Initial Polysomnography Research Articles

Evaluating the added-value of video recording in respiratory polygraphy for the diagnosis of obstructive sleep apnea in children.

Polysomnography (PSG) is the gold standard for diagnosing obstructive sleep apnea (OSA) in children but not always available. Abbreviated exams exist, such as respiratory polygraphy (RP), but are less accurate for OSA diagnosis. Video recording (video-RP) may provide a more precise estimation of the total sleep time (TST) compared to RP alone. The aim of this study was to evaluate the diagnostic power of video-RP compared to RP and PSG.Overall, 68 PSG from 68 children (median [1st; 3rd quartile] age of 9 [7; 12]years) were included. After the interpretation of the initial PSG, the analysis was deleted, and the recording was analyzed by taking into account only the respiratory signals and video recording (video-RP). Finally, a third interpretation, after deleting the previous, was performed by considering only the respiratory signals (RP).The median [1st; 3rd percentile] obstructive apnea-hypopnea index (OAHI) was underestimated in video-RP (4.1 [2.7; 6.5]/h) as well as RP (4.0 [2.7; 6.2]/h) compared to PSG (4.8 [2.9; 6.7]/h, p=0.02 and p=0.01, respectively). Bland-Altman analysis confirmed the underestimation of OAHI by video-RP and RP compared to PSG, the magnitude of the difference being -0.69 ± 2.16 and -0.78 ± 2.12, respectively. OSA severity grading was different when scored by video-RP and RP compared to PSG in 14 (21%) children.Video-RP underestimated the OAHI compared to PSG, similar to RP. Adding the video recording did not improve the diagnostic power of RP for the diagnosis of OSA. The use of video-RP at home should be investigated in future studies.

Periodic limb movements during sleep in children with neuromuscular disease or cerebral palsy – An important potential contributor to sleep-related morbidity

ObjectivesPoor sleep is frequently reported in children with neuromuscular diseases (NMD) and cerebral palsy (CP) however breathing disorders during sleep are often the clinical focus. Periodic limb movements (PLMs) have an increased prevalence in adults with NMD and may contribute to sleep disturbance in this population. We assessed the prevalence of PLMs in children with NMD or CP. MethodsRetrospective review of polysomnography (PSG) with leg electromyography in children age 1–18 years with NMD (including Duchenne muscular dystrophy, myotonic dystrophy, spinal muscular atrophy) or CP performed at a paediatric sleep centre 2004–2022. ResultsLeg electromyography was available in at least 1 PSG in 239 children (125 NMD, 114 CP), and in 2 PSGs in 105 children (73 NMD, 32 CP). At initial PSG, 72 (30 %) were female with a median age 9y and respiratory disturbance index 3.5/h (interquartile range 1.3–9.9/h). Elevated PLM index (PLMI; >5/h) occurred in 9.6 % of each of the CP and NMD groups, quantified by initial PSG. Overall, PLMI increased from baseline (median 0, maximum 33/h) to follow-up (median 0, maximum 55.8/h; p < 0.05). In those with an elevated PLMI, arousal percentage attributable to PLMs was up to 25 % (median 7.5 %). ConclusionsElevated PLMI occurred at a higher prevalence in children with NMD and CP than reported in other clinic-referred paediatric populations. It is important that PLMs are not overlooked as identification and treatment may help improve sleep outcomes. Further research is required to understand the pathophysiology and consequences of PLMs specifically in this population.

Long-term effect of growth hormone on sleep-disordered breathing in Malaysian children with Prader-Willi syndrome: a retrospective study.

The effect of recombinant human growth hormone (rhGH) on sleep-disordered breathing (SDB) in Malaysian children with Prader-Willi syndrome (PWS) is under-investigated. We determined (1) the short- and long-term effects of rhGH and (2) factors associated with worsening SDB in children with PWS receiving rhGH. This retrospective study included children with PWS (with and without rhGH) who had undergone at least 1 polysomnography. Outcomes measured were the presence of SDB before and after starting rhGH and the progress of SDB with and without rhGH. Serial insulin-like growth factor 1 (IGF-1) measurements were recorded. One-hundred and thirteen polysomnograms were analyzed. The majority (92.3%) of initial polysomnograms showed SDB, with a median (interquartile range) apnea-hypopnea index of 5.0 (2.6, 16.3) events/h. The age for receiving rhGH was a median (IQR) of 1.9 (0.7, 3.4) years. One-third (36.8%) had worsening SDB after initiating rhGH, which was associated with higher IGF-1 levels post-rhGH (P = .007). After a median of 5 years of rhGH, 73.6% maintained or reduced their positive airway pressure settings. Without rhGH, 80% had increased their positive airway pressure settings. Worsening SDB while on rhGH was associated with higher body mass index, lower rhGH dose, higher IGF-1 levels, and non-15q deletion. The majority of Malaysian children with PWS had SDB. At initiation of rhGH, one-third of patients had worsening SDB, associated with increased IGF-1 levels. Stabilization of SDB was more frequently seen in those receiving long-term rhGH. Worsening SDB while on rhGH was associated with a higher body mass index, receiving a lower dose of rhGH, higher IGF-1 levels, and non-15q deletion. Tan YT, Azanan MS, Hng SY, etal. Long-term effect of growth hormone on sleep-disordered breathing in Malaysian children with Prader-Willi syndrome: a retrospective study. J Clin Sleep Med. 2024;20(8):1291-1299.

