Correlates of Respiratory Cycle-Related EEG Changes in Children with Sleep-Disordered Breathing

Chervin, Ronald D.; Burns, Joseph W.; Subotic, Nikolas S.; Roussi, Christopher; Thelen, Brian J.; Ruzicka, Deborah L.

doi:10.1093/sleep/27.1.116

Cited by 86 publications

(42 citation statements)

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“…11 The first demonstration of this algorithm proved the existence of respiratory cycle-related EEG changes (RCREC) and suggested in a small sample of 10 children that the new measure could help to explain sleepiness even when the rate of apneic events (the respiratory disturbance index, or RDI) does not. 12 Studies in adults showed that RCREC, at least in the sigma EEG frequency ranges, explained substantial amounts of objectively assessed daytime sleepiness, beyond that explained by combinations of the best measures derived from polysomnography. 13 Furthermore, the observations that sigma power increased on average during inspiration while delta power simultaneously decreased suggested that the RCREC do reflect inspiratory microarousals, possibly associated with the work of breathing.…”

Section: S C I E N T I F I C I N V E S T I G a T I O N Smentioning

confidence: 99%

“…Ninety-five percent of these subjects had follow-up assessments, and among subjects with follow-up, missing data for each individual measure were minimal. The pre-specified primary explanatory variables were the arousal index (arousals per hour of sleep) and delta RCREC, which had shown initial promise as a predictor of improvements in both MSLT results 12 and parent rating scales for hyperactive behavior 49 after adenotonsillectomy in children. The primary outcome variable was the behavioral hyperactivity index.…”

Section: Analysesmentioning

confidence: 99%

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Do Respiratory Cycle-Related EEG Changes or Arousals from Sleep Predict Neurobehavioral Deficits and Response to Adenotonsillectomy in Children?

Chervin

Garetz

Ruzicka

et al. 2014

Journal of Clinical Sleep Medicine

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Study Objectives: Pediatric obstructive sleep apnea (OSA) is associated with hyperactive behavior, cognitive defi cits, psychiatric morbidity, and sleepiness, but objective polysomnographic measures of OSA presence or severity among children scheduled for adenotonsillectomy have not explained why. To assess whether sleep fragmentation might explain neurobehavioral outcomes, we prospectively assessed the predictive value of standard arousals and also respiratory cycle-related EEG changes (RCREC), thought to refl ect inspiratory microarousals. Methods: Washtenaw County Adenotonsillectomy Cohort II participants included children (ages 3-12 years) scheduled for adenotonsillectomy, for any clinical indication. At enrollment and again 7.2 ± 0.9 (SD) months later, children had polysomnography, a multiple sleep latency test, parent-completed behavioral rating scales, cognitive testing, and psychiatric evaluation. The RCREC were computed as previously described for delta, theta, alpha, sigma, and beta EEG frequency bands. Results: Participants included 133 children, 109 with OSA (apnea-hypopnea index [AHI] ≥ 1.5, mean 8.3 ± 10.6) and 24 without OSA (AHI 0.9 ± 0.3). At baseline, the arousal index and RCREC showed no consistent, signifi cant associations with neurobehavioral morbidities, among all subjects or the 109 with OSA. At follow-up, the arousal index, RCREC, and neurobehavioral measures all tended to improve, but neither baseline measure of sleep fragmentation effectively predicted outcomes (all p > 0.05, with only scattered exceptions, among all subjects or those with OSA). Conclusion S C I E N T I F I C I N V E S T I G A T I O N SN eurobehavioral morbidity is among the most prominent manifestations of obstructive sleep apnea (OSA), in adults or children. Exactly what causes adverse cognitive and behavioral outcomes, however, remains incompletely understood. Recommended evaluations for children suspected to have OSA include objective testing, usually by polysomnography.1 However, studies to date have had diffi culty showing that polysomnographic results predict the hyperactive behavior, cognitive defi cits, psychiatric morbidity, or sleepiness that accompany OSA, or their improvement after OSA is treated. [2][3][4][5][6][7][8] For example, in a previous cohort of children investigated before and after adenotonsillectomy, usually for suspected OSA, our group showed that standard polysomnographic measures do not provide strong, if any, predictive value for neurobehavioral BRIEF SUMMARY Current Knowledge/Study Rationale: Obstructive sleep apnea (OSA) in children is associated with neurobehavioral morbidity, but common polysomnographic measures of OSA presence or severity do not predict which children experience such morbidity or improvement in these areas after adenotonsillectomy. This study was performed to assess whether sleep fragmentation-in the form of standardly scored arousals or respiratory cycle-related EEG changes (RCREC) believed to refl ect inspiratory microarousals-might improve predictive utility of sl...

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Section: S C I E N T I F I C I N V E S T I G a T I O N Smentioning

confidence: 99%

Section: Analysesmentioning

confidence: 99%

Do Respiratory Cycle-Related EEG Changes or Arousals from Sleep Predict Neurobehavioral Deficits and Response to Adenotonsillectomy in Children?

Chervin

Garetz

Ruzicka

et al. 2014

Journal of Clinical Sleep Medicine

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“…The rules will miss some whose symptoms are truly related to their sleep disorder(s), but given increasing pleas for medical economic restraint, full-court press PSG techniques should perhaps be reserved for those whose first study is thought to be false-negative or non-diagnostic. Studies remain to be done and published which confirm that scoring subcortical arousals, cyclic alternating pattern, [70][71][72][73][74] respiratory cycle-related EEG changes to identify respiratory events, [75][76][77] abnormal nocturnal regulation of cardiac autonomic function, 78 computerized analysis of submentalis muscle activity to diagnose REM sleep behavior disorder, 79 and assessment of periodicity and circadian distribution of periodic limb movements 65,66,68,[80][81][82] are warranted, valid, and alter outcomes.…”

Section: In Closingmentioning

confidence: 99%

The AASM Scoring Manual Four Years Later

Grigg-Damberger

2012

Journal of Clinical Sleep Medicine

123

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lent and incident blood pressure; 6,7 (2) lower neurocognitive test scores; 8 and (3) automobile crashes due to sleepiness. 9 The respiratory review paper also provided suffi cient evidence for scoring hypopneas which caused as little as ≥ 20% to 30% fall in airfl ow and/or ≥ 2% or ≥ 3% desaturations. [10][11][12] However, the AASM wanted rules for scoring hypopneas which had substantial or excellent interscorer reliability. Interrater reliability (IRR) as it relates to scoring sleep in a PSG measures how closely individuals score the same sleep study. IRR when scoring a PSG depends upon the: (1) skill, experience, and training of scorer; (2) technical quality of study; (3) clarity and simplicity of scoring rules; (4) diligence with which scoring rules are applied; and (5) degree of physiological ambiguity of the sleep/wake patterns. 13 When two or more individuals score a stage of sleep or an event in a PSG differently, it can introduce enough variability to lead to a false positive or false negative for a particular diagnosis.The IRR for scoring respiratory events in a PSG is particularly affected by the: (1) duration of the event; (2) degree of reduction in the amplitude of the measured signal(s); (3) level of the oxyhemoglobin desaturation associated with it; and (4) presence and duration of arousal which accompanies it. Ayappa et al. found the percent scoring agreement for scoring apneas using a nasal pressure sensor was excellent (0.91) but only moderate for hypopneas (0.69) or fl ow limitation events (0.64).14 The more subtle the reduction in airfl ow, the more diffi cult to achieve good interscorer agreement: one scorer identifi ed 35% more fl ow limitation events than the other. Whitney et al. found a hypopnea associated with 2% to 5% desaturations could be scored with IRR of 0.90, but scoring agreement inPurpose of Review: Review published studies and critiques which evaluate the impact and effects of the American Academy of Sleep Medicine (AASM) Sleep Scoring Manual in the four years since its publication. Findings: Using the AASM Manual rules to score sleep and events in a polysomnogram (PSG) results in: (1) very large differences in apnea-hypopnea indexes (AHI) when using the recommended and alternative rule for scoring hypopneas in adults; (2) increases in NREM 1 and sleep stage shifts with compensatory decreases in NREM 2 in children and adults when following rule 5.C.b. for ending NREM 2 sleep; (3) increases in NREM 3 in adults scoring slow wave activity in the frontal EEG derivations; (4) improved interscorer reliability; and (5) successfully identifi ed fragmented sleep in children with obstructive sleep apnea (OSA) from primary snorers or normal controls because they had more NREM 1 and stage shifts using rule 5.C.b. Criticism of the Manual most often cited: (1) two rules for scoring hypopneas; (2) alternative EEG montage cancellation effects; (3) scoring stages 3 and 4 as NREM 3; and (4) too few rules for scoring arousals and REM sleep without atonia. Summary: Four years have passed since the...

