Validation of mandibular movements' analysis to measure sleep in adults with sleep complaints by comparison with actigraphy and polysomnography.

Objective: In adults with sleep complaints, we assessed the software of automatic analysis of mandibular movements to identify sleep and wake states by confrontation with the polysomnography (PSG) and the actigraphy (ACTG). Material and Methods: Simultaneous and synchronized in-lab PSG, ACTG, and JAWAC were carried out in 100 patients with a sleep complaint. Epoch by epoch analysis was realized to assess the ability to sleep-wake distinction. Sleep parameters as measured by the three devices were compared. These included three regularly reported parameters: total sleep time (TST), sleep onset latency (SOL), and wake after sleep onset (WASO). Also, two supplementary parameters, wake during sleep period (WDSP) and latency to arising (LTA) were added to measure separately the quiet wakefulness states. Results: The epoch by epoch analysis showed that the JAWAC, as compared to ACTG, classified sleep and wake states with greater specificity, while the overall accuracy and sensitivity of the two devices were comparable. The sleep parameters analysis showed that for the JAWAC estimates, the differences in TST, SOL, and LTA values were not statistically significant. However, WDSP and subsequently WASO were slightly underestimated. In contrast, the dissimilarities between ACTG estimates and PSG measurements of all the above sleep parameters were statistically significant; TST was overestimated whilst SOL, LTA, WDSP, and WASO were underestimated. Conclusion: This study indicated that, besides its ability to reliably estimate TST, the JAWAC based on mandibular movements' analysis was able, in adults with sleep complaints, to overcome the important problem of the recognition of the state of quiet wakefulness.

Comparison of clinical scores in their ability to detect hypoxemic severe OSA patients.

BACKGROUND: Severe obstructive sleep apnea (sOSA) and preoperative hypoxemia are risk factors of postoperative complications. Patients exhibiting the combination of both factors are probably at higher perioperative risk. Four scores (STOP-Bang, P-SAP, OSA50, and DES-OSA) are currently used to detect OSA patients preoperatively. This study compared their ability to specifically detect hypoxemic sOSA patients. METHODS: One hundred and fifty-nine patients scheduled for an overnight polysomnography (PSG) were prospectively enrolled. The ability of the four scores to predict the occurrence of hypoxemic episodes in sOSA patients was compared using sensitivity (Se), specificity (Sp), Youden Index, Cohen kappa coefficient, and the area under ROC curve (AUROC) analyses. RESULTS: OSA50 elicited the highest Se [95% CI] at detecting hypoxemic sOSA patients (1 [0.89-1]) and was significantly more sensitive than STOP-Bang in that respect. DES-OSA was significantly more specific (0.58 [0.49-0.66]) than the three other scores. The Youden Index of DES-OSA (1.45 [1.33-1.58]) was significantly higher than those of STOP-Bang, P-SAP, and OSA50. The AUROC of DES-OSA (0.8 [0.71-0.89]) was significantly the largest. The highest Kappa value was obtained for DES-OSA (0.33 [0.21-0.45]) and was significantly higher than those of STOP-Bang, and OSA50. CONCLUSIONS: In our population, DES-OSA appears to be more effective than the three other scores to specifically detect hypoxemic sOSA patients. However prospective studies are needed to confirm these findings in a perioperative setting. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov: NCT02050685.

Validation of midsagittal jaw movements to measure sleep in healthy adults by comparison with actigraphy and polysomnography.

OBJECTIVE: In a device based on midsagittal jaw movements analysis, we assessed a sleep-wake automatic detector as an objective method to measure sleep in healthy adults by comparison with wrist actigraphy against polysomnography (PSG). METHODS: Simultaneous and synchronized in-lab PSG, wrist actigraphy and jaw movements were carried out in 38 healthy participants. Epoch by epoch analysis was realized to assess the ability to sleep-wake distinction. Sleep parameters as measured by the three devices were compared. This included three regularly reported parameters: total sleep time, sleep onset latency, and wake after sleep onset. Also, two supplementary parameters, wake during sleep period and latency time, were added to measure quiet wakefulness state. RESULTS: The jaw movements showed sensitivity level equal to actigraphy 96% and higher specificity level (64% and 48% respectively). The level of agreement between the two devices was high (87%). The analysis of their disagreement by discrepant resolution analysis used PSG as resolver revealed that jaw movements was right (58.9%) more often than actigraphy (41%). In sleep parameters comparison, the coefficient correlation of jaw movements was higher than actigraphy in all parameters. Moreover, its ability to distinct sleep-wake state allowed for a more effective estimation of the parameters that measured the quiet wakefulness state. CONCLUSIONS: Midsagittal jaw movements analysis is a reliable method to measure sleep. In healthy adults, this device proved to be superior to actigraphy in terms of estimation of all sleep parameters and distinction of sleep-wake status.

