Measurement of snoring and stertor using the Sonomat to assess effectiveness of upper airway surgery in children.

STUDY OBJECTIVES: The success of surgical treatment for pediatric sleep-disordered breathing is typically assessed using the mixed and obstructive apnea-hypopnea index (MOAHI). Although an important metric, previous work has shown that snoring and stertor are also associated with sleep disruption. Our aim was to assess the efficacy of surgery using the Sonomat (Sonomedical Pty Ltd), a noncontact sleep assessment system, that accurately records complete and partial upper airway obstruction. METHODS: Forty children (< 18 years) had a Sonomat study, in their own beds, before and after surgery. As an MOAHI ≥ 1 event/h is considered abnormal, the same threshold was applied to snore/stertor runs. Median (interquartile range) values are reported. RESULTS: Respiratory event-induced movements decreased from 12.0 (8.7-19.0) to 0.5 (0.1-3.2) events/h (P < .01), with no significant change in spontaneous movements: 12.8 (9.8-17.9) to 16.5 (13.7-26.1) events/h (P = .07). The MOAHI decreased from 4.5 (1.9-8.6) to 0.0 (0.0-0.4) events/h (P < .01). Snoring and/or stertor runs decreased from 32.8 (23.4-44.4) to 3.0 (0.2-14.6) events/h (P < .01). Thirty-four children had an MOAHI < 1 event/h following surgery; however, 20 had snore and/or stertor runs ≥ 1 event/h and 11 had snore and/or stertor runs ≥ 5 events/h. Only 14 (35%) children had a postsurgery MOAHI < 1 event/h combined with snoring and/or stertor < 1 runs/h. CONCLUSIONS: Although surgery is effective in improving breathing, success rates are overestimated using the MOAHI. Our results indicate that snoring and/or stertor are still present at levels that may disrupt sleep despite a normalization of the MOAHI and that when obstructed breathing was objectively measured, there was a large variation in its response to surgery. CITATION: Norman MB, Harrison HC, Sullivan CE, Milross MA. Measurement of snoring and stertor using the Sonomat to assess effectiveness of upper airway surgery in children. J Clin Sleep Med. 2022;18(6):1649-1656.

TcCO2 changes correlate with partial obstruction in children suspected of sleep disordered breathing.

INTRODUCTION: Pediatric sleep disordered breathing (SDB) is characterized by long periods of partial upper airway obstruction (UAO) with low apnea-hypopnea indices (AHI). By measuring snoring and stertor, Sonomat studies allow quantification of these periods of partial UAO. AIM: To determine whether transcutaneous CO2 (TcCO2 ) levels correlate with increasing levels of partial UAO and to examine patterns of ΔTcCo2 in the transitions from (a) wakefulness to sleep and (b) non-rapid eye movement (NREM) to rapid eye movement (REM) sleep. METHODS: This was a retrospective review of sleep studies in seven asymptomatic controls aged 7 to 12 years and 62 symptomatic children with suspected SDB and no comorbidities, aged 2 to 13 years. Both groups underwent overnight polysomnography, including continuous TcCO2 , at one of two pediatric hospitals in Sydney. Changes in carbon dioxide levels between wake to NREM (sleep onset) and NREM to REM sleep were evaluated using an all-night TcCO2 trace time-linked to a hypnogram. Paired Sonomat recordings were used to quantify periods of UAO in the symptomatic group. RESULTS: The ΔTcCO2 at sleep onset was greater in SDB children than controls and ΔTcCO2 with sleep onset correlated with the duration of partial obstruction (r = .60; P < .0001). Children with an increase in TcCO2 from NREM to REM had a higher number of snoring and stertor events compared to those in whom TcCO2 decreased from NREM to REM (91 vs 30 events/h; P = < .0001). CONCLUSIONS: In children without comorbidities, the measurement of TcCO2 during sleep correlates with indicators of partial obstruction.

Nasal mask average volume-assured pressure support in an infant with congenital central hypoventilation syndrome.

Congenital central hypoventilation syndrome (CCHS) is a rare disorder characterized by alveolar hypoventilation and autonomic dysregulation secondary to mutations of the PHOX 2B genes. Treatment consists of assisted ventilation using positive pressure ventilators via tracheostomy, bi-level positive airway pressure (BPAP), negative pressure ventilators, or diaphragm pacing. Previous case reports have highlighted early use of nasal non-invasive BPAP use in infants with CCHS. We present a case of a 10-month-old infant who was successfully managed on a new feature of non-invasive ventilation called average volume assured pressure support (AVAPS) without the need for tracheostomy. The AVAPS feature enables the machine to automatically adjust the inspiratory pressures to deliver a constant targeted tidal volume. This feature enabled a better control of ventilation as indicated by a more stable transcutaneous carbon dioxide profile compared to conventional nasal non-invasive BPAP, making non-invasive ventilation a more accessible method of managing sleep hypoventilation in CCHS.

