Comparison of Nasal Prong Pressure and Thermistor Measurements for Detecting Respiratory Events during Sleep

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1 Clinical Investigations Respiration 2004;71: DOI: / Received: August 25, 2003 Accepted after revision: March 16, 2004 Comparison of Nasal Prong Pressure and Thermistor Measurements for Detecting Respiratory Events during Sleep Ahmed BaHammam Sleep Disorders Center, Respiratory Unit, Department of Medicine, College of Medicine, King Saud University, Riyadh, Saudi Arabia Key Words Airflow W Nasal prong W Thermistor W Respiratory effort-related arousals W Apnea W Cannula Abstract Introduction and Objectives: Thermistor (TH) measurements have been traditionally used to determine airflow during polysomnographic studies (PSG). However, low accuracy in detecting hypopneas is a major drawback. Nasal prong pressure (NPP) measurements are becoming increasingly popular for quantifying respiratory events during sleep. We prospectively compared NPP and TH measurements with respect to their ability to detect respiratory events during routine PSG. Methods: Forty consecutive patients (26 male, 14 female) with clinically suspected sleep-disordered breathing (SDB) underwent routine diagnostic PSG. Airflow was measured using NPP and TH devices simultaneously. PSG was scored manually according to R and K criteria. Respiratory events were scored in two passes. During the first pass, the TH signal was disabled and the NPP signal was scored. During the second pass, the NPP signal was disabled and the TH signal was scored. Scorers for one method were blinded from the results of the other method. To assess respiratory events, we used the respiratory arousal index (RAI), which was defined as the number of apneas and/or hypopneas followed by an arousal per hour of sleep, as detected by TH (RAI-TH) or NPP (RAI- NPP). Agreement analysis of the results obtained using the two different techniques was performed using the methodology of Bland-Altman. Results: Twenty-six patients had obstructive sleep apnea, 10 had respiratory effort-related arousals and 4 had habitual snoring. The failure time of the flow signal on the raw data was not different between the two methods (NPP: 6 B 13 min, TH: 4 B 7 min). The Bland-Altman analysis of RAIs demonstrated that more events were nearly always detected using NPP compared to TH devices (44.4 B 37 vs B 31, p! 0.001). No difference in the index of central apneas between the two methods could be detected. Sleep position had no effect on either measurement method. Conclusions: NPP measurements are superior to TH measurements for detecting obstructive respiratory events during sleep. Measurement of NPP is a simple, practical, sensitive and reliable method for detecting the whole spectrum of SDB. We recommend incorporating nasal prongs in routine polysomnographic monitoring. Introduction Copyright 2004 S. Karger AG, Basel Obstructive sleep-disordered breathing (SDB) ranges from obstructive apneas and obstructive hypopneas to respiratory effort-related arousals (RERAs). Obstructive sleep apnea hypopnea syndrome (OSAHS) is characterized by a repetitive reduction or cessation of airflow dur- ABC Fax karger@karger.ch S. Karger AG, Basel /04/ $21.00/0 Accessible online at: Dr. Ahmed BaHammam, Associate Professor Director, Sleep Disorders Center Respiratory Unit, College of Medicine, Department of Medicine 38 King Saud University, Box 2925, Riyadh (Saudi Arabia) Tel , Fax ashammam2@yahoo.com or ashammam@ksu.edu.sa

2 ing sleep caused by partial or complete upper airway occlusion in the presence of respiratory efforts. Airflow measurement is vital for the diagnosis of respiratory events during sleep. Although there is universal consensus on the definition of apnea in adults, the definition of hypopnea continues to include various criteria. Reduction in airflow is an essential sign for a hypopnea diagnosis [1]. The method used to measure flow may influence the diagnosis of OSAHS and its perceived severity. Different scoring criteria for hypopneas may result in varying apnea-hypopnea indices [2]. In the American Academy of Sleep Medicine (AASM) Task Force report, the reference standard for measuring flow in OSAHS is achieved using a pneumotachometer placed in a well-fitted mask, while RERA