Risk factors for nocturnal hypoxemia in severe obstructive sleep apnea patients.

BACKGROUND: Severe obstructive sleep apnea (sOSA) and oxygen desaturations are both risk factors for postoperative complications. In some but not all patients, sOSA is associated with frequent oxygen desaturation episodes during sleep. The aim of this retrospective study was to identify the risk factors for exhibiting oxygen desaturation in patients with sOSA. METHODS: Records of 786 patients, mainly obese (Body Mass Index [mean+SD]=30.2+6.0 kg/m2), were analyzed. Univariate and multivariate analyzes were applied to identify predictive risk factors for oxygen desaturation. Prediction probability was used to test the association between potential risk factors (obesity, age, gender, smoking, alcohol consumption, and benzodiazepines use) and the combination of sOSA and oxygen desaturation. A P value <0.05 was considered as statistically significant. RESULTS: Univariate and multivariate analyses identified five risk factors for oxygen desaturation in the whole population: age (P<0.001), obesity (P<0.001), benzodiazepine use (P<0.001), smoking (P=0.016), and male gender (P=0.029). The same analyses applied to patients with sOSA identified two independent risk factors for oxygen desaturation: obesity (P<0.001), and benzodiazepine use (P=0.017). Obesity obtains the best prediction probability [95% CI] for the combination of sOSA and oxygen desaturation: 0.74 [0.69-0.79]. A BMI >49 kg/m2 was associated with a 50% probability of combining severe OSA and nocturnal oxygen desaturation. CONCLUSIONS: Less than 50% of patients with sOSA experience nocturnal oxygen desaturation. Obesity and daily benzodiazepine intake are independent risk factors for these patients to exhibit nocturnal oxygen desaturation. Benzodiazepine in obese patients with sOSA should, therefore, be used cautiously.

Three-dimensional analysis of craniofacial bones and soft tissues in obstructive sleep apnea using cone beam computed tomography.

A total of 154 adult patients with sleep complaints underwent a polysomnography and a craniofacial cone beam computed tomography (CBCT). OSA was defined as an apnea and hypopnea index (AHI) or an oxygen desaturation index (ODI) ≥ 10. Soft tissues and craniofacial bones volumes were prospectively measured by CBCT and collected blindly from sleep polysomnography. Among the study patients, 127 (83%) suffered from OSA and 27 (17%) did not. OSA patients demonstrated a narrower maxillo-palatine core volume (11.7±3.2 vs 14.6±4.9cm3) even when adjusting for age, gender, height, neck circumference and body mass index. These upper airway measures provide a comprehensive analysis of bony structures and soft tissues, which can be involved in OSA.

Development and Validation of a Morphologic Obstructive Sleep Apnea Prediction Score: The DES-OSA Score.