0470 Factors Associated with Discordant Initial Home Sleep Apnea Testing and Polysomnography

Abstract Introduction Nocturnal polysomnography (PSG) is the gold standard for diagnosing obstructive sleep apnea (OSA). Home sleep apnea tests (HSAT) have been incorporated in the diagnostic algorithm in patients with a high pre-test suspicion of OSA. While many studies have compared HSATs with PSGs, it is not well understood what factors may be responsible for inconclusive HSAT results. Methods We performed a retrospective chart review of adult patients who underwent a non-diagnostic HSAT evaluation, who subsequently tested positive for OSA (on PSG) between 1/1/2022 and 11/1/2022. We collected demographic and sleep study data. Patients who did not have a follow up PSG were excluded. Results A total of 20 patients were reviewed. 80% had a negative HSAT with a positive subsequent PSG. The average age was 33.9 years (SD +/- 11.3 years). 43% were male and 50% were Caucasian. The average BMI was 29 kg/m2 (SD +/- 5.3 kg/m2). The average Epworth Sleepiness Scale score (ESS) was 8 (median 6.5) with only 31% reporting an ESS &amp;gt;10. The average HSAT recording time was 449.1 minutes. The average respiratory disturbance index (RDI) on the follow up PSG was 17.7 events/hour of sleep (SD +/- 12). Only 1 patient was diagnosed with severe OSA. 38% were diagnosed with anxiety in this cohort. Other co-morbidities were insignificant. Of all the HSATs performed, 40% were denied for an initial PSG evaluation and converted to an HSAT evaluation. Conclusion HSATs are validated in patients with a high pretest probability of OSA. Anxiety was found in one third of patients included (possibly contributing to a negative initial HSAT). Patient demographics however were also not remarkable for a high risk of OSA in this group (e.g. non-obese, &amp;lt; 55 years, female). The subsequent diagnosis for OSA was also only mild or moderate (93.8%) in this lower risk cohort. Hence, another explanation for the initial negative HSAT evaluation may have been the insurance denial of the initial PSG request (40%). Denials of low risk patients for PSG may contribute to a misuse of resources. We also need to educate referring physicians to follow appropriate HSAT ordering criteria (based on high OSA risk factors). Support (if any)

Effect of occlusal equilibration on masticatory muscle activity in females with sleep bruxism: a double-blind randomised controlled trial.

Masticatory muscle activity during sleep has been considered independent of variations in the structural characteristics of the dental occlusion. However, scientific evidence contradicting an occlusal causal role is missing. The purpose of this study was to test the null hypothesis that sleep bruxism (SB) is independent of the presence of occlusal interferences. A total of 17 healthy female subjects (mean [SD] age 24.9[4.1]years) presenting with SB, and randomly divided into two groups, were evaluated after receiving either elimination of occlusal interferences (Test group) or elimination of sharp margins without change in occlusal contacts (Control group). Audio-video polysomnography (PSG) recordings were undertaken before and after treatment (mean [SD] duration 14.4[3.8]months). Two subjects in each group (< 2 rhythmic masticatory muscle activity [RMMA]/h) were excluded for statistical analysis. During the total sleep time (TST), the Test group exhibited a higher reduction in frequency of episodes per hour than the Control group (p < 0.05). The reduction in duration of episodes was also higher in the Test group during the TST. The Test group presented an increase in sleep stage N3 (p < 0.05) at the final PSG when compared with the initial PSG, and a higher percentage of N3 (p < 0.05) at the final PSG when compared to the Control group. Elimination of occlusal interferences resulted in a significant reduction of masseter and temporal muscle activity during sleep in females presenting with SB. Based on these results, the null hypothesis is rejected. The hypothesis of occlusal interferences as a risk factor for SB is still patent.