Snoring and stertor are associated with more sleep disturbance than apneas and hypopneas in pediatric SDB.

PURPOSE: Polysomnography is not recommended for children at home and does not adequately capture partial upper airway obstruction (snoring and stertor), the dominant pathology in pediatric sleep-disordered breathing. New methods are required for assessment. Aims were to assess sleep disruption linked to partial upper airway obstruction and to evaluate unattended Sonomat use in a large group of children at home. METHODS: Children with suspected obstructive sleep apnea (OSA) had a single home-based Sonomat recording (n = 231). Quantification of breath sound recordings allowed identification of snoring, stertor, and apneas/hypopneas. Movement signals were used to measure quiescent (sleep) time and sleep disruption. RESULTS: Successful recordings occurred in 213 (92%) and 113 (53%) had no OSA whereas only 11 (5%) had no partial obstruction. Snore/stertor occurred more frequently (15.3 [5.4, 30.1] events/h) and for a longer total duration (69.9 min [15.7, 140.9]) than obstructive/mixed apneas and hypopneas (0.8 [0.0, 4.7] events/h, 1.2 min [0.0, 8.5]); both p < 0.0001. Many non-OSA children had more partial obstruction than those with OSA. Most intervals between snore and stertor runs were < 60 s (79% and 61% respectively), indicating that they occur in clusters. Of 14,145 respiratory-induced movement arousals, 70% were preceded by runs of snore/stertor with the remainder associated with apneas/hypopneas. CONCLUSIONS: Runs of snoring and stertor occur much more frequently than obstructive apneas/hypopneas and are associated with a greater degree of sleep disruption. Children with and without OSA are frequently indistinguishable regarding the amount, frequency, and the degree of sleep disturbance caused by snoring and stertor.

Generation rate and fate of surplus soil extracted in New York City.

With increasing urgency to build earthworks projects to protect against flooding from climate change and mitigate exposure to pollutants in degraded urban soils, many cities could experience increased demand for soil of between 10 and 35 million t in coming decades. This study showed that building construction in New York City (NYC) produces an estimated 1.7 × 106 t of surplus clean native soil (mostly glacial sediments) each year and could be an important source to meet future urban soil demand. This quantity of soil is sufficient to build a 3-m-high earthen levee 21-km long each year and a continuous levee along NYC's 840 km shoreline in about 40 years. Alternately, this quantity is sufficient to build a 15-cm-thick clean soil cover over 7.3 km2 of degraded urban soil each year. Detailed study of the fate of 1.03 × 106 t of surplus soil from 113 building construction projects showed that over 95% was exported, with average one-way soil transportation of about 72 km. Paradoxically, while >74% of soil was recycled, long transportation through a diffused network of recycling facilities caused significant environmental and economic impacts. Each year, surplus soil management from building construction in NYC requires an estimated 60,000 truck-trips and 8.7 × 106 km of truck travel, combusts 4.3 × 106 l of fossil fuel, emits 11,800 t of CO2 and costs over $60 M USD. Soil banking and other programs and public policies to retain soil within cities could increase urban soil supply to meet the rising demand for earthworks projects while also reducing soil transportation and associated environmental and economic impacts and achieving circular urban materials metabolism goals.

Adolescent Perinatal Outcomes in South West Sydney, Australia.

OBJECTIVE: To compare perinatal outcomes, blood pressures throughout pregnancy, rates of hypertensive disorders of pregnancy, preeclampsia, gestational diabetes mellitus, and immediate obstetric outcomes in adolescents younger than 20 years at delivery and those in the 20- to 34-year age group. PATIENTS AND METHODS: Questionnaires were administered to pregnant women at Campbelltown and Liverpool hospitals within South West Sydney, Australia, as part of a broader study of sleep-disordered breathing in pregnancy between February 1, 2009, and February 28, 2013. Data collected included demographic data, blood pressure readings, pregnancy complications, delivery type, and neonatal outcomes. Adolescents were compared with older women using Student t tests and χ2 statistics. RESULTS: A total of 103 adolescents were compared with 2291 women aged 20 to 34 years. Adolescents were more likely to be primiparous, had longer average gestations, and had lower pre-pregnancy body mass index. Adolescents had lower rates of cesarean section delivery and gestational diabetes mellitus. There was no significant difference in smoking rates, perinatal mortality rate, small for gestational age, intrauterine growth restriction, Apgar score of less than 7 at 5 minutes, admission to special care nursery, or hypertensive disorder of pregnancy rates. Adolescents had lower booking systolic and diastolic blood pressures, and their highest antenatal systolic blood pressures were lower. CONCLUSION: Adolescents have birth outcomes to similar to those of their older counterparts. Adolescents had lower booking blood pressures. This may have implications for the screening and diagnosis of hypertensive disorders of pregnancy in adolescents.