identification is achieved by measuring esophageal pressure [3]. However, sleep technologists and patients realize that both techniques are cumbersome. The use of the pneumotachometer is limited by patient discomfort from the tightly fitting facemask making it often unsuitable for clinical respiratory studies during sleep, while esophageal pressure monitoring is an invasive technique that can have a negative effect on the sleep architecture [4, 5]. Thus, more practical methods for measuring airflow are being used in daily practice. Traditionally, thermal devices such as thermistors (TH) and thermocouples have been used to detect OSAHS during polysomnography (PSG). These devices measure the heat content of passing air, providing an indirect qualitative assessment of airflow. It appears these approaches do not always reliably identify hypopnea [6] and RERAs, and occasionally cannot distinguish central from obstructive apnea-hypopneas [3]. Nasal prong pressure (NPP) measured using nasal prongs has recently been proposed as an accurate method for measuring minimal changes in airflow in both hypopneas and RERAs [7]. NPP devices measure airflow directly and quantitatively with a pneumotachograph that detects changes in nasal pressure during respiration. However, concerns were recently raised that NPP measurements may lead to higher failure rates of flow signal, overestimation of apneas and hypopneas, and that there is a lack of signal upon breathing shifting from the nose to the mouth [8]. The present study examined airflow using NPP and TH devices to determine which method was better for detecting respiratory events during routine polysomnographic studies in consecutive patients with clinically suspected SDB. We hypothesized that most concerns regarding NPP do not have significant clinical implications and do not preclude the routine use of NPP measurements in overnight sleep studies. Materials and Methods The study subjects were 40 consecutive patients with clinically suspected SDB, comprising 26 males and 14 females with a mean age of 45.8 B 14.6 years, body mass index of 36.2 B 11.9 kg/m 2 and an Epworth Sleepiness Scale (ESS) of 10.4 B 5.9, who were referred to the Sleep Disorders Center (SDC) at the University Hospital for an overnight sleep study (PSG). Patients for continuous positive airway pressure titration were not included. Each patient had been evaluated in the sleep disorders clinic before PSG. Patients with a history of nasal blockade at the time of PSG and those with obvious nasal septal deviation were not included. Polysomnography Alice -4 diagnostic equipment (Respironics/HealthDyne, Pa., USA) was used for data acquisition. The patients were connected to the monitoring machine (hook-up process) by a trained technician who remained in the SDC control room throughout the study in order to monitor the recording. During PSG, the following parameters were monitored: four EEG (C1-A4, C2-A3, O1-A4, O2-A3), chin EMG, EOG (eye movement), leg EMG, EKG, oxygen saturation, chest and abdominal wall movements, sleep position, and snoring (using a microphone). Airflow Measurement Airflow was measured using two methods simultaneously: (1) Alice-4 built in oral/nasal TH and (2) NPP (ProFlow nasal cannula, PTAF Pressure Transducer, Pro-Tech, USA). The amplifier gain and filter settings used for NPP were as follows: gain: 500 ÌV, high pass: 0.1 Hz, low pass: 15 Hz and 60 Hz, filter: on. For each study, an initial calibration was performed, during which the gain settings for each device were slightly modified to achieve good signal strength during normal breathing. Analysis and Scoring of Sleep Studies Analysis and scoring of sleep and breathing were done manually epoch (30 s) by epoch. Total sleep time and sleep efficiency are shown in this paper. The effect of the sleep position on each monitoring method was assessed. Sleep scoring and arousals of each record were scored according to established criteria [9, 10]. To assess respiratory events, we used a respiratory arousal index (RAI), which was defined as the number of apneas and/or hypopneas followed by an arousal per hour of sleep, as detected by TH (RAI-TH) or NPP (RAI-NPP). Respiratory event scoring was performed in two separate passes by two trained and experienced sleep technicians working independently