BACKGROUND: Obstructive sleep apnea (OSA) is a common and underdiagnosed entity that favors perioperative morbidity. Several anatomical characteristics predispose to OSA. We developed a new clinical score that would detect OSA based on the patient's morphologic characteristics only. METHODS: Patients (n = 149) scheduled for an overnight polysomnography were included. Their morphologic metrics were compared, and combinations of them were tested for their ability to predict at least mild, moderate-to-severe, or severe OSA, as defined by an apnea-hypopnea index (AHI) >5, >15, or >30 events/h. This ability was calculated using Cohen κ coefficient and prediction probability. RESULTS: The score with best prediction abilities (DES-OSA score) considered 5 variables: Mallampati score, distance between the thyroid and the chin, body mass index, neck circumference, and sex. Those variables were weighted by 1, 2, or 3 points. DES-OSA score >5, 6, and 7 were associated with increased probability of an AHI >5, >15, or >30 events/h, respectively, and those thresholds had the best Cohen κ coefficient, sensitivities, and specificities. Receiver operating characteristic curve analysis revealed that the area under the curve was 0.832 (95% confidence interval [CI], 0.762-0.902), 0.805 (95% CI, 0.734-0.876), and 0.834 (95% CI, 0.757-0.911) for DES-OSA at predicting an AHI >5, >15, and >30 events/h, respectively. With the aforementioned thresholds, corresponding sensitivities (95% CI) were 82.7% (74.5-88.7), 77.1% (66.9-84.9), and 75% (61.0-85.1), and specificities (95% CI) were 72.4% (54.0-85.4), 73.2% (60.3-83.1), and 76.9% (67.2-84.4). Validation of DES-OSA performance in an independent sample yielded highly similar results. CONCLUSIONS: DES-OSA is a simple score for detecting OSA patients. Its originality relies on its morphologic nature. Derived from a European population, it may prove useful in a preoperative setting, but it has still to be compared with other screening tools in a general surgical population and in other ethnic groups.

Mandible behaviour interpretation during wakefulness, sleep and sleep-disordered breathing.

The mandible movement (MM) signal provides information on mandible activity. It can be read visually to assess sleep-wake state and respiratory events. This study aimed to assess (1) the training of independent scorers to recognize the signal specificities; (2) intrascorer reproducibility and (3) interscorer variability. MM was collected in the mid-sagittal plane of the face of 40 patients. The typical MM was extracted and classified into seven distinct pattern classes: active wakefulness (AW), quiet wakefulness or quiet sleep (QW/S), sleep snoring (SS), sleep obstructive events (OAH), sleep mixed apnea (MA), respiratory related arousal (RERA) and sleep central events (CAH). Four scorers were trained; their diagnostic capacities were assessed on two reading sessions. The intra- and interscorer agreements were assessed using Cohen's κ. Intrascorer reproducibility for the two sessions ranged from 0.68 [95% confidence interval (CI): 0.59-0.77] to 0.88 (95% CI: 0.82-0.94), while the between-scorer agreement amounted to 0.68 (95% CI: 0.65-0.71) and 0.74 (95% CI: 0.72-0.77), respectively. The overall accuracy of the scorers was 75.2% (range: 72.4-80.7%). CAH MMs were the most difficult to discern (overall accuracy 65.6%). For the two sessions, the recognition rate of abnormal respiratory events (OAH, CAH, MA and RERA) was excellent: the interscorer mean agreement was 90.7% (Cohen's κ: 0.83; 95% CI: 0.79-0.88). The discrimination of OAH, CAH, MA characteristics was good, with an interscorer agreement of 80.8% (Cohen's κ: 0.65; 95% CI: 0.62-0.68). Visual analysis of isolated MMs can successfully diagnose sleep-wake state, normal and abnormal respiration and recognize the presence of respiratory effort.

Upper airway imaging in sleep-disordered breathing.

Our understanding of sleep-disordered breathing has evolved considerably over the past three decades, and clinical techniques of evaluation have progressed tremendously. Myriad imaging techniques are now available for the physician to approach the dynamic features resulting in turbulent airflow, upper airway narrowing or collapse at different levels. Controversy exists in the choice of investigations, probably because the best evaluation should be a combination of different techniques. Physical, radiographic, endoscopic and acoustic evaluations could be integrated to understand the degree and the levels of airway reduction and/or obstruction in a given patient. This review focuses on cost-effective and easily implemented techniques in daily practice, allowing quality assessment of the dynamic anatomy of sleep-disordered breathing: cephalometry, (sleep-)endoscopy and acoustic reflectometry of the upper airway.

Added value of a mandible movement automated analysis in the screening of obstructive sleep apnea.