Sleep disordered breathing controlled by CPAP and sFlt-1 in a pregnant patient with chronic hypertension: Case report and literature review.

BACKGROUND: There is recent interest exploring the possible impact of sleep disordered breathing on the mechanisms of preeclampsia. A biomarker of preeclampsia, soluble fms-like tyrosine kinase-1, has come to prominence in recent years. The aim of this study was to investigate the relationship between continuous positive airway pressure treatment, sleep disordered breathing and soluble fms-like tyrosine kinase-1 concentrations during pregnancy. METHODS: A 38-year-old G1P0 presented at 20 + 5 weeks. She had a history of chronic hypertension. Sleep studies revealed she had sleep disordered breathing with an AHI of 7.3/h. She was commenced on continuous positive airway pressure. Soluble fms-like tyrosine kinase-1 concentrations and blood pressure recordings were taken at various points during her pregnancy. RESULTS: She did not develop preeclampsia or require an escalation in her antihypertensives. Soluble fms-like tyrosine kinase-1 concentrations rose 16% from a low baseline. She remained compliant with her continuous positive airway pressure. She progressed to birth a well, live, term baby. CONCLUSION: Continuous positive airway pressure treatment controlled sleep disordered breathing in a high risk pregnant woman with chronic hypertension with no increase in soluble fms-like tyrosine kinase-1 concentrations.

Long-term non-invasive ventilation therapies in children: A scoping review.

Long-term non-invasive ventilation (NIV) is a common modality of breathing support used for a range of sleep and respiratory disorders. The aim of this scoping review was to provide a summary of the literature relevant to long-term NIV use in children. We used systematic methodology to identify 11,581 studies with final inclusion of 289. We identified 76 terms referring to NIV; the most common term was NIV (22%). Study design characteristics were most often single center (84%), observational (63%), and retrospective (54%). NIV use was reported for 73 medical conditions with obstructive sleep apnea and spinal muscular atrophy as the most common conditions. Descriptive data, including NIV incidence (61%) and patient characteristics (51%), were most commonly reported. Outcomes from sleep studies were reported in 27% of studies followed by outcomes on reduction in respiratory morbidity in 19%. Adverse events and adherence were reported in 20% and 26% of articles respectively. Authors reported positive conclusions for 73% of articles. Long-term use of NIV has been documented in a large variety of pediatric patient groups with studies of lower methodological quality. While there are considerable data for the most common conditions, there are fewer data to support NIV use for many additional conditions.

Validation of the Sonomat Against PSG and Quantitative Measurement of Partial Upper Airway Obstruction in Children With Sleep-Disordered Breathing.

Study Objectives: To validate the Sonomat against polysomnography (PSG) metrics in children and to objectively measure snoring and stertor to produce a quantitative indicator of partial upper airway obstruction that accurately reflects the pathology of pediatric sleep-disordered breathing (SDB). Methods: Simultaneous PSG and Sonomat recordings were performed in 76 children (46 male, age 5.8 ± 2.8, BMI = 18.5 ± 3.8 kg/m2). Sleep time, individual respiratory events and the apnea/hypopnea index (AHI) were compared. Obstructed breathing sounds were measured from the unobtrusive non-contact experimental device. Results: There was no significant difference in total sleep time (TST), respiratory events or AHI values, the latter over-estimated by 0.3 events hr-1 by the Sonomat. Poor signal quality was minimal and gender, BMI, and body position did not adversely influence event detection. Obstructive and central events were classified correctly. The number of runs and duration of snoring (13 399 events, 20% TST) and stertor (5748 events, 24% TST) were an order of magnitude greater than respiratory events (1367 events, 1% TST). Many children defined as normal by PSG had just as many or more runs of snoring and stertor as those with mild, moderate and severe obstructive sleep apnea (OSA). Conclusions: The Sonomat accurately diagnoses SDB in children using current metrics. In addition, it permits quantification of partial airway obstruction that can be used to better describe pediatric SDB. Its non-contact design makes it ideal for use in children.