and blinded to the other scorer s results. In addition, each scorer was blinded to the results of the breathing analysis made using the other scoring method. Reports were generated using Alice-4 software. The average score of the two scorers was used in the final analysis. In the first respiratory pass, the TH flow signal was not displayed on the screen and respiratory events were identified from the NPP flow signal using the following definitions: obstructive apneas were identified as a decrease in peak inspiratory flow to below 10% of the surrounding baseline for at least 10 s; central apneas were defined as the absence of flow and rib/thoracic movement during the event for at least 10 s, and hypopneas were defined as a decrease in flow amplitude for two or more consecutive breaths followed by arousal regardless of oxygen desaturation associated with paradoxical movements of the chest and abdominal belts (to minimize the possibility of shift- 386 Respiration 2004;71: BaHammam

3 ing from nasal to mouth breathing). One week later, a second scoring pass was performed after rescanning the data to delete all tagged events in the raw data. During the second pass, the NPP signal was not displayed on the computer screen and obstructive respiratory events were identified from the TH flow signal using the following definitions: obstructive apneas were identified as a decrease in peak inspiratory flow to below 10% of the surrounding baseline for at least 10 s; central apneas were defined as the absence of flow and rib/ thoracic movement during the event for at least 10 s, and hypopneas were defined as any visually appreciable decrease in flow amplitude for two or more consecutive breaths followed by arousal regardless of oxygen desaturation. Based on our scoring results, we classified patients into three groups: obstructive sleep apnea (OSA), RERAs and habitual snoring (HS), based on previously published criteria [11]. OSA was defined as RAI-TH 615 [12]. RERAs were defined as RAI-TH! 15, frequent EEG arousals in association with flow-limited respiration determined by NPP, excessive daytime sleepiness and no other sleep abnormality [13]. HS was defined as RAI-TH! 15, normal sleep study, and an absence of clinical symptoms [14]. Statistical Analysis Data are expressed as mean B standard deviation. A comparison between the two methods was made using paired t tests. The results were considered statistically significant at the p = 0.05 level. Pearson s correlation was used to assess the relationship between RAI-TH and RAI-NPP. An agreement analysis between the results obtained by the two different methods was performed following the methodology of Bland and Altman [15]. Results Complete data were available for all 40 patients. Total sleep time during monitoring was 253 B 90 min with a sleep efficiency of 75 B 18%. In 4 of the 40 patients (10%), technicians were required to refix the NPP device due to poor signal, while no such adjustments were required for the TH device. The failure time of the flow signal (total loss of signal) on the raw data was not significantly different between the two methods (NPP: 6 B 13 min, TH: 4 B 7 min). Patient demographic and polysomnographic characteristics are shown in table 1. There were 26 patients with OSA, 10 with RERAs and 4 with HS. Patients with HS were younger than those with OSA and RERAs. Patients with HS and RERAs had a lower body mass index compared to OSA patients. ESS scores were high in both OSA and RERAs. Sleep efficiency was reduced in OSA compared to the RERAs and HS groups. NPP measurements provided a good association between arousals and respiratory events in patients with RERAs, whereas TH data rarely indicated this association. Incidentally, OSA patients in this study had very high RAIs. Total respiratory events detected by the NPP and TH methods were 1,792 and 1,422 events/h, respectively. Table 1. Demographic and polysomnographic patient information OSA (n = 26) RERAs (n = 10) HS (n = 4) Age, years 49.4B B B15 Male/female 17/9 6/4 3/1 ESS 11B5 12.2B3.3 4B2 BMI 38B B7 33.8B3.7 TST, min 247B75 270B88 252B63 Sleep efficiency, % 71B B9 8 3B12.3 Arousal index, h 1 65B29 19B88.5B3 RAI-TH, h 1 56B34 7.4B3 4.9B1.3 RAI-NPP, h 1 62B B B2.4 ESS = Epworth Sleepiness Scale; BMI = body mass index; TST = total