In-laboratory polysomnography is the 'gold standard' for diagnosing obstructive sleep apnea syndrome, but is time consuming and costly, with long waiting lists in many sleep laboratories. Therefore, the search for alternative methods to detect respiratory events is growing. In this prospective study, we compared attended polysomnography with two other methods, with or without mandible movement automated analysis provided by a distance-meter and added to airflow and oxygen saturation analysis for the detection of respiratory events. The mandible movement automated analysis allows for the detection of salient mandible movement, which is a surrogate for arousal. All parameters were recorded simultaneously in 570 consecutive patients (M/F: 381/189; age: 50±14 years; body mass index: 29±7 kg m(-2) ) visiting a sleep laboratory. The most frequent main diagnoses were: obstructive sleep apnea (344; 60%); insomnia/anxiety/depression (75; 13%); and upper airway resistance syndrome (25; 4%). The correlation between polysomnography and the method with mandible movement automated analysis was excellent (r: 0.95; P<0.001). Accuracy characteristics of the methods showed a statistical improvement in sensitivity and negative predictive value with the addition of mandible movement automated analysis. This was true for different diagnostic thresholds of obstructive sleep severity, with an excellent efficiency for moderate to severe index (apnea-hypopnea index ≥15h(-1) ). A Bland & Altman plot corroborated the analysis. The addition of mandible movement automated analysis significantly improves the respiratory index calculation accuracy compared with an airflow and oxygen saturation analysis. This is an attractive method for the screening of obstructive sleep apnea syndrome, increasing the ability to detect hypopnea thanks to the salient mandible movement as a marker of arousals.

Contribution of postero-anterior cephalometry in obstructive sleep apnea.

OBJECTIVES/HYPOTHESIS: Lateral cephalometry has been widely used to characterize facial and maxillary morphology in obstructive sleep apnea (OSA) patients. It is a useful tool to assess orthodontic and maxillofacial procedures, but transverse dimensions of the airway (e.g., nasal framework) have not been well described yet by cephalometry. We explored whether postero-anterior cephalometry could refine the analysis of the facial morphology, with a special attention paid to nasal morphology. We validated cephalometric measurements relevant to the diagnosis of OSA. STUDY DESIGN: Controlled study. METHODS: We explored postero-anterior and lateral cephalometric bony structures in OSA patients and in control subjects to determine which were predictive of an association with OSA. Healthy volunteers paired for age and sex to OSA patients underwent polysomnography and cephalometry. Data were analyzed by Shapiro-Wilk, Fisher, Wilcoxon, and paired t tests where appropriate. RESULTS: Nasal fossae and maxillary bone proportions were positively and independently associated with the absence of OSA. Measurements of maxillary width, nasal fossae angle, and anterior skull base contributed to the characterization of OSA patients. CONCLUSIONS: Postero-anterior cephalometry is an easy, rapid, informative, and reliable technique, which is complementary to the lateral cephalometry in the assessment of OSA patients. Our study may also suggest the negative impact of the nasal resistance on the upper airway resistance in sleep disorders.

The sleep/wake state scoring from mandible movement signal.

PURPOSE: Estimating the total sleep time in home recording devices is necessary to avoid underestimation of the indices reflecting sleep apnea and hypopnea syndrome severity, e.g., the apnea-hypopnea index (AHI). A new method to distinguish sleep from wake using jaw movement signal processing is assessed. METHODS: In this prospective study, jaw movement signal was recorded using the Somnolter (SMN) portable monitoring device synchronously with polysomnography (PSG) in consecutive patients complaining about a lack of recovery sleep. The automated sleep/wake scoring method is based on frequency and complexity analysis of the jaw movement signal. This computed scoring was compared with the PSG hypnogram, the two total sleep times (TST(PSG) and TST(SMN)) as well. RESULTS: The mean and standard deviation (in minutes) of TST(PSG) on the whole dataset (n = 124) were 407 ± 95.6, while these statistics were 394.2 ± 99.3 for TST(SMN). The Bland and Altman analysis of the difference between the two TST was 12.8 ± 57.3 min. The sensitivity and specificity (in percent) were 85.3 and 65.5 globally. The efficiency decreased slightly when AHI lies between 15 and 30, but remained similar for lower or greater AHI. In the 24 patients with insomnia/depression diagnosis, a mean difference in TST of -3.3 min, a standard deviation of 58.2 min, a sensitivity of 86.3%, and a specificity of 66.2% were found. CONCLUSIONS: Mandible movement recording and its dedicated signal processing for sleep/wake recognition improve sleep disorder index accuracy by assessing the total sleep time. Such a feature is welcome in home screening methods.

