Diagnostic Techniques in the assessment of sleep wake disorders

Prof. Dr. J. Verbraecken

Pulmonologist and medical coordinator
Multidisciplinary sleep disorders centre
Antwerp University Hospital (Belgium)
Wilrijkstraat 10,
B-2650 Edegem
[email protected]

Aims
- To get insight in
o the available diagnostic techniques
o how to perform polysomnography
o the advantages and disadvantages of the different sensors to measure flow or tidal
volume and respiratory effort
o which sensors are useful to measure inspiratory flow limitation ?
o how to measure pulse-transit-time (PTT)

Summary
Polysomnography (PSG)
Nocturnal polysomnography is the most important lab technique in the management of sleep wake
disturbances and can be considered as the “gold standard”. Respiratory phenomena have to be linked
with other sleep characteristics, like sleep stage and leg movements. The following parameters are
measured during sleep by means of PSG : the electroencephalogram (EEG) with different
configurations but most often at least C4-M1 and C3-M2, detection of eye movements or
electrooculogram (EOG by means of 2 electrodes on the outer canthi of the eyes), muscle tone or
electromyogram (EMG) of the chin and the lower extremities. Based on the information obtained by
EEG, EMG and EOG sleep stages can be defined according to the criteria of Rechtschaffen & Kales
1, and according to the new AASM criteria 2. Ventilation is often measured qualitatively by means
of thermistors, but can be measured more appropriate with nasal pressure canulas or by means of a
pneumotachograph, connected with a full face mask, or eventually by means of calibrated inductance
plethysmography, although calibration is difficult 3,4. Breathing effort can also be detected by
recording movements of chest and abdomen, surface EMG, snoring and changes in arterial blood
pressure, but most effectively by detection of intrathoracic pressure swings. These swings can be
detected by measuring oesophageal pressure. Movements of chest and abdomen can be recorded with
strain gauges (which detect changes in resistance according to length changes), inductance
plethysmography or respitrace (with detection of inductance characteristics of electrical conductors),
impedance or even a static charge sensitive bed (which detects respiratory movements). If respiratory
effort is detected during an apnoea, this can be explained by occlusion of the upper airways. Blood
gases are seldom measured directly, because correlations with the respiratory phenomena, due to the
intermittent presentation of apnoeas, are not possible. Instead, oxygen saturation is measured by
means of pulse oximetry (eventually also transcutaneous PCO2 measures). Sound recording is another
method to detect ventilation. Frequency analysis of the sounds (predominantly snoring) can deliver
more information on flow limitation. Routinely also body position (position sensor on the chest) is
recordered.

Measurement of ventilation at night: pneumotachography, thermistors, nasal canulas, PVDF

sensors, respiratory induction plethysmography
Pneumotachography is the gold standard technique to evaluate airflow 3,4 . This tool can be
connected with a nose mask or a nosemouth mask, which is however less comfortable for the patient
than other systems more often used. Therefore, temperature sensors (=thermistors) were often used in
the past: since expired air is hotter than inspired air 3,4. With this technique a differentiation can be

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made between inspiration and expiration and the signal is in phase with the volume changes of the
thorax. This signal is however minimally quantitative (which means that it changes minimally with a
deep tidal volume), and can only be used reliably to score apnoeas, for hypopnoeas the thermistor is
unreliable and is therefore obsolete. A much better solution is the measurement of pressure at the nose
with a nasal canula 3,4. This technique gives similar burden to the patient as a thermistor, but can
be used quantitatively. The signal is in phase with the flow. Its amplitude is correlated quadratically
with the flow. For a correct classification of a hypopnoea (decrease of the signal compared to baseline
with more than 30% and oxygen saturation dip ≥4% or decreased signal with more than 50% and
oxygen saturation dip ≥3% or and arousal), it is important to know which signal has been measured.
Disposable canulas are more expensive than thermistors which can be cleaned. A variable nasal
patency makes calibration cumbersome. No signal is available when breathing takes place through the
mouth. Often it is also able to evaluate snoring with a nasal canula. Recently, polyvinylidene fluoride
(PVDF) sensors were shown to be extremely sensitive to evaluate ventilation 5.