Revisiting level II sleep studies in the era of COVID-19: a theoretical economic decision model in patients with suspected obstructive sleep apnea

BackgroundThe recent pandemic has made it more challenging to assess patients with suspected obstructive sleep apnea (OSA) with in laboratory polysomnography (PSG) due to concerns of patient and staff safety. The purpose of this study was to assess how Level II sleep studies (LII, full PSG in the home) might be utilized in diagnostic algorithms of suspected OSA using a theoretical decision model.MethodsWe examined four diagnostic algorithms for suspected OSA: an initial PSG approach, an initial LII approach, an initial Level III approach (LIII, limited channel home sleep study) followed by PSG if needed, and an initial LIII approach followed by LII if needed. Costs per patient assessed was calculated as a function of pretest OSA probability and a variety of other variables (e.g. costs of tests, failure rate of LIII/LII, sensitivity/specificity of LIII). The situation in British Columbia was used as a case study.ResultsThe variation in cost per test was calculated for each algorithm as a function of the above variables. For British Columbia, initial LII was the least costly across a broad range of pretest OSA probabilities (< 0.80) while initial LIII followed by LII as needed was least costly at very high pretest probability (> 0.8). In patients with a pretest OSA probability of 0.5, costs per patient for initial PSG, initial LII, initial LIII followed by PSG, and initial LIII followed by LII were: $588, $417, $607, and $481 respectively.ConclusionsUsing a theoretical decision model, we developed a preliminary cost framework to assess the potential role of LII studies in OSA assessment. Across a broad range of patient pretest probabilities, initial LII studies may provide substantial cost advantages. LII studies might be especially useful during pandemics as they combine the extensive physiologic information characteristic of PSG with the ability to avoid in-laboratory stays. More empiric studies need to be done to test these different algorithms.

Effects of maxillomandibular advancement surgery on a skeletal Class III patient with obstructive sleep apnea: A case report

This case report describes the successful surgical treatment of a patient diagnosed with obstructive sleep apnea (OSA). A 55-year-old Caucasian male patient with a body mass index (BMI) of 25.6 kg/m2 sought treatment with a chief concern of excessive daytime sleepiness and fatigue. An initial polysomnography report showed moderate OSA with an apnea-hypopnea index (AHI) of 21.2 events/h, and Epworth Sleepiness Score (ESS) of 12/24. The patient was initially prescribed with CPAP treatment but was unable to tolerate treatment after a few months. Clinical and radiographic examination revealed a concave facial profile with maxillary retrognathism. Intraoral examination revealed generalized gingival recession, missing upper lateral incisors and lower first premolars, anterior crossbite, and maxillary transverse deficiency with bilateral posterior crossbite. The lateral cephalogram showed a narrow posterior airway space at the level of the base of the tongue. The patient was treated with maxillomandibular advancement (MMA) surgery to improve airway obstruction. Results showed balanced facial esthetic and stable occlusion with a complete resolution of the patient’s OSA and a post-operative improvement of AHI from 21.2 to 0.7 events/h and ESS from 12/24 to 3/24. The lowest oxyhemoglobin saturation during sleep was improved to 97%, and the BMI decreased from 25.6 to 25.2 kg/m2. These results suggest that MMA surgical procedure can be used as a definitive treatment for patients with maxillomandibular deficiency and OSA.

The role of long-term continuous positive airway pressure in the progression of obstructive sleep apnoea: A longitudinal cohort study.

Recent evidence suggests that short-term obstructive sleep apnea (OSA) treatment could affect OSA pathogenesis such as ventilatory control. The aim of our present study was to identify the impact of long-term treatment on the change in pathogenesis and natural progression of OSA. In a longitudinal analysis of a non-obese cohort study, patients with OSA treated with either continuous positive airway pressure (CPAP) or an oral appliance (OA), interrupted their treatment for 1week and underwent a polysomnography (PSG) off treatment that was compared with their initial PSG taken 5years before treatment initiation. In all, 154 consecutive patients with OSA who were treated by CPAP using an auto-titrating continuous positive airway pressure device (CPAP-APAP) (n=112), or by OA (n=27) or were untreated (n=15), PSG was performed twice with a median (range) follow-up of 93(60-176)months. Multivariate logistic regression showed that reduction of body mass index (BMI) and good treatment adherence to be significant predictors of favourable OSA progression, as represented by an improved or unchanged apnea-hypopnea index (AHI) (odds ratios were 5.14 and 2.89, respectively). Amongst the patients with an unchanged BMI and good CPAP-APAP adherence (n=55), the improvement in AHI was significantly associated with the decrease in supine non-rapid eye movement-AHI and mixed apnoea index/apnoea index, which are generally recognised to be determinants of ventilator instability. These findings suggest that not only weight but also treatment adherence are determinants in the natural progression of OSA severity.

