A diagnostic system for sleep apnea based on oxygen saturation and RR intervals obtained from the EKG (electrocardiogram) is proposed with the goal to detect and quantify minute long segments of sleep with breathing pauses. We measured the discriminative capacity of combinations of features obtained from RR series and oximetry to evaluate improvements of the performance compared to oximetry-based features alone. Time and frequency domain variables derived from oxygen saturation (SpO2) as well as linear and non-linear variables describing the RR series have been explored in recordings from 70 patients with suspected sleep apnea. We applied forward feature selection in order to select a minimal set of variables that are able to locate patterns indicating respiratory pauses. Linear discriminant analysis (LDA) was used to classify the presence of apnea during specific segments. The system will finally provide a global score indicating the presence of clinically OPEN ACCESSEntropy 2015, 17 2933 significant apnea integrating the segment based apnea detection. LDA results in an accuracy of 87%; sensitivity of 76% and specificity of 91% (AUC = 0.90) with a global classification of 97% when only oxygen saturation is used. In case of additionally including features from the RR series; the system performance improves to an accuracy of 87%; sensitivity of 73% and specificity of 92% (AUC = 0.92), with a global classification rate of 100%.

Our contribution focuses on the characterization of sleep apnea from a cardiac rate point of view, using Recurrence Quantification Analysis (RQA), based on a Heart Rate Variability (HRV) feature selection process. Three parameters are crucial in RQA: those related to the embedding process (dimension and delay) and the threshold distance. There are no overall accepted parameters for the study of HRV using RQA in sleep apnea. We focus on finding an overall acceptable combination, sweeping a range of values for each of them simultaneously. Together with the commonly used RQA measures, we include features related to recurrence times, and features originating in the complex network theory. To the best of our knowledge, no author has used them all for sleep apnea previously. The best performing feature subset is entered into a Linear Discriminant classifier. The best results in the “Apnea-ECG Physionet database” and the “HuGCDN2014 database” are, according to the area under the receiver operating characteristic curve, 0.93 (Accuracy: 86.33%) and 0.86 (Accuracy: 84.18%), respectively. Our system outperforms, using a relatively small set of features, previously existing studies in the context of sleep apnea. We conclude that working with dimensions around 7–8 and delays about 4–5, and using for the threshold distance the Fixed Amount of Nearest Neighbours (FAN) method with 5% of neighbours, yield the best results. Therefore, we would recommend these reference values for future work when applying RQA to the analysis of HRV in sleep apnea. We also conclude that, together with the commonly used vertical and diagonal RQA measures, there are newly used features that contribute valuable information for apnea minutes discrimination. Therefore, they are especially interesting for characterization purposes. Using two different databases supports that the conclusions reached are potentially generalizable, and are not limited by database variability.

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Abstract:In this paper the permutation entropy (PE) obtained from heart rate variability (HRV) is analyzed in a statistical model. In this model we also integrate other feature extraction techniques, the cepstrum coefficients derived from the same HRV and a set of band powers obtained from the electrocardiogram derived respiratory (EDR) signal. The aim of the model is detecting obstructive sleep apnea (OSA) events. For this purpose, we apply two statistical classification methods: Logistic Regression (LR) and Quadratic Discriminant Analysis (QDA). For testing the models we use seventy ECG recordings from the Physionet database which are divided into equal-size learning and testing sets. Both sets consist of 35 recordings, each containing a single ECG signal. In our experiments we have found that the features extracted from the EDR signal present a sensitivity of 65.6% and specificity of 87.7% (auc = 85) in the LR classifier, and sensitivity of 59.4% and specificity of 90.3% (auc = 83.9) in the QDA classifier. The HRV-based cepstrum coefficients present a sensitivity of 63.8% and specificity of 89.2% (auc = 86) in the LR OPEN ACCESSEntropy 2015, 17 915 classifier, and sensitivity of 67.2% and specificity of 86.8% (auc = 86.9) in the QDA. Subsequent tests show that the contribution of the permutation entropy increases the performance of the classifiers, implying that the complexity of RR interval time series play an important role in the breathing pauses detection. Particularly, when all features are jointly used, the quantification task reaches a sensitivity of 71.9% and specificity of 92.1% (auc = 90.3) for LR. Similarly, for QDA the sensitivity is 75.1% and the specificity is 90.5% (auc = 91.7).

Many sleep centres try to perform a reduced portable test in order to decrease the number of overnight polysomnographies that are expensive, time-consuming, and disturbing. With some limitations, heart rate variability (HRV) has been useful in this task. The aim of this investigation was to evaluate if inclusion of symbolic dynamics variables to a logistic regression model integrating clinical and physical variables, can improve the detection of subjects for further polysomnographies. To our knowledge, this is the first contribution that innovates in that strategy. A group of 133 patients has been referred to the sleep center for suspected sleep apnea. Clinical assessment of the patients consisted of a sleep related questionnaire and a physical examination. The clinical variables related to apnea and selected in the statistical model were age (p < 10(-3)), neck circumference (p < 10(-3)), score on a questionnaire scale intended to quantify daytime sleepiness (p < 10(-3)), and intensity of snoring (p < 10(-3)). The validation of this model demonstrated an increase in classification performance when a variable based on non-linear dynamics of HRV (p < 0.01) was used additionally to the other variables. For diagnostic rule based only on clinical and physical variables, the corresponding area under the receiver operating characteristic (ROC) curve was 0.907 (95% confidence interval (CI) = 0.848, 0.967), (sensitivity 87.10% and specificity 80%). For the model including the average of a symbolic dynamic variable, the area under the ROC curve was increased to 0.941 (95% = 0.897, 0.985), (sensitivity 88.71% and specificity 82.86%). In conclusion, symbolic dynamics, coupled with significant clinical and physical variables can help to prioritize polysomnographies in patients with a high probability of apnea. In addition, the processing of the HRV is a well established low cost and robust technique.