Respiratory inductance plethysmography (RIP) is an evaluation technique which makes use of a belt at
thorax and abdomen, with an inbuilt electrical wire 3,4 . This wire functions as a coil and the
features of the coil change when the belt is stretched. The signal is in phase with volume changes of
the chest and changes almost linearly with increasing tidal volume. Such system is performing well
with nose as well as mouth breathing. The disadvantage is that the belts have to be cleaned in case of
non disposable belts, while disposable belts are expensive.

Home recordings and polygraphy

The available capacity to perform PSG in the hospital is limited. Therefore these measurements would
be better performed in the patient’s natural sleep environment 6,7. The disadvantage is that
insufficient electrodes cannot be corrected and the lack of supervision on the nocturnal behaviours
makes interpretation difficult. Failure of measurements due to technical problems occurs in 5-20% of
the cases. Also polygraphy, which combines different parameters, with exception of EEG and very
often also of EOG/EMG, can be used in case of a high probability to find OSAS. In practice each
technique has its specific place in the diagnostic arsenal. Simple pulse oximetry is often used as
screening method. In case of suspicion of a sleep apnoea syndrome its sensitivity and specificity are
75 and 86% respectively. One has to consider false negative results. Frequent short apnoeas can
occur without significant oxygen saturation dips, f.i. in lean patients with sufficient oxygen reserves.

Definitions
- TIB: time in bed, or the total time recordered
- TST: total sleep time, this is the total time asleep
- TSP or SPT: total sleep period or “sleep period time”, this is the time from the First
epoch sleep till the last epoch sleep
- WASO = “wake after sleep onset”: Total duration of wake epochs during the SPT
(thus: SPT= TST+WASO)
- Sleepp latency: time from “lights out” till sleep onset
- “Sleep onset” : defined as the the First of 3 consecutive sleep epochs or a First sleep
epoch different from stage 1 (only 1 epoch needed)
- REM latency: period from “sleep onset” till the beginning of the first REM epoch
(minus intermittent wake)
- Sleep efficiency:TST/TIB*100 or TST/SPT*100

Additional techniques
Intraluminal pressure measurements
In specific cases, it can be indicated to perform additional diagnostic assessment to determine the site
of upper airway collapse (pressure measurement, sleep endoscopy), collapsibility (Pcrit) or the degree
of obstruction/collapse (impedance/FOT) of the upper airway. The site of upper airway collapse can

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be determined by means of an intraluminal pressure measurement 8. This technique makes use of a
special catheter with pressure sensors inserted in the upper airway and oesophagus during sleep.
Based on the recordered pressure changes in the different sensors during episodes of apnoea, one can
determine the type of apnoea (obstructive/central) as well as the site of collapse.
The critical closing pressure (Pcrit) is a measure of collapsibility of the upper airway and reflects the
pressure of the surrounding tissues. If the intraluminal pressure drops below this pressure, the upper
airway will close. It seems there is a good correlation between Pcrit and the clinical picture: Pcrit
normals < snorers<obstructive hypopnoea<obstructive apnoea. Recently a standardised protocol has
been developed to measure Pcrit during sleep.
Sleependoscopy
During sleependoscopy the site of collapse is evaluated endoscopically during an artificially induced
sleep with a short acting hypnotic 9,10,11,12. Probably an overestimation takes place of the
tendancy to obstruction in comparison with a natural sleep.
Forced oscillation technique
The degree of upper airway obstruction can be determined by means of the technique of forced
oscillations 13. The mean impedance-value during a respiratory event, derived from the
relationship between pressure and flow, can be considered as a marker of the degree of upper airway
obstruction.