REM Sleep and Total Sleep Time Improvement After Routine Repetitive Transcranial Magnetic Stimulation in Active Duty Service Members With Depression.

The prevalence of depression and insomnia in the military are substantial. Several transcranial magnetic stimulation (TMS) studies have used self-report sleep data as secondary research outcomes; however, there are limited studies using the gold standard of polysomnography (PSG) to ascertain actual sleep changes. Here, we provide data from a pilot and feasibility study using PSG to measure sleep changes after repetitive TMS. Thirty-eight active duty service members (ADSM) were consented, of which 20 completed the study. The ADSM who met study criteria where sent for an initial PSG and completed baseline self-report measures. They then completed a standard course of TMS, and self-report measures were completed every fifth session. After TMS completion, ADSM underwent final PSG. Comparison of baseline and postintervention PSG sleep parameters highlight that total rapid eye movement sleep improved after a course of TMS, regardless of improvements in depression. Total sleep time also improved, but only in the TMS responders subgroup. The Public Health Questionnaire-9 showed statistically significant improvement as did the Insomnia Severity Index and some components of the RAND Medical Outcomes Short Form 36. Our small study confirms the feasibility of obtaining pre and post PSG for research purposes. We found similar results to previous studies with regard to depression improvement and self-reported sleep. Interestingly, almost all (including electroconvulsive therapy) somatic depression treatments have been shown to decrease REM, whereas our study found an increase in REM. Overall, this study helps further our understanding of TMS effects on sleep and presents new questions for potential larger follow-on studies.

852 Severe Central Sleep Apnea in a Patient with Cornelia de Lange Syndrome

Abstract Introduction Cornelia de Lange syndrome (CdLS) is a rare multisystem disorder with characteristic facial dysmorphisms, upper airway structural abnormalities, and varying degrees of intellectual and neurologic deficits. Affected patients can have many sleep problems including chronic insomnia and obstructive sleep apnea; however, there is no literature indicating central sleep apnea as a common sleep disorder in this patient population. We describe a patient with CdLS with an unusual presentation of both severe obstructive and central sleep apnea. Report of case(s) The patient is a 12-year-old female with CdLS, global developmental delay, repaired bilateral cleft-palate, and oropharyngeal dysphagia. She was referred for diagnostic polysomnography for evaluation of snoring. Physical examination findings were significant for distinctive features of the head and face including microcephaly, micrognathia, and synophrys. Neurologically, the patient was non-verbal and wheelchair bound. Pre-evaluation screening indicated no concerns from the caregiver regarding problems with sleep initiation, maintenance, or daytime symptoms. Polysomnography (PSG) at age 7 years revealed severe obstructive and central sleep apnea with an apnea-hypopnea index (AHI) of 78.2/hr. The majority of these were central events (68.44/hr). There were no epileptiform foci recorded. Bilevel Positive Airway Pressure (BPAP) in Spontaneous/Timed (S/T) mode was titrated during the study which resolved all central events. Magnetic resonance imaging of the brain was obtained indicating mild hypoplasia of the corpus callosum. Since the initial PSG, 5 additional routine studies were conducted and progressive worsening of central sleep apnea was noted with the highest recorded AHI of 108.8/hr (central events: 81.4/hr). Apneic events were fairly managed with BPAP in ST mode. Conclusion Sleep-disordered breathing in CdLS is an increasingly diagnosed entity. While previous literature indicates airway obstruction as a common cause for sleep apnea in children with CdLS, our case suggests that clinicians should consider central causes of sleep apnea in these patients. Given the sub-clinical progression of sleep apnea in this case study, routine follow up PSGs should be considered. Further research is necessary to increase knowledge of the incidence and management of central sleep apnea in children with CdLS. Support (if any):

False-positive cases in multiple sleep latency test by accumulated sleep debt.