sleep time. Table 2. Abnormal respiratory events identified using NPP and TH methods TH, n/h NPP, n/h p value RAI 35.4B B37! Central apnea 0.67B B1.4 NS Obstructive apnea 7.3B B Mixed apnea 0.8B B2 NS Hypopnea 26.7B B RAI supine 47.4B3853.2B39! RAI lateral 3.8B6 5.4B Table 2 summarizes the data obtained using the two approaches. The RAI was significantly less using TH compared to NPP data. Figure 1 shows a typical example of an obstructive event, demonstrating flattening of the NPP signal and paradoxical thoracic and abdominal wall movements followed by arousal, while no changes were seen in the TH signal. Although the relationship between RAI-TH and RAI-NPP showed an excellent correlation (R = 0.99, p ), the relationship between the two different methods showed a systematic bias that could be observed in the Bland and Altman [15] agreement analysis (fig. 2). For the whole group, the RAI was almost always below the identity line, reflecting underrecognition of obstructive events by the TH. The mean difference in RAI between the two methods was 8.5/h (p! 0.001). The difference was significant in obstructive apneas and hypopneas. The difference between the NPP and TH methods in detecting obstructive apneas was greater than the difference in detecting hypopneas. This is probably due to Nasal Prong Pressure vs. Thermistor Respiration 2004;71:

4 C3A1 O2A2 Chin EMG Thermistor NPP Thorax Abdomen Microphone SaO2 Leg EMG 1 Fig. 1. Thirty-second recording of a typical apneic event recorded by NPP associated with paradoxical movements of the thoracic and abdominal wall signals and followed by arousal. No change in the TH flow signal is seen. Fig. 2. Bland-Altman agreement plot: the mean values of the RAI of TH and NPP are represented on the x-axis, while on the y- axis, their difference (TH NPP) is represented. The dotted lines are the mean difference B2 SD. The continuous line represents the identity line. Fig. 3. The difference in the RAI between NPP and TH expressed as mean B standard error of the mean as a function of the mean RAI (TH) Respiration 2004;71: BaHammam

5 the fact that conventional hypopneas detected by TH are scored as apneas using NPP, which could account for the significantly higher apnea index obtained with NPP. No difference in the indices of mixed and central apneas between the two methods could be detected. NPP maintained its superiority in detecting obstructive respiratory events in all sleep positions. We frequently observed events that caused a flattening of the NPP flow signal but no change to the TH signal. Those events were not scored unless they were associated with arousal. Such events may represent periods of increased upper airway resistance. However, as we did not use an esophageal pressure monitor (the gold standard diagnostic test for detecting increased upper airway resistance) in this study, we elected not to include those events in the final analysis. The difference in the RAI between NPP and TH measurements tended to increase as a function of the mean RAI (fig. 3). However, the difference was still important even at the clinically useful lower diagnostic thresholds. At an RAI threshold of 10 events/h, 10% of the patients (4 of 40) would have been missed if monitored by TH alone. Discussion To date, the predominant techniques for assessing oral/nasal airflow during sleep involve the use of thermocouple or TH technology. However, the possibility of not detecting hypopneas or increased upper airway resistance while using the TH alone remains a genuine concern. In the present study on patients suspected of having obstructive SDB, we compared airflow signals using TH and NPP devices, and examined the effect of data generated using these two systems on the final diagnosis. Our results indicate that measuring airflow with an NPP device is superior to measuring airflow using TH technology. TH measurements significantly underestimated both apneic and hypopneic events. Measuring the flow signal using NPP during sleep studies was simple and more accurate in detecting obstructive events. Our findings concur with the few reports that have compared the two methods. Norman et al. [16] found that almost all events detected by a TH were also detected using NPP, but that events completely missed by a TH were recognized in NPP