s Kappa 0.6231 and 0.4495, in CHAT and the private datasets, respectively. All diagnostic accuracies on increasing AHI cutoffs (1, 5 and 10 events/h) surpassed 84%. The Grad-CAM heatmaps revealed that the model focuses on sudden AF cessations and SpO₂ drops to detect apneas and hypopneas with desaturations, and often discards patterns of hypopneas linked to arousals. Therefore, an interpretable CNN + RNN model to analyze AF and SpO₂ can be helpful as a diagnostic alternative in symptomatic children at risk of OSA.
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Pulmonary hypertension (PH) secondary to obstructive sleep apnea (OSA) is an uncommon but serious perioperative risk factor in children undergoing surgery for adenotonsillar hypertrophy. Routine pre-operative echocardiography is commonly requested if severe OSA is suspected. We investigated the incidence of PH in children with suspected OSA and explored the association between PH and OSA severity.
A prospective study of children aged 1–13 years with suspected OSA admitted for overnight oximetry (OO) and echocardiography at a pediatric referral hospital in Cape Town, South Africa from 2018 to 2019. OSA severity was defined by McGill Oximetry Score (MOS): MOS 1–2 (mild-moderate) and MOS 3–4 (severe). PH was defined as mean pulmonary arterial pressure (mPAP) ≥20 mmHg estimated on echocardiographic criteria. Children with congenital heart disease, underlying cardio-respiratory or genetic disorders, and severe obesity were excluded.
One hundred and seventy children median age 3.8 years (IQR 2.7–6.4) were enrolled and 103 (60%) were female. Twenty-two (14%) had a BMIz >1.0 and 99 (59%) had tonsillar enlargement grade 3/4. One hundred and twenty-two (71%) and 48 (28%) children had mild-moderate and severe OSA, respectively. Echocardiographic assessment for PH was successful in 160 (94%) children of which eight (5%) had PH with mPAP 20.8 mmHg (SD 0.9): six with mild-moderate OSA and two with severe OSA. No significant difference in mPAP and other echocardiographic indices was observed in children with mild-moderate (16.1 mmHg; SD 2.4) and severe OSA (15.7 mmHg; SD 2.1). Similarly, no clinical and OSA severity differences were observed in children with and without PH.
PH is uncommon in children with uncomplicated OSA and there is no association of PH with severity of OSA measured by OO. Routine echocardiographic screening for PH in children with clinical symptoms of OSA without co-morbidity is unwarranted.
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Clinical reviewPediatric OSAS: Oximetry can provide answers when polysomnography is not available

Summary

Section snippets

Introduction and aims

Methods and literature search

Search results

Studies reporting reference values for nocturnal pulse oximetry parameters

Discussion

Conclusion

Practice points

Funding source

Financial disclosures

Conflicts of interest

Sleep Med

Int J Pediatr Otorhinolaryngol

Sleep Med Rev

Int J Pediatr Otorhinolaryngol

Sleep Med

Chest

Int J Pediatr Otorhinolaryngol

Chest

J Pediatr

Int J Pediatr Otorhinolaryngol

Int J Pediatr Otorhinolaryngol

Chest

Int J Pediatr Otorhinolaryngol

J Otolaryngology - Head Neck Surg

Sleep Med

Pathophysiology of pediatric obstructive sleep apnea

Proc Am Thorac Soc

Standards and indications for cardiopulmonary sleep studies in children

Am J Respir Crit Care Med

A randomized trial of adenotonsillectomy for childhood sleep apnea

N Engl J Med

Activity-adjusted 24-hour ambulatory blood pressure and cardiac remodeling in children with sleep disordered breathing

Hypertension

Nocturnal enuresis is associated with moderate-to-severe obstructive sleep apnea in children with snoring

Pediatr Res

Planning adenotonsillectomy in children with obstructive sleep apnea: the role of overnight oximetry

Pediatrics

Diagnosis and management of childhood obstructive sleep apnea syndrome

Pediatrics

Current practice patterns for sleep-disordered breathing in children

Laryngoscope

Nocturnal pulse oximetry as an abbreviated testing modality for pediatric obstructive sleep apnea

Pediatrics

Testing for pediatric obstructive sleep apnea when health care resources are rationed

JAMA Otolaryngology– Head Neck Surg

Clinical review
Pediatric OSAS: Oximetry can provide answers when polysomnography is not available