PurposeMultiple sleep latency test (MSLT) is performed as objective assessment of sleepiness, on the following day after polysomnography (PSG). In most clinics, patients are required to stay for 2 days. However, if patients have chronic sleep debt before the examination, even if they get adequate nocturnal sleep during the initial PSG, their sleep debt would not be fully resolved, affecting MSLT results. This may lead to improper administration of psycho‐stimulant medication. To clarify the sleep debt for the patients who showed short sleep latencies, we compared the mean sleep latencies of MSLTs.MethodsTwelve hypersomnolent males, who underwent MSLTs (1st MSLT with 1 night and 2nd MSLT with more than 3 nights), were enrolled. We selected these cases based on the longer total sleep time on PSG night compared to the mean total sleep time on pre‐examination sleep logs and shortened sleep latencies on PSG. To evaluate the effect of the sleep debt for the patients who showed short sleep latencies, we extended their hospitalization or re‐hospitalized them.ResultsThe mean sleep latency of 1st MSLT was 5.8 minutes and that of 2nd was 13.9 minutes (P < .001). Among these 12 cases, 5 cases altered from short to normal sleep latencies at the 2nd MSLT. These 5 cases were prevented from over‐diagnoses by the extension of evaluations.ConclusionsThe sleep debt may produce false‐positive results when patients are examined by standard PSG and MSLT. Accumulation of sleep debt will cause shortened sleep latencies in the following nights. Patients should be advised to extend their hospitalization before PSG and MSLT to reduce the chronic sleep debt for accurate diagnosis of hypersomnia.

Management of obstructive sleep apnea in children with achondroplasia: Outcomes of surgical interventions

IntroductionChildren with achondroplasia are predisposed to obstructive sleep apnea (OSA), however little is known regarding surgical interventions and outcomes for this condition. The aim of this study was to evaluate the severity of OSA in children with achondroplasia and report outcomes of surgical interventions using polysomnography (PSG) parameters. MethodsRetrospective chart review of children with achondroplasia with documented OSA from 2002 to 2018 that had pre- and post-operative PSG results. Additional data extracted included age, gender, and type of surgical interventions. The primary outcome was change in postoperative obstructive apnea hypopnea index (OAHI). ResultsTwenty-two children with achondroplasia were identified that underwent formal PSG before and after confirmed OSA. The median age was 12 months (range 4 days–15.3 years, IQR 2 years) at time of initial PSG evaluation. The majority (72.7%) of patients had severe OSA with a median preoperative OAHI of 14.25 (IQR 9.4). The most common surgical intervention was adenotonsillectomy (n = 15). Multilevel surgical intervention was required in 9 (41.0%) patients. Post-operatively, 16 (72.7%) children experienced a reduction in OAHI, of which four (18.2%) had complete OSA resolution. OAHI scores increased in six (27.3%) children. Patients with the most severe OSA at baseline had greater improvements in post-operative OAHI (P < 0.01). Neither type nor number of surgical interventions was associated with improved outcomes (P = 0.51, P = 0.89 respectively). ConclusionsTreatment of OSA in children with achondroplasia remains challenging. Although reduction of OAHI is possible, caregivers should be counseled about the likelihood of persistent OSA and the potential for multilevel airway surgery.

0633 Volume Assured Pressure Support is an Effective Treatment in Patients with Central Sleep Apnea Syndrome

Abstract Introduction Central sleep apnea syndrome (CSA) is commonly found in patients with congestive heart failure, brainstem disorders, and narcotic use. Various treatment modalities have been used with varied effectiveness in reducing the apnea-hypopnea index (AHI) and improving ventilation in patients with CSA. This study assessed whether Volume Assured Pressure Support (VAPS), a BiLevel mode of ventilation, is effective in treating CSA. Methods We performed a retrospective review of polysomnography (PSG) and VAPS titration studies on 11 patients at our institution: 7 patients had CSA with Cheyne-Stokes Respiration, 2 patients had CSA attributed to narcotic use, and 2 patients had primary CSA. CSA was diagnosed if more than 50% of the disordered breathing events were central. Five patients had failed a Continuous Positive Airway Pressure (CPAP) titration and then proceeded to VAPS while in 6 patients, VAPS was the initial treatment modality tried. We examined the effectiveness of VAPS in reducing AHI, improving oxygenation, and improving sleep architecture. Results Among the 11 patients, age was 63.0±12.1 yo, BMI was 33.7 ±4.5, 7 were males, Epworth sleepiness score was 9.3±4.9. The following significant changes from baseline PSG to VAPS titration were observed: AHI: 59.1± 8.0 to 27.2 ± 9.9 (p&amp;lt;.01); Time ≤ 88% O2 saturation (min): 48.1±14.5 to 15.4±6.1 (p&amp;lt;.05). Improvement in AHI was not related to gender, body mass index, narcotic use, or age. No significant changes in sleep architecture between the two studies were found. Ten (91%) patients had AHI &amp;gt; 30 on initial PSG. In 6 (55%) patients AHI was reduced to &amp;lt;15 with VAPS use. An additional patient had AHI reduced to 22.2, while 4 (36%) patients did not achieve an AHI &amp;lt; 30 with VAPS. Conclusion VAPS is an effective mode of treating CSA in the majority of patients. Support NA

Trans-oral robotic surgery versus coblation tongue base reduction for obstructive sleep apnea syndrome.

