Clin Exp Otorhinolaryngol.  2024 Aug;17(3):226-233. 10.21053/ceo.2023.00037.

Influence of Sleep Stage on the Determination of Positional Dependency in Patients With Obstructive Sleep Apnea

• Ryu S
• Kim SC
• Kim RB
• Lee BM
• Park SW
• Jeon YJ
• Joo YH
• Cho HJ
• Kim SW

• KMID: 2558839
• DOI: http://doi.org/10.21053/ceo.2023.00037

Abstract

Objectives
. The supine sleep position and the rapid eye movement (REM) stage are widely recognized to exacerbate the severity of obstructive sleep apnea (OSA). Position-dependent OSA is generally characterized by an apnea-hypopnea index (AHI) that is at least twice as high in the supine position compared to other sleep positions. However, this condition can be misdiagnosed if a particular sleep stage—REM or non-REM (NREM)—predominates in a specific position. We explored the impact of the sleep stage on positional dependency in OSA.
Methods
. Polysomnographic data were retrospectively analyzed from 111 patients with OSA aged 18 years or older, all of whom had an AHI exceeding five events per hour and slept in both supine and non-supine positions for at least 5% of the total sleep time. The overall ratio of non-supine AHI to supine AHI (NS/S-AHI ratio) was compared between total, REM, and NREM sleep. Additionally, a weighted NS/S-AHI ratio, reflecting the proportion of time spent in each sleep stage, was calculated and compared to the original ratio.
Results
. The mean NