One Negative Polysomnogram Does Not Exclude Obstructive Sleep Apnea

doi:10.1378/chest.103.3.756

Chest

Volume 103, Issue 3, March 1993, Pages 756-760

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Night-to-night variability of apneas on overnight polysomnography exists in patients with documented obstructive sleep apnea (OSA). In this study, we evaluated the possibility that this variability may be severe enough to miss the diagnosis of OSA in patients clinically at risk for the disease. We prospectively studied 11 patients who were deemed on clinical grounds to have probable OSA, but had a negative result on overnight polysomnography. Six of the 11 patients were found to have a positive second study with a significant rise in the apnea/hypopnea index (AHI) from 3.1 ± 1.0 to 19.8 ± 4.7 (mean ± SEM, p<0.01). The cause of the negative first study in these patients is unclear, but it does not seem related to risk factor pattern, sleep architecture, or test interval. The change in AHI was not found to be rapid eye movement (REM)-dependent. This study demonstrates that a negative first-night study is insufficient to exclude OSA in patients with one or more clinical markers of the disease.

Section snippets

Patients

All patients were examined in the Rhode Island Hospital Sleep Disorders Center for suspected OSA between 1989 and 1991. Baseline blood pressure, height, and weight were obtained on the initial clinical evaluation prior to the first sleep study. Based on clinical criteria defined by Crocker et al⁸ patients were believed to have significant risk for OSA if they fulfilled one or more of the following: (1) a history of witnessed apneas, (2) the presence of hypertension, and (3) an increased BMI.

RESULTS

As shown in Figure 1, 6 of the 11 patients in this study (group A) had a positive second night study with a mean AHI of 19.8 ± 4.7 (mean ± SEM) compared with a first night AHI of 3.1 ± 1.0 (p<0.05). The remaining five patients (group B) had a negative second night study with no significant increase in AHI between the first and second nights (1.1 ± 0.6 and 2.4 ± 0.7, respectively). The first and second night apnea indices (AI) for group A were 1.4 ± 0.9 and 5.5 ± 2.3 (p = 0.21), respectively,

DISCUSSION

The results of this study clearly demonstrate that a single negative sleep study is insufficient to exclude OSA in patients with one or more clinical markers for the disease. It is not clearly apparent, however, why one group of patients developed a positive second night study, and the other group did not. The two groups of patients in this study were similar with respect to age, risk factor pattern, and test interval. There were also no significant differences in sleep architecture within each

CONCLUSION

Overnight polysomnography is the diagnostic gold standard for OSA. However, it is known that night-to-night variability in apneas exists in patients with documented OSA, raising the possibility of missing the diagnosis of this serious disease. Our prospective study shows that a significant number of patients with OSA can be missed with one study alone. These patients all presented with significant predictive clinical risk factors for OSA. Reasons for a negative first study are not readily

REFERENCES (18)

DT Berry et al.
Sleep apnea syndrome: a critical review of the apnea index as a diagnostic criterion
Chest
(1984)
DL Bliwise et al.
Factors associated with nightly variability in sleep-disordered breathing in the elderly
Chest
(1991)
RJ Dean et al.
Negative polysomnogram in patients with obstructive sleep apnea syndrome
Chest
(1992)
KD Olsen et al.
Nasal influences on snoring and obstructive sleep apnea
Mayo Clin Proc
(1990)
BA Phillips et al.
Effect of sleep position on sleep apnea and parafunctional activity
Chest
(1986)
Indications and standards for cardiopulmonary sleep studies. Am Rev Respir Dis 1989;...
GA Gould et al.
The sleep hypopnea syndrome
Am Rev Respir Dis
(1988)
RM Wittig et al.
Night-to-night consistency of apneas during sleep
Am Rev Respir Dis
(1984)
RJ Dean et al.
Case report: multiple negative polysomnograms in patients with obstructive sleep apnea
Am J Med Sci
(1992)

There are more references available in the full text version of this article.

Cited by (132)