ObjectivesTo compare the efficacy of trans-oral robotic surgery (TORS) with that of coblation assisted tongue base reduction surgery in patients with obstructive sleep apnea syndrome (OSAS).Subjects and MethodsThe medical charts were retrospectively reviewed for all OSAS patients admitted to one institution for surgical intervention between 2012 and 2017. We analyzed 33 cases; 16 patients received TORS and 17 received coblation surgery for tongue base reduction. Both groups received concomitant uvulopalatoplasty. Surgical outcomes were evaluated by comparing the initial polysomnography (PSG) parameters with the follow-up PSG data (at least 3 months after the surgery). Epworth sleepiness scale (ESS) and complications were also compared between the 2 groups.ResultsThe success rate (≥50% reduction of pre-operative AHI and post-operative AHI <20) in the TORS group and coblation group were 50% and 58%, respectively, and there was no significant difference (p = .611). The AHI (mean ± SD) reduction in the TORS and coblation groups were 24.9 ± 26.5 events/h and 19.4 ± 24.8 events/h, respectively; the between-group difference was not significant (p = .631). ESS improvement did not differ significantly between the TORS and coblation groups (3.8 ± 6.6 and 3.1 ± 9.2, respectively, p = .873). The rates of minor complication were higher in the TORS group (50%) than that of the coblation group (35.3%) without statistical significance (p = .393).ConclusionTORS achieved comparable surgical outcomes compared to coblation assisted tongue base reduction surgery in OSAS patients. Multilevel surgery using either TORS or coblation tongue base reduction combined with uvulopalatoplasty is an effective approach for the management of OSAS.

Predictors of OSA on Home Sleep Test After Polysomnography

SESSION TITLE: Obstructive Sleep Apnea: Insights & Management SESSION TYPE: Original Investigation Slide PRESENTED ON: Sunday, October 29, 2017 at 01:30 PM - 03:00 PM PURPOSE: Polysomnography is considered the “gold standard” of obstructive sleep apnea (OSA) evaluation. In most populations, home sleep testing (HST) is an acceptable alternative to polysomnography (PSG). Limitation of PSG compared to HST include disruption of usual sleep habits in an unfamiliar environment which can lead to reduced sleep efficiency and a suboptimal real-life PSG. Understanding this limitation, there are no recommendations on when HST should be ordered after a PSG. We hypothesized that when a sleep physician ordered a HST after PSG, it would more likely change the sleep diagnosis and our aim was to identify the clinical characteristics more commonly seen in that group. METHODS: This was an observational retrospective study from 2/14/2012 thru 1/20/2015 including all patients who underwent a PSG and a subsequent HST under the discretion of the primary sleep physician. We excluded children <18 years old. Consent was waived secondary to the retrospective observational nature of the study. Each patient’s demographics, Epworth sleepiness scale, neck circumference, body mass index (BMI), medical, surgical and medication history were recorded. Variables were collected from each patient’s PSG and HST. RESULTS: One hundred seventy-seven patients underwent an in-lab PSG and had a subsequent HST. The initial PSG were grouped according to AHI <5.0 (n=149) or >AHI ≥5.0 (n=28). Of the 149 who had a PSG AHI <5.0, the HST revealed OSA in 84.5% (95 mild, 27 moderate, 4 severe). Of those 28 with PSG AHI≥5.0, the HST changed severity in 16/28 (57.1%). In 4 patients, the HST showed no OSA (2 mild, 1 moderate, 1 severe). The HST increased severity of OSA in 7 patients (5 mild to moderate, 2 mild to severe) and decreased severity in 5 patients (2 severe to mild, 1 moderate to mild, and 2 severe to moderate). Of the patients where the PSG was a false negative and the HST provided the diagnosis, they were more likely to be older (56.2 vs 47.8), have larger neck circumference (16.5 vs 15.3 in), suffered from hypertension (65.4% vs 37.5%), diabetes (22.0% vs 12.5%), and utilized a sleep aide (21.3% vs 16.7%). There appears to be no difference between the two groups in terms of sleep efficiency on the initial PSG (67.6% vs 64.6%), but there was more time spent with SpO2 ≤ 90% (25.6±70.6 vs 5.1 ±22.4 minutes) during the PSG. CONCLUSIONS: In this observational retrospective study, there are patients in which PSG may give a false negative study. Patients who have negative PSG and positive HST are more likely to be older, have larger necks, suffer from hypertension or diabetes, and appear to have utilized sleep aides. These risk factors may have played a role. The reason for the large number is that the physicians were likely relying on patient complaints and their own clinical decision making to determine when an HST was needed. CLINICAL IMPLICATIONS: Even though polysomnography continues to be the “gold standard” in OSA evaluation, in certain circumstances, an HST can diagnose OSA unidentified on polysomnography in patients suspected to have a sleep disordered breathing. DISCLOSURE: The following authors have nothing to disclose: Katie Lipatov, Adam Hayek, Chhaya Patel, Sarah Andry, Thomas Delmas, Shekhar Ghamande, Carl Boethel, Shirley Jones No Product/Research Disclosure Information

