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

Abstract

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...

Long-Term Cognitive and Behavioral Outcomes following Resolution of Sleep Disordered Breathing in Preschool Children

“…Mean number of arousals per hour for the entire cohort reduced from 13.8 to 11.2. This is similar to the 14% decrease reported by Chervin et al [ 60 ] who found no association between sleep fragmentation, defined by respiratory cycle-related changes in the EEG, and neurobehavioral outcomes following treatment. The mixed model analysis used in the current study may have provided the statistical sensitivity to detect an association, however the clinical relevance needs to be considered.…”

Obstructive sleep disordered breathing in 2- to 18-year-old children: diagnosis and management

“…Primary nocturnal enuresis among children with snoring referred for polysomnography is a significant predictor of OSAS severity (class IV) [106]. However, neither the AHI nor sophisticated measures of sleep fragmentation, such as respiratory cycle-related electroencephalogram (EEG) changes, are associated with behavioural problems, cognitive deficits or sleepiness, and they do not explain the improvement in neurobehavioral outcomes following adenotonsillectomy (meta-analysis, class III and IV) [92,145,149,150]. b) In the CHAT study, participants with moderate-to-severe disease (AHI >4.7 episodes·h −1 ) assigned to watchful waiting were less likely to improve spontaneously compared with those with mild disease (class I) [126].…”

Clinical validation of a mandibular movement signal based system for the diagnosis of pediatric sleep apnea

“…Furthermore, obstructive events, and increases in respiratory efforts with or without arousals may not necessarily be reflected by gas exchange alterations or even by visually recognizable EEG arousals. This is restricting the recognition of respiratory‐related sleep fragmentation that has been identified as an important contributor to OSA morbidity 18–21 . Thus, it is highly desirable when adopting innovative techniques for diagnosis of pediatric OSA to include a reliable assessment of respiratory effort (RE).…”

“…This is restricting the recognition of respiratoryrelated sleep fragmentation that has been identified as an important contributor to OSA morbidity. [18][19][20][21] Thus, it is highly desirable when adopting innovative techniques for diagnosis of pediatric OSA to include a reliable assessment of respiratory effort (RE). Application of such advanced diagnostic approaches has recently greatly benefited from the advent of machine learning applications in the field of sleep medicine, as those techniques can facilitate complex signal processing and improve reproducibility of sleep staging and respiratory pattern evaluation.…”