measurements. Other authors have recently reported similar findings showing increased sensitivity of NPP measurements compared to TH measurements [17, 18]. In the present study, many hypopneas scored using the TH were scored as apneas according to NPP, resulting in a significant difference in the apnea index between the two methods. Similar findings were recently reported where 39% of hypopneas scored using a TH were scored as apneas using NPP [17]. Additionally, NPP has the advantage of detecting RERAs or what is known as the upper airway resistance syndrome. Recent studies comparing the signal from esophageal manometry with the signal from NPP demonstrated that the NPP transducer provided noninvasive detection of all SDB events, and detected the same events as esophageal manometry [7, 19]. Previous reports have raised concerns regarding NPP measurements. One concern is loss of NPP signal due to obstruction by secretion or displacement from nares. Sériés and Marc [17] reported that technicians had to reposition the nasal catheter at least once in up to 35% of the NPP recordings. In contrast, repositioning of the nasal catheter was required in only 4 patients (10%) in the present study, and displacement rates have also been low in our other patients. A low displacement rate was reported by Hernández et al. [18], who encountered a loss of signal in 11% of the patients (3 of 27) during some period of the trace. In agreement with our findings, that study reported a low failure rate, with the total loss of signal never exceeding 10 min [18]. Another problem with NPP is mouth breathing during sleep. Many patients either spontaneously, or in response to respiratory disturbance, change the major passage for airflow from the nose to the mouth during sleep, which may result in a decline in the NPP airflow signal. Although this problem was reported recently by Sériés and Marc [17], they found an increase in effort (measured by esophageal balloon) in these kinds of events similar to that found in typical obstructive respiratory events. Therefore, they considered changes in the NPP signal with mouth breathing equivalent to true obstructive breathing disorders that are included in the apnea-hypopnea index. Nevertheless, to minimize this effect in our study, we included paradoxical movement of the thoracic and abdominal belts as a criterion in obstructive events. A further concern with NPP is that when only NPP data are analyzed there is the potential to exaggerate changes in airflow resulting in an overestimation of the amount of apnea. The relationship between pressure and flow in NPP measurements is nonlinear. The pressure in the cannula is roughly proportional to the square of the flow, causing airflow changes to be exaggerated such that a 50% drop in airflow may appear as a 75% drop. Some investigators have tried to linearize this relationship using a square root transformation [20], however the relation- Nasal Prong Pressure vs. Thermistor Respiration 2004;71:

6 ship among these signals was highly variable if comparisons were extended over the whole night. Furthermore, such transformations have not been shown to improve the accuracy of apnea-hypopnea index scoring compared with an analysis of the nasal pressure raw signal. Others used a linearizing circuit [21], but this is not commercially available at present. We believe that this problem can be overcome by only scoring flow limitations that are followed by arousals, as this will indicate true upper airway narrowing and increased upper airway resistance. Another issue is the effect of the nasal cannula on nasal airflow resistance. Lorino et al. [22] showed that the NPP apparatus could markedly increase nasal airway resistance in subjects with narrowness of the nares or a deviated nasal septum. This effect was minimized by using an internal nasal dilator [23]. The clinical significance of these changes in nasal resistance as regards sleep architecture and the diagnosis of OSA is not yet known. It is important to note that the above concerns regarding NPP signal analysis are currently all theoretical, and have not been shown to have significant clinical implications in the final diagnosis. The present study confirms previous work showing the superiority of NPP compared to TH readings in detecting obstructive events