Polysomnographic findings in infants with Pierre Robin sequence.

INTRODUCTION:Pierre Robin sequence (PRS) is characterized by the triad of micrognathia, glossoptosis, and upper airway obstruction. It is commonly associated with the secondary cleft palate. Infants with PRS commonly have sleep-disordered breathing (SDB); including obstructive sleep apnea (OSA) as well as central sleep breathing abnormalities that are present from infancy.AIM OF THE STUDY:Evaluate the prevalence and severity of SDB in infants with PRS using polysomnography (PSG).SETTINGS AND DESIGN:We retrospectively reviewed the sleep laboratory database at The Hospital for Sick Children, Toronto, during the period of May 2007 to March 2016.STATISTICAL ANALYSIS:Comparisons of PSG data were made between the OSA and non-OSA group using the Student's t-test for age and body mass index, Wilcoxon signed ranks test for the continuous PSG data and Chi-squared test for the categorical variables.METHODS:Patients with PRS were identified and their initial PSG was selected for this study. The main indication for referral was ongoing concerns regarding OSA symptoms.RESULTS:A total of 46 patients (28 females) were included with a mean age (±standard deviation) of 0.8 (±0.3) year. Twenty-two out of 46 (47%) had evidence of OSA of which 10 had mild, 3 had moderate, and 9 had severe OSA. The PRS infants with OSA were younger than the non-OSA group. Significant correlations were found between desaturation and arousal indices with obstructive apnea–hypopnea index.CONCLUSION:This retrospective chart review confirms a high prevalence of OSA in this population. Prospective longitudinal studies are needed to evaluate the outcomes of OSA in PRS population.

Treatment of Obstructive Sleep Apnea Syndrome through Orthodontics and Orthognathic Surgery: A Case Report with a Five Year Follow-Up

Introduction: Obstructive sleep apnea (OSA) results from the presence of abnormal soft and hard tissues in the upper airway, which cause the collapse of the oropharynx in the deeper stages of sleep. Different treatment modalities have been proposed for OSA, aiming to offer a better quality of life for the patients. Orthognathic surgery via maxillary-mandibular advancement (MMA) decreases the collapse of soft and hard tissue structures during sleep and has a high success rate. The facial and occlusal improvement, the enhancement on respiratory function and the less morbid postoperative period are some advantages responsible for the growing acceptance of this technique. Case report: This case reports a combination of orthodontic treatment and orthognathic surgery via MMA in a 51 year old man with OSA. The initial polysomnography showed an apnea-hypopnea index of 49.2 and arousal index of 21.7. Follow-up polysomnography performed 15 months after surgery revealed significant improvement. The apneahypopnea index decreased to 2.9 and the arousal index to 12.3. The patient reported significant improvements in life quality, sleep quality, and nasal breathing capacity, as well as a decrease in daytime sleepiness and snoring. Thus far, the patient has been under postoperative follow-up for 5 years and 6 months, without any complaints of breathing difficulties during the day or night. Conclusion: The combination of orthodontic and surgical treatment via MMA may be a favorable alternative treatment for improving the respiratory symptoms of patients with OSA and is highly indicated for patients with maxillary-mandibular discrepancies.

