Free AccessOximetry - Home Sleep Apnea Test - CommentaryReady for Primetime? Home Sleep Apnea Tests for Children Rakesh Bhattacharjee, MD Rakesh Bhattacharjee, MD Address correspondence to: Rakesh Bhattacharjee, Associate Professor of Clinical Pediatrics, Section of Respiratory Medicine, Department of Pediatrics, 9500 Gilman Drive #0984, La Jolla CA 92093(858) 966-5846(858) 966-7732 E-mail Address: [email protected] University of California San Diego, La Jolla, California Search for more papers by this author Published Online:May 15, 2019https://doi.org/10.5664/jcsm.7748Cited by:2SectionsPDF ShareShare onFacebookTwitterLinkedInRedditEmail ToolsAdd to favoritesDownload CitationsTrack Citations AboutINTRODUCTIONGiven an increased awareness of the complications related to pediatric obstructive sleep apnea (OSA),1,2 measures to improve the diagnosis of pediatric OSA are of paramount importance. Studies have defined prevalence rates of pediatric OSA ranging from 2% to 5% of all children.3,4 The challenges to adequately identify pediatric OSA are largely related to an insufficiency of resources to diagnose pediatric OSA, specifically the lack of access to pediatric polysomnography (PSG) laboratories, pediatric trained sleep physicians, and pediatric trained sleep technologists. Not surprising, in most cases where surgery is offered to treat pediatric OSA, most surgery is performed without PSG to confirm a diagnosis.5In the study by Masoud and colleagues6 published in this issue of the Journal of Clinical Sleep Medicine, the investigators sought to evaluate the utility of a level 3 portable monitor (PM) device to diagnose pediatric OSA in children age 7 to 17 years. The key findings of their study reveal that compared to PSG, identification of the apnea-hypopnea index (AHI) by a level 3 PM was strongly correlated to AHI determined using standard in-laboratory level 1 PSG (r = .932, P < .001). Further, this correlation was strongest in older children (age 12 to 17 years). Level 3 PM also demonstrated high sensitivity and specificity to diagnose severe OSA (AHI > 10 events/h), but was inferior to mild and moderate cases of OSA. Finally, the authors evaluated the frequency of “bad data” recorded by PM and compared autoscoring to manual scoring. They reported improvements in diagnostic utility with manual scoring following exclusion of “bad data.”Before level 3 PM can be enthusiastically accepted in the arena of pediatric sleep medicine, several comments must be made. The authors reported 15 of the 85 (∼18%) included PM studies had failed. Although this is not far discrepant from previous studies by Lesser et al.7 and Massicotte et al.,8 this should be considered a rather high failure rate for studies that were attended by night technologist and for older children. The authors cite that most study failures were related to poor oximetry signal and that most inaccuracy was related to oxygen desaturation artifact.The authors did not report a high frequency of failed studies related to poor airflow signals. As they stated, if airflow was poor quality or interrupted during the recording, the night technologist was present to adjust and correct the problem, implying the feasibility of their study design was enhanced by having recordings attended by a sleep technologist. In one of the few studies examining unattended PM in children in their home environment, Marcus et al.9 reported that the nasal pressure signal was satisfactory for ≥ 75% of PM recording time in only 67% of children. This supports the notion that nasal canula-based flow signals are often suboptimal when pediatric studies are not continuously monitored by a sleep technologist.In contrast to the study by Masoud and colleagues,6 the study by Marcus et al.9 was an evaluation of a level 2 PM device in which there was the inclusion of electroencephalogram, bilateral electrooculogram, and submental and tibial electromyogram leads. In contrast to level 3 PM, this study was able to discern events that culminated in cortical arousal rather than just oxyhemoglobin desaturation. Further, Marcus et al. reported greater signal stability of these leads in children compared to nasal flows in an unattended home setting. The addition of these signals should further improve the accuracy of AHI by including events that lead to cortical arousals exclusively, but also by confirming whether the child is asleep during an obstructive event. In addition, level 2 PM has the ability to identify rapid eye movement (REM) sleep, which compared to non-REM (NREM) sleep, is more typically associated