Midsagittal jaw movements as a sleep/wake marker.

The seriousness of the Obstructive Sleep Apnea/Hypopnea Syndrome is measured by the apnea-hypopnea index (AHI), the number of sleep apneas and hypopneas over the total sleep time (TST). Cardiorespiratory signals are used to detect respiratory events while the TST is usually assessed by the analysis of electroencephalogram traces in polysomnography (PSG) or wrist actigraphy trace in portable monitoring. This paper presents a sleep/wake automatic detector that relies on a wavelet-based complexity measure of the midsagittal jaw movement signal and multilayer perceptrons. In all, 63 recordings were used to train and test the method, while 38 recordings constituted an independent evaluation set for which the sensitivity, the specificity, and the global agreement of sleep recognition, respectively, reached 85.1%, 76.4%, and 82.9%, compared with the PSG data. The AHI computed automatically and only from the jaw movement analysis was significantly improved (p < 0.0001) when considering this sleep/wake detector. Moreover, a sensitivity of 88.6% and a specificity of 83.6% were found for the diagnosis of the sleep apnea syndrome according to a threshold of 15. Thus, the jaw movement signal is reasonably accurate in separating sleep from wake, and, in addition to its ability to score respiratory events, is a valuable signal for portable monitoring.

Midsagittal jaw movement analysis for the scoring of sleep apneas and hypopneas.

Given the importance of the detection and classification of sleep apneas and hypopneas (SAHs) in the diagnosis and the characterization of the SAH syndrome, there is a need for a reliable noninvasive technique measuring respiratory effort. This paper proposes a new method for the scoring of SAHs based on the recording of the midsagittal jaw motion (MJM, mouth opening) and on a dedicated automatic analysis of this signal. Continuous wavelet transform is used to quantize respiratory effort from the jaw motion, to detect salient mandibular movements related to SAHs and to delineate events which are likely to contain the respiratory events. The classification of the delimited events is performed using multilayer perceptrons which were trained and tested on sleep data from 34 recordings. Compared with SAHs scored manually by an expert, the sensitivity and specificity of the detection were 86.1% and 87.4%, respectively. Moreover, the overall classification agreement in the recognition of obstructive, central, and mixed respiratory events between the manual and automatic scorings was 73.1%. The MJM signal is hence a reliable marker of respiratory effort and allows an accurate detection and classification of SAHs.

Nonvisual responses to light exposure in the human brain during the circadian night.

The brain processes light information to visually represent the environment but also to detect changes in ambient light level. The latter information induces non-image-forming responses and exerts powerful effects on physiology such as synchronization of the circadian clock and suppression of melatonin. In rodents, irradiance information is transduced from a discrete subset of photosensitive retinal ganglion cells via the retinohypothalamic tract to various hypothalamic and brainstem regulatory structures including the hypothalamic suprachiasmatic nuclei, the master circadian pacemaker. In humans, light also acutely modulates alertness, but the cerebral correlates of this effect are unknown. We assessed regional cerebral blood flow in 13 subjects attending to auditory and visual stimuli in near darkness following light exposures (>8000 lux) of different durations (0.5, 17, 16.5, and 0 min) during the biological night. The bright broadband polychromatic light suppressed melatonin and enhanced alertness. Functional imaging revealed that a large-scale occipito-parietal attention network, including the right intraparietal sulcus, was more active in proportion to the duration of light exposures preceding the scans. Activity in the hypothalamus decreased in proportion to previous illumination. These findings have important implications for understanding the effects of light on human behavior.

[The role of maxillofacial surgery in obstructive sleep hypopnea and apnea syndrome]. / La place de la chirurgie maxillo-faciale dans le Syndrome d'Apnées et d'Hypopnées Obstructives du Sommeil (SAHOS).

One of the most common symptoms of obstructive sleep apnea syndrome (OSAS) is daytime drowsiness. It is associated with a high cardiovascular morbidity and mortality, and an elevated incidence of car crashes. In general, young patients don't want conservative treatment because symptomatic and to prevent secondary effects. In this article, we briefly define sleep disorders and the interest of cephalometric examination. We describe the different treatment possibilities and stress the important role of orthognathic surgery in this syndrome.