Night-to-night variability in respiratory sleep parameters to diagnose obstructive sleep apnea in children: A systematic review and meta-analysis
2022, International Journal of Pediatric Otorhinolaryngology
This systematic review aims to assess the night-to-night variability (NtNV) in respiratory sleep parameters in children and the accuracy of diagnosing obstructive sleep apnea (OSA) in children based on a single-night sleep study.
The PubMed, EMBASE, and Cochrane Library databases were searched until March 8, 2021. This study was registered in the International Prospective Register of Systematic Reviews (PROSPERO) database (CRD42021239838).
Our study included 395 patients from 5 articles. The mean (SD) age of all included patients was 11.78 (4.05) years. AHI was reported for 325 participants in 4 studies, and the mean change between two consecutive nights was −0.13 [95% CI: −0.40, 0.14] events per hour. The mean change in OAI was −0.07 [95% CI: −0.27, 0.12] events per hour in 187 participants across 3 studies. Based on the diagnostic criteria used, three studies reported that the diagnostic rates of OSA patients in a single-night sleep study were 83%, 84.6%, and 91%. The NtNV in AHI in children with severe and moderate OSA was greater than that in children with mild OSA (3.35 [95% CI: 0.07, 6.62] events per hour vs −0.15 [95% CI: −0.42, 0.12] events per hour), and these children with more severe OSA may have shown a higher AHI on the first night.
The NtNV in AHI was not statistically significant in the group sample of children. However, there were significant differences in NtNV in AHI between children with mild and moderate-to-severe OSA. Individual NtNV in respiratory sleep parameters may cause children to be misdiagnosed by single-night diagnostic sleep studies.
The Accuracy of Repeated Sleep Studies in OSA: A Longitudinal Observational Study With 14 Nights of Oxygen Saturation Monitoring
2021, Chest
Citation Excerpt :
Our current data confirmed these findings in a cohort of CPAP-naïve patients with suspected OSA, showing a change in OSA severity in 76% of patients over 14 nights using the highest ODI3%. The intraindividual variability of our cohort measured by CV was similarly high (32%) and comparable with the results reported by Stöberl et al.3 Only few data are available in literature that address the change in accuracy in relationship to different numbers of sleep studies in the diagnostic workup of OSA.4,12,25 These studies are limited by their small patient numbers, lack of a priori power calculations, and poor comparability because of different study designs.
Strong evidence exists for clinically relevant night-to-night variability of respiratory events in patients with suspected OSA.
How many sleep study nights are required to diagnose OSA accurately?
Patients with suspected OSA underwent up to 14 nights of pulse oximetry (PO) at home and one night of in-hospital respiratory polygraphy (RP). The accuracy of each of the 13 sleep study nights was analyzed using the mean oxygen desaturation index 3% (ODI_3%) of all 14 nights as a reference. Multiple regression analyses assessed possible predictors for night-to-night variability.
One hundred three patients underwent in-hospital RP. Using only the results of the RP, 19.7% were misdiagnosed using an ODI_3% cutoff of 15/h. One hundred eight patients underwent properly performed PO studies at home with a coefficient of variation (CV) of 31.5% (SD, 14.7%) across all nights. The first PO night demonstrated a sensitivity of 71.4% (95% CI, 55.4%-84.3%) and a specificity of 89.4% (95% CI, 79.4%-95.6%) to diagnose moderate OSA. Using only the first PO night, the negative predictive value was 83.1%. Adding a second recording night increased sensitivity up to 88.1% (95% CI, 74.4%-96.0%) with a slightly lower specificity of 85.9% (95% CI, 74.9%-93.4%). The ODI_3% of the in-hospital RP showed an independent negative association to the log-transformed CV (exponentiated coefficient, 0.989; 95% CI, 0.984-0.995).
One single night of in-hospital RP may miss relevant OSA. Multiple study nights, for example, using ambulatory oxygen saturation monitoring, increase accuracy for diagnosing moderate OSA.
ClinicalTrials.gov; No.: NCT03819361; URL: www.clinicaltrials.gov
It's Time for Multiple Sleep Night Testing in OSA
2020, Chest
Variability and Misclassification of Sleep Apnea Severity Based on Multi-Night Testing
2020, Chest
Portable monitoring is a convenient means for diagnosing sleep apnea. However, data on whether one night of monitoring is sufficiently precise for the diagnosis of sleep apnea are limited.
The current study sought to determine the variability and misclassification in disease severity over three consecutive nights in a large sample of patients referred for sleep apnea.
A sample of 10,340 adults referred for sleep apnea testing was assessed. A self-applied type III monitor was used for three consecutive nights. The apnea-hypopnea index (AHI) was determined for each night, and a reference AHI was computed by using data from all 3 nights. Pairwise correlations and the proportion misclassified regarding disease severity were computed for each of the three AHI values against the reference AHI.
Strong correlations were observed between the AHI from each of the 3 nights (r = 0.87-0.89). However, substantial within-patient variability in the AHI and significant misclassification in sleep apnea severity were observed based on any 1 night of monitoring. Approximately 93% of the patients with a normal study on the first night and 87% of those with severe sleep apnea on the first night were correctly classified compared with the reference derived from all three nights. However, approximately 20% of the patients with mild and moderate sleep apnea on the first night were misdiagnosed either as not having sleep apnea or as having mild disease, respectively.
In patients with mild to moderate sleep apnea, one night of portable testing can lead to misclassification of disease severity given the substantial night-to-night variability in the AHI.
Night-to-night variability of the obstructive sleep apnoea-hypopnoea syndrome
2016, Revue des Maladies Respiratoires
Bien qu’il soit le principal outil utilisé pour le diagnostic du syndrome des apnée-hypopnées obstructives du sommeil (SAHOS), l’index apnées/hypopnées (IAH) connaît plusieurs facteurs limitants dont la variabilité inter-nuits.
Évaluer la variabilité de l’IAH au cours du SAHOS.
Les patients adressés à l’unité de sommeil pour suspicion clinique de SAHOS ont eu deux enregistrements polygraphiques espacés de 24 heures. Les sujets avec troubles psychiatriques, habitudes ou professions pouvant induire une modification du sommeil ont été exclus. La population d’étude a été par la suite divisée en deux groupes selon la variabilité de l’IAH.
Vingt patients âgés en moyenne de 50,6 ± 9,3 ans ont été inclus. Le SAHOS était léger dans 4 cas, modéré dans 6 cas et sévère dans 8 cas. L’IAH était inférieur à 5 dans deux cas. Les IAH des nuits 1 et 2 étaient comparables (33,2 vs 31,8) et significativement corrélés. Toutefois, une variabilité importante était retrouvée au niveau individuel. La variabilité de l’IAH était corrélée à l’index de masse corporelle.
L’IAH est correctement corrélé au cours de deux nuits consécutives. Un seul enregistrement nocturne est donc suffisant. Toutefois, une variabilité individuelle significative doit être prise en considération.
The apnoea-hypopnoea index (AHI) is the primary measurement used to characterize the obstructive sleep apnoea-hypopnoea syndrome (OSAHS). Despite its popularity, there are limiting factors to its application such as night-to-night variability.
To evaluate the variability of AHI in the OSAHS.
A prospective study was designed in our university hospital's sleep unit. Adults with clinical suspicion of OSAHS underwent 2 consecutive nights of polysomnographic recording. The population was divided in two groups according to an AHI > or < 10. Patients with psychiatric disorders or professions that might result in sleep deprivation or an altered sleep/wake cycle were excluded.
Twenty patients were enrolled. The mean age was 50.6 ± 9.3 years. OSAHS was mild in 4 cases, moderate in 6 cases and severe in 8 cases. AHI was less than 5 in two cases. AHI values were not significantly altered throughout both recording nights (33.2 vs. 31.8 events/h). A significant positive correlation was found between AHI measured on the first and the second night. However, a significant individual variability was noted. Comparison between both patient's groups showed a correlation between AHI and the body mass index.
This study demonstrates that the AHI in OSAHS patients is well correlated between two consecutive nights. However, a significant individual variability should be taken into consideration, especially when AHI is used in the classification of OSAHS or as a criterion of therapeutic success.
Effects of suvorexant, an orexin receptor antagonist, on breathing during sleep in patients with chronic obstructive pulmonary disease
2015, Respiratory Medicine
There is a general concern that hypnotic medications in patients with respiratory disorders have the potential to decrease respiratory effort and blunt the arousal response to hypoxemia which may lead to sleep breathing disorders. We investigated whether suvorexant, an orexin receptor antagonist approved for treatment of insomnia at a maximum daily dose of 20 mg in the US, causes sleep breathing disorders in patients with chronic obstructive pulmonary disease (COPD).
This was a randomized, double-blind, placebo-controlled, 2-period, cross-over, study performed in 9 sleep laboratories/clinical research units in the United States. The participants were 25 COPD patients aged 39–72 y with mild-to-moderate airflow limitation based on GOLD spirometry criteria. In each period, patients received suvorexant (40 mg in <65 y-olds; 30 mg in ≥65 y-olds) or placebo for four consecutive nights. Respiratory function during sleep was measured by oxygen saturation using pulse oximetry (SpO₂, primary endpoint) and Apnea Hypopnea Index (AHI, secondary endpoint). The study was powered to rule out a difference between treatments of −2 percentage points in SpO₂ on Day 4.
There was no treatment effect following single and multiple doses of suvorexant on mean SpO₂ during total sleep time (Day 1: suvorexant = 93.14%, placebo = 93.24%, difference = −0.10 [90% CI: −0.50, 0.31]; Day 4: suvorexant = 93.38%, placebo = 92.99%, difference = 0.39 [90% CI: −0.12, 0.91]). There was no clinically meaningful increase in mean AHI by suvorexant compared with placebo on Day 1 (difference = 0.72 [90% CI: −0.60, 2.04]) or Day 4 (difference = 2.05 [90% CI: 0.33, 3.77]).
These data do not suggest an overt respiratory depressant effect with 30–40 mg daily doses of suvorexant, up to twice the maximum recommended dose for treating insomnia in the US, in patients with mild-to-moderate COPD.
Trial registration Clinicaltrials.gov identifier: NCT01293006.

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: Manuscript received April 24; revision accepted July 30

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Chest

Clinical InvestigationsOne Negative Polysomnogram Does Not Exclude Obstructive Sleep Apnea

Section snippets

Patients

RESULTS

DISCUSSION

CONCLUSION

Chest

Chest

Chest

Mayo Clin Proc

Chest

The sleep hypopnea syndrome

Am Rev Respir Dis

Night-to-night consistency of apneas during sleep

Am Rev Respir Dis

Case report: multiple negative polysomnograms in patients with obstructive sleep apnea

Am J Med Sci

Clinical Investigations
One Negative Polysomnogram Does Not Exclude Obstructive Sleep Apnea