with obstructive sleep-disordered breathing in children.10 Identifying sleep stages improves characterization of pediatric OSA through determination of REM and NREM AHI indices.Despite the inability to stage sleep or identify cortical arousal, Masoud and colleagues6 report excellent sensitivity and specificity in diagnosing pediatric OSA using a level 3 PM device. Certainly, an attempt to improve oximetry signals in their device would have resulted in fewer failed studies and even greater detection of respiratory events. A recent study by Hornero et al.11 in a very large cohort of children across 13 pediatric sleep centers placed emphasis on accurate oximetry signals. The authors suggest that these signals alone can be used to adequately diagnose pediatric OSA.Taken together, findings by Masoud and colleagues6 add a certain level of excitement that home sleep apnea tests may help improve the diagnosis of pediatric OSA with the potential to reduce, if not eliminate, the issue of access of sleep testing in children. However, implementation of PM may still need further refinement to improve signal stability and additional studies12 would be needed that carefully evaluate their accuracy in the setting that these were originally developed for, in the child's home, where the study would be unattended.DISCLOSURE STATEMENTDr. Bhattacharjee reports no conflicts of interest.CITATIONBhattacharjee R. Ready for primetime? Home sleep apnea tests for children. J Clin Sleep Med. 2019;15(5):685–686.REFERENCES1 Tan HL, Gozal D, Kheirandish-Gozal LObstructive sleep apnea in children: a critical updateNat Sci Sleep20135109123 Google Scholar2 Bhattacharjee R, Kheirandish-Gozal L, Pillar G, Gozal DCardiovascular complications of obstructive sleep apnea syndrome: evidence from childrenProg Cardiovasc Dis2009515416433 CrossrefGoogle Scholar3 Lumeng JC, Chervin RDEpidemiology of pediatric obstructive sleep apneaProc Am Thorac Soc200852242252 CrossrefGoogle Scholar4 Marcus CL, Brooks LJ, Draper KA, et al.Diagnosis and management of childhood obstructive sleep apnea syndromePediatrics20121303576584 CrossrefGoogle Scholar5 Mitchell RB, Pereira KD, Friedman NRSleep-disordered breathing in children: survey of current practiceLaryngoscope20061166956958 CrossrefGoogle Scholar6 Masoud AI, Patwari PP, Adavadkar PA, Arantes H, Park C, Carley DWValidation of the MediByte portable monitor for the diagnosis of sleep apnea in pediatric patientsJ Clin Sleep Med2019155733742 LinkGoogle Scholar7 Lesser DJ, Haddad GG, Bush RA, Pian MSThe utility of a portable recording device for screening of obstructive sleep apnea in obese adolescentsJ Clin Sleep Med201283271277 LinkGoogle Scholar8 Massicotte C, Al-Saleh S, Witmans M, Narang IThe utility of a portable sleep monitor to diagnose sleep-disordered breathing in a pediatric populationCan Respir J20142113135 CrossrefGoogle Scholar9 Marcus CL, Traylor J, Biggs SN, et al.Feasibility of comprehensive, unattended ambulatory polysomnography in school-aged childrenJ Clin Sleep Med2014108913918 LinkGoogle Scholar10 Marcus CLSleep-disordered breathing in childrenAm J Respir Crit Care Med200116411630 CrossrefGoogle Scholar11 Hornero R, Kheirandish-Gozal L, Gutierrez-Tobal GC, et al.Nocturnal oximetry-based evaluation of habitually snoring childrenAm J Respir Crit Care Med20171961215911598 CrossrefGoogle Scholar12 Tan HL, Kheirandish-Gozal L, Gozal DPediatric home sleep apnea testing: slowly getting there!Chest2015148613821395 CrossrefGoogle Scholar Previous article Next article FiguresReferencesRelatedDetailsCited byHome portable monitoring for the diagnosis of sleep-disordered breathing in adolescents and adults with neuromuscular disorders: not yet ready for prime timeHunasikatti M Journal of Clinical Sleep Medicine, Vol. 17, No. 12, (2565-2566), Online publication date: 1-Dec-2021. Validity and Cost-Effectiveness of Pediatric Home Respiratory Polygraphy for the Diagnosis of Obstructive Sleep Apnea in Children: Rationale, Study Design, and MethodologyOceja E, Rodríguez P, Jurado M, Luz Alonso M, del Río G, Villar M, Mediano O, Martínez M, Juarros S, Merino M, Corral J, Luna C, Kheirandish-Gozal L, Gozal D and Durán-Cantolla J Methods and Protocols, 10.3390/mps4010009, Vol. 4, No. 1, (9) Volume 15 • Issue 05 • May 15, 2019ISSN (print): 1550-9389ISSN (online): 1550-9397Frequency: Monthly Metrics History Submitted for publicationApril 17, 2019Submitted in final revised formApril 17, 2019Accepted for publicationApril 17, 2019Published onlineMay 15, 2019 Information© 2019 American Academy of Sleep MedicinePDF download