Pulse-transit-time (PTT)
When the ECG tracings show a QRS complex, one stroke volume of blood is pumped into the aorta.
This leads to a transient dilatation of the vascular wall, and this wave is transmitted over the vessel. A
pulse-oximeter makes use of this small amount of extra arterial blood to calculate the ratio between
oxy- and deoxyhemoglobine. We can now measure the time between the R-peak of the ECG and the
steep part of the plethysmogram. This interval is 200-350 ms.
During an arousal a sympathetic activation takes place, which leads to a stiffened vascular wall and for
a shortening of the PTT. Moreover, an intrathoracic underpressure develops during an apnoea.
The left ventricle receives blood at a lower pressure and will add her normal pressure, what leads to a
netto decrease of blood pressure, and hence, to a more compliant vascular wall and an increase in
PTT. The difference between PTT during inspiratory effort and expiration is ΔPTT. ΔPTT will
increase during an obstructive apnoea and decrease during a central apnoea compared to normal
breathing 14,15 .
The differences in PTT are small (15-20 ms) what means that ECG and oximeter-plethysmogram have
to be sampled at high frequency (f.i. 500 Hz or each 2 ms).

References
1. Rechtschaffen A, Kales A. (1968) A manual of standardised terminology, techniques and
scoring for sleep stages of human subjects. Brain information Service/Brain Research
Institute. University of California at ULCA, Los Angeles.

2. Iber C et al. The AASM Manual for the Scoring of Sleep and Associated Events. Rules,
Terminology and Technical Specifications. 1st edition: Westchester Illinois: American
Academy of Sleep Medicine, 2007.

3. Berry RB, Budhiraja R, Gottlieb DJ, Gozal D, Iber C, Kapur VK, Marcus CL, Mehra R,
Parthasarathy S, Quan SF, Redline S, Strohl KP, Davidson Ward SL, Tangredi MM. Rules
for scoring respiratory events in sleep: update of the 2007 AASM manual for the scoring of
sleep and associated events. J Clin Sleep Med 2012;8(5):597-619.

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4. Sleep-related breathing disorders in adults: recommendations for syndrome definition and
measurement techniques in clinical research. The report of an American Academy of Sleep
Medicine Task Force. Sleep 1999;22:667-89.

5. Berry RB, Koch GL, Trautz S, Wagner MH. Comparison of respiratory event detection by
a polyvinylidene fluoride film airflow sensor and a pneumotachograph in sleep apnea patients.
Chest 2005;128:1331-8.

6. Douglas NJ. Home diagnosis of the obstructive sleep apnoea/hypopnoea syndrome. Sleep
Med Rev 2003; 7: 53-59.

7. Ferber R et al. Portable recording in the assessment of obstructive sleep apnea. ASDA
standards of practice. Sleep 1994; 17: 378-392.

8. Rama AN et al. Sites of obstruction in obstructive sleep apnea. Chest 2002; 122: 1139-1147

9. Berry S et al. Validity of sleep nasendoscopy in the investigation of sleep related breathing
disorders. Laryngoscope 2005;115:538-540.

10. Kotecha BTet al. Sleep nasendoscopy: a 10-year retrospective audit study. Eur Arch
Otorhinolaryngol 2007; 264: 1361-1367.

11. Hamans E et al. Outcome of sleep endoscopy in obstructive sleep apnea. B-ENT
2010;6:97-103

12. Kezirian E et al. Drug-induced sleep endoscopy: the VOTE classification. Eur Arch
Otorhinolaryngol 2011; 268: 1233-1236.

13. Vanderveken O et al. Quantification of pharyngeal patency in patients with sleep-

disordered breathing. ORL 67, 168-179. 2005.

14. Pitson D et al. Use of pulse transit time as a measure of inspiratory effort in patients with
obstructive sleep apnoea. Eur Respir J 1995; 8:1669-74.

15. Smith RP et al. Pulse transit time: An appraisal of potential clinical applications. Thorax
1999; 54:452-57