Positive airway pressure improves nocturnal beat-to-beat blood pressure surges in obesity hypoventilation syndrome with obstructive sleep apnea.

Positive airway pressure (PAP) treatment has been shown to have a modest effect on ambulatory blood pressure (BP) in patients with obstructive sleep apnea (OSA). However, there is a paucity of data on the effect of PAP therapy on rapid, yet significant, BP swings during sleep, particularly in obesity hypoventilation syndrome (OHS). The present study hypothesizes that PAP therapy will improve nocturnal BP on the first treatment night (titration PAP) in OHS patients with underlying OSA, and that these improvements will become more significant with 6 wk of PAP therapy. Seventeen adults (7 men, 10 women; age 50.4 ± 10.7 years, BMI 49.3 ± 2.4 kg/m(2)) with OHS and clinically diagnosed OSA participated in three overnight laboratory visits that included polysomnography and beat-to-beat BP monitoring via finger plethysmography. Six weeks of PAP therapy, but not titration PAP, lowered mean nocturnal BP. In contrast, when nocturnal beat-to-beat BPs were aggregated into bins consisting of at least three consecutive cardiac cycles with a >10 mmHg BP surge (i.e., Δ10-20, Δ20-30, Δ30-40, and Δ>40 mmHg), titration, and 6-wk PAP reduced the number of BP surges per hour (time × bin, P < 0.05). PAP adherence over the 6-wk period was significantly correlated to reductions in nocturnal systolic (r = 0.713, P = 0.001) and diastolic (r = 0.497, P = 0.043) BP surges. Despite these PAP-induced improvements in nocturnal beat-to-beat BP surges, 6 wk of PAP therapy did not alter daytime BP. In conclusion, PAP treatment reduces nocturnal beat-to-beat BP surges in OHS patients with underlying OSA, and this improvement in nocturnal BP regulation was greater in patients with higher PAP adherence.

Reactive Center Loop (RCL) Peptides Derived from Serpins Display Independent Coagulation and Immune Modulating Activities.

Serpins regulate coagulation and inflammation, binding serine proteases in suicide-inhibitory complexes. Target proteases cleave the serpin reactive center loop scissile P1-P1' bond, resulting in serpin-protease suicide-inhibitory complexes. This inhibition requires a near full-length serpin sequence. Myxomavirus Serp-1 inhibits thrombolytic and thrombotic proteases, whereas mammalian neuroserpin (NSP) inhibits only thrombolytic proteases. Both serpins markedly reduce arterial inflammation and plaque in rodent models after single dose infusion. In contrast, Serp-1 but not NSP improves survival in a lethal murine gammaherpesvirus68 (MHV68) infection in interferon γ-receptor-deficient mice (IFNγR(-/-)). Serp-1 has also been successfully tested in a Phase 2a clinical trial. We postulated that proteolytic cleavage of the reactive center loop produces active peptide derivatives with expanded function. Eight peptides encompassing predicted protease cleavage sites for Serp-1 and NSP were synthesized and tested for inhibitory function in vitro and in vivo. In engrafted aorta, selected peptides containing Arg or Arg-Asn, not Arg-Met, with a 0 or +1 charge, significantly reduced plaque. Conversely, S-6 a hydrophobic peptide of NSP, lacking Arg or Arg-Asn with -4 charge, induced early thrombosis and mortality. S-1 and S-6 also significantly reduced CD11b(+) monocyte counts in mouse splenocytes. S-1 peptide had increased efficacy in plasminogen activator inhibitor-1 serpin-deficient transplants. Plaque reduction correlated with mononuclear cell activation. In a separate study, Serp-1 peptide S-7 improved survival in the MHV68 vasculitis model, whereas an inverse S-7 peptide was inactive. Reactive center peptides derived from Serp-1 and NSP with suitable charge and hydrophobicity have the potential to extend immunomodulatory functions of serpins.

Efficacy of Noncontrast Computed Tomography of the Abdomen and Pelvis for Evaluating Nontraumatic Acute Abdominal Pain in the Emergency Department.