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“…Some interim results, mainly on polysomnographic methodology within this 4-year study, have been reported previously. [12][13][14][15][16] …”

Section: Introductionmentioning

confidence: 99%

Sleep-Disordered Breathing, Behavior, and Cognition in Children Before and After Adenotonsillectomy

et al. 2006

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Objectives: Most children with sleep-disordered breathing (SDB) have mild to moderate forms, for which neurobehavioral complications are believed to be the most important adverse outcomes. To improve understanding of this morbidity, its long-term response to adenotonsillectomy, and its relationship to polysomnographic measures, we studied a series of children before and after clinically-indicated adenotonsillectomy or unrelated surgical care.Methods: We recorded sleep and assessed behavioral, cognitive, and psychiatric morbidity in 105 children 5.0 to 12.9 years old: 78 were scheduled for clinically-indicated adenotonsillectomy, usually for suspected SDB, and 27 for unrelated surgical care. One year later, we repeated all assessments in 100 of these children.Results: Adenotonsillectomy subjects, in comparison to controls, were more hyperactive on wellvalidated parent rating scales (p<0.001), inattentive on cognitive testing (p=0.003), sleepy on Multiple Sleep Latency Tests (p=0.002), and likely to have DSM-IV-defined Attention-Deficit/ Hyperactivity Disorder as judged by a child psychiatrist (p=0.03). In contrast, one year later, the two groups showed no significant differences in the same measures. Adenotonsillectomy subjects had improved substantially (p≤0.01) in all measures and control subjects in none. However, polysomnographic assessment of baseline SDB and its subsequent amelioration did not clearly predict either baseline neurobehavioral morbidity or improvement in any area other than sleepiness.Conclusions: Children scheduled for adenotonsillectomy often have mild to moderate SDB and significant neurobehavioral morbidity --including hyperactivity, inattention, Attention-Deficit/ Hyperactivity Disorder, and excessive daytime sleepiness --all of which tend to improve by one year after surgery. However, the lack of better correspondence between SDB measures and neurobehavioral outcomes suggests the need for better measures or improved understanding of underlying causal mechanisms.

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Correlates of Respiratory Cycle-Related EEG Changes in Children with Sleep-Disordered Breathing

Abstract: The RCREC may reflect brief but numerous microarousals that could help to explain neurobehavioral consequences of SDB.

Cited by 86 publications

References 44 publications

Do Respiratory Cycle-Related EEG Changes or Arousals from Sleep Predict Neurobehavioral Deficits and Response to Adenotonsillectomy in Children?

Do Respiratory Cycle-Related EEG Changes or Arousals from Sleep Predict Neurobehavioral Deficits and Response to Adenotonsillectomy in Children?

The AASM Scoring Manual Four Years Later

Sleep-Disordered Breathing, Behavior, and Cognition in Children Before and After Adenotonsillectomy

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