during polysomnographic monitoring. The importance of NPP becomes clearer in regard to mild events that can be missed using the TH alone, potentially leading to inaccurate diagnoses. Moreover, NPP has the advantage of detecting RERAs usually missed using the TH alone. NPP is a simple, practical, sensitive and reliable method for detecting the whole spectrum of SDB. Therefore, we recommend incorporating nasal prongs in routine polysomnographic monitoring. Acknowledgments The author thanks SDC sleep technicians Saji Thomas and Eden Peirella, and Dr. Shaffi Shaikh for advice in statistical analysis. References 1 Philips BA, Anstead MI, Gottleib DJ: Monitoring sleep and breathing: Methodology. I. Monitoring breathing. Clin Chest Med 1998;1: Manser RL, Rochford P, Pierce RJ, Byrnes GB, Campbell DA: Impact of different criteria for defining hypopneas in the apnea hypopnea index. Chest 2001;120: American Academy of Sleep Medicine Task Force: Sleep related breathing disorders in adults: Recommendation for syndrome definition and measurement techniques in clinical research. Sleep 1999;22: Chevrin RD, Aldrich MS: Effects of esophageal pressure monitoring on sleep architecture. Am J Respir Crit Care Med 1997;156: Loiodice C, Selek M, Loire M, Levy P, Pepin JL: Measurement of respiratory effort (esophageal pressure) and estimation of resistance of the upper airway in polysomnography: Indications, limitations and results. Neurophysiol Clin 1998;28: Farré R, Montserrat JM, Rotger M, Ballester E, Navajas D: Accuracy of thermistors and thermocouples as flow-measuring devices for detecting hypopneas. Eur Respir J 1998;11: Ayappa I, Norman RG, Krieger AC, Rosen A, O Malley RL, Rapoport DM: Non-invasive detection of respiratory effort-related arousals (RERAs) by a nasal cannula/pressure transducer system. Sleep 2000;23: Kerl J, Köhler D, Schönhofer B: The application of nasal and oronasal cannulas in the detection of respiratory disturbances during sleep: A review. Somnologie 2002;6: Rechtschaffen A, Kales A: A Manual of Standardized Terminology, Techniques and Scoring System for Sleep Stages of Human Subjects. NIH Publication No Washington, US Government Printing Office, EEG arousals: Scoring rules and examples: A preliminary report from the Sleep Disorders Atlas Task Force of the American Sleep Disorders Association. Sleep 1992;15: Epstein MD, Chicoine SA, Hanumara RC: Detection of upper airway resistance syndrome using a nasal cannula/pressure transducer. Chest 2000;117: Strollo PJ, Rogers RM: Obstructive sleep apnea. N Engl J Med 1996;334: Guilleminault C, Stoohs R, Shiomi T, et al: A cause of excessive daytime sleepiness: The upper airway resistance syndrome. Chest 1993; 104: Thorpy MJ: The International Classification of Sleep Disorders, Revised. Diagnostic and Coding Manual. Rochester, American Sleep Disorders Association, Bland MJ, Altman DG: Statistical methods for assessing agreement between two methods of clinical measurement. Lancet 1986;i: Norman RG, Ahmed MM, Walsleben JA, Rapoport DA: Detection of respiratory events during NPSG: Nasal cannula/pressure sensor versus thermistor. Sleep 1997;20: Sériés F, Marc I: Nasal pressure recording in the diagnosis of sleep apnea hypopnea syndrome. Thorax 1999;54: Hernández L, Ballester E, Farré R, Badia JR, Lobelo R, Navajas D, Montserrat JM: Performance of nasal prongs in sleep studies: Spectrum of flow related events. Chest 2001;119: Hosselet JJ, Norman RG, Ayappa I, Rapoport DM: Detection of flow limitation with a nasal cannula/pressure transducer system. Am J Respir Crit Care Med 1998;157: Thurnheer A, Xiaobin X, Block K: Accuracy of nasal cannula pressure recordings for assessment of ventilation during sleep. Am J Respir Crit Care Med 2001;164: Farré R, Rigau J, Montserrat JM, Ballester E, Navajas D: Relevance of linearizing nasal prongs for assessing hypopneas and flow limitation during sleep. Am J Respir Crit Care Med 2001;163: Lorino AM, Lorino H, Dahan E, d Ortho MP, Coste A, Harf A, Lofaso F: Effects of nasal prongs on nasal airflow resistance. Chest 2000; 118: Lorino AM, d Ortho MP, Dahan E, Bignani O, Vastel C, Lorino H: Combined effects of a nasal dilator and nasal prongs on nasal airflow resistance. Chest 2001;120: Respiration 2004;71: BaHammam

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