BACKGROUND: Computed tomography (CT) clarity has significantly improved since it became widely available in the early 1980s, making the utility and benefit of contrast material for image quality of the abdomen and pelvis uncertain, and so far, minimally studied. OBJECTIVES: This study sought to assess the efficacy of a noncontrast CT scan of the abdomen and pelvis by evaluating patients presenting to the emergency department (ED) with acute nontraumatic abdominal pain by following them for 7 days and observing for signs and symptoms of clinically significant acute emergent pathology. METHODS: We enrolled, and for 7 days followed, a prospective observational convenience sample of patients who received a noncontrast CT scan of the abdomen and pelvis in the ED for acute nontraumatic abdominal pain. The primary outcome, and defined as a failure, was abdominal surgery or death as the result of an intraabdominal process not found on the original noncontrast CT scan, or a subsequent contrasted CT scan with a finding that could explain the original complaint of abdominal pain that was also not seen on the initial noncontrast CT, during the 7-day observation. RESULTS: Seventy-two patients were enrolled in the study. The incidence of failure was 0% (0/72), 46% of patients (33/72) had a negative CT scan, 54% (39/72) had a positive CT scan, 57% (41/72) were admitted, 43% (31/72) discharged, 11% (8/72) had abdominal surgery, and a repeat contrasted CT scan was done on 4% (3/72). CONCLUSIONS: With certain inclusion and exclusion criteria, noncontrast CT of the abdomen and pelvis is likely a reliable diagnostic modality for the evaluation of acute nontraumatic abdominal pain in the ED.

Chicago's Sanitary and Ship Canal sediment: Polycyclic aromatic hydrocarbons, polychlorinated biphenyls, brominated flame retardants, and organophosphate esters.

The Chicago Sanitary and Ship Canal (CSSC) links the Great Lakes to the Mississippi River starting in downtown Chicago. In addition to storm water, the CSSC receives water from Chicago's wastewater treatment plants (WWTP). Such effluents are known to be sources of organic pollutants to water and sediment. Therefore in 2013, we collected 10 sediment samples from the CSSC and measured the concentrations of polycyclic aromatic hydrocarbons (PAHs), polychlorinated biphenyls (PCBs), brominated flame retardants, and organophosphate esters (OPEs). Geometric mean concentrations of the summed concentrations of 16 PAHs ranged from 11,000 to 420,000 ng/g dw, with the highest concentrations located at each end of the canal. Total PCB concentrations had a geometric mean of 1,400 ± 500 ng/g dw. Brominated flame retardants were separated into two groups: polybrominated diphenyl ethers (PBDEs) and non-PBDEs. Concentrations of PBDEs and those of the non-PBDE flame retardants had a geometric average of 83 ± 19 and 7.0 ± 5.8 ng/g dw, respectively. The summed concentrations of 8 OPEs ranged from 470 to 2,800 ng/g dw, with the highest concentration detected at a site located downstream of the Stickney water reclamation plant. Using ANOVA results, some hypotheses on sources to the CSSC could be formulated: downtown Chicago is probably a source of PAHs, the Cal-Sag Channel may be a source of PCBs, and neither the WWTP nor the Cal-Sag Channel seem to be significant sources of brominated flame retardants or OPEs.

Validation of the Sonomat: a contactless monitoring system used for the diagnosis of sleep disordered breathing.

STUDY OBJECTIVES: To evaluate the ability of the Sonomat to diagnose obstructive sleep apnea (OSA). DESIGN: Prospective and randomized. SETTING: Sleep laboratory and home. PARTICIPANTS: 62 subjects; 54 with a clinical history of OSA and 8 normal control subjects. INTERVENTIONS: N/A. MEASUREMENTS AND RESULTS: Simultaneous PSG and Sonomat recordings were made in 62 subjects; 2 were excluded due to a poor nasal flow recording in PSG. There were positive correlations between the two devices for measures of sleep time, respiratory events, and the AHI (all correlations > 0.89). Bland-Altman analysis of the AHI showed positive agreement between devices, particularly at levels around common diagnostic thresholds. The mean difference in AHI values was 1.4 events per hour, and at a diagnostic threshold of 15 events per hour, sensitivity and specificity were 88% and 91%. More than 93% of PSG defined respiratory events were identified by the Sonomat and the absence of respiratory events was correctly identified in 91% of occasions. Gender, obesity, and body position did not influence the accuracy of the Sonomat. PSG snore sensors differed in how much snoring was detected when compared to the Sonomat. CONCLUSION: These data indicate that the Sonomat was reliable and accurate for the diagnosis of OSA. The provision of audible breath sound/snoring replay permits more accurate quantification of snoring. It requires no patient attachment and can be performed in the home with minimal training.