Autonomic Nervous System: A Biomarker of Neurodevelopmental Comportment- the AuBE Study

Background: While a dysfunction of the autonomic nervous system (ANS) determined from the cardio-respiratory rhythms in children may represent a key criteria in the physiopathology of possible neurodevelopmental disorders, the normal thresholds and profile of the ANS maturation during the two first years of life have not been established. Method : The Autonomic Baby Evaluation (AuBE) study is a prospective observational prospective single-center cohort following a population of 302 consecutive term and preterm newborns. The primary objective of the “AuBE” prospective cohort is to define the autonomic nervous system maturity profile obtained, during the two first years of life, by repeated polysomnography and 24-hour ECG recordings, with a time scale values for each autonomic indices of interest and the secondary objective is to determine, the potential influence of this autonomic profile, on sleep disorders and on cognitive development at the age of 3. Parental questionnaires on sleep quality of children and mood status of the mother are collected at birth and at 6, 12, 18 and 24 months (i.e. M0, M6, M12, M18 and M24). A psychometric status is measured at 3 years for all children. Results: Study population was included between September 2009 and September 2011. During these two years, a cohort of 302 children was recruited, including 271 (89.7%) term, and 31 (10.3%) preterm newborns. After an initial polysomnography at birth (M0), Holter ECG recordings ECG Holter recordings were performed at M6, M12 M18 and M24. A temporal and frequency domain analysis of the heart rate variability is being performed on each recording. Conclusion: The strength of this study, is based on the longitudinal organization of a large cohort of newborns (n=302) including physiological maturation of cardiorespiratory systems drive, together with the quantitative and qualitative analysis of sleep and neurological and psychomotor outcome. The demonstration of such a link between autonomic disorders in the neonatal period and the subsequent onset of sleep and/or psychomotor disorders 3 years later may improve the monitoring of neonates and help schedule early and adapted therapeutic interventions.

Adenotonsillectomy for sleep-disordered breathing in a predominantly obese pediatric population

ObjectivesTo determine the efficacy of adenotonsillectomy (T&A) in the treatment of pediatric sleep-disordered breathing, and to determine the natural history in untreated children. MethodsThe charts of children aged 1–12 who underwent polysomnography (PSG) between 1/2006 and 6/2009 were reviewed to identify children with positive studies. Children not treated by T&A were recruited and matched by age, time since initial PSG, and apnea-hypopnea index (AHI) to children who underwent T&A. All participants were evaluated by a clinical assessment score (CAS-15), follow-up PSG, and the Child Behavior Checklist (CBCL). ResultsSixteen matched pairs completed the study. Ten (63%) T&A patients were overweight or obese compared with 14 (88%) untreated patients. There was a greater median improvement in AHI in the surgical group compared to the nonsurgical group (10.3 vs. 6.5, p=0.044). Although the T&A children were more likely to have a follow-up AHI<5 (81% vs. 69%) and <1 (44% vs. 25%), these results were not significant. The T&A group had significantly lower mean (SD) scores on the CAS-15 [8.9(6.1) vs. 29.4(16.2), p<0.001] and the CBCL total problem score [43.9(8.7) vs. 58.9(13.0), p<0.001]. Younger age at presentation (rho=−0.76, p<0.001), initial AHI (0.87, p<0.001), and initial AI (0.63, p=0.05) were correlated with change in AHI among T&A subjects. ConclusionsT&A was more effective in reducing AHI than no surgery. Median AHI improved in the nonsurgical group, and 4/16 (25%) untreated patients were cured (AHI<1).

Breathing irregularity during wakefulness associates with CPAP acceptance in sleep apnea

Individuals have different breathing patterns at rest, during wakefulness, and during sleep, and patients with sleep apnea are no different. The hypothesis for this study was that breathing irregularity during wakefulness associates with CPAP acceptance in obstructive sleep apnea (OSA). From a 2007-2010-database of patients with a diagnostic polysomnography (PSG) and prescribed CPAP (n = 380), retrospectively, 66 patients who quit CPAP treatment at 6 months were identified. Among them, 27 OSA patients quit despite having no side effects for discontinuing CPAP (Group A) and were compared to a matched group (age, body mass index, and apnea-hypopnea index) with good 6-month CPAP adherence (Group B; n = 21). Five minutes of respiratory signal during wakefulness at the initial PSG were extracted from respiratory inductance plethysmography recordings, and measured in a blinded fashion. The coefficients of variation (CV) for the breath-to-breath inspiration time (T i), expiration time (T e), T i + T e (T tot), and relative tidal volume, as well as an independent information theory-based metric of signal pattern variability (mutual information) were compared between groups. The CV for tidal volume was significantly greater (p = 0.001), and mutual information was significantly lower (p = 0.041) in Group A as compared to Group B. Differences in two independent measures of breathing irregularity correlated with CPAP rejection in OSA patients without nasal symptoms or comorbidity. Prospective studies of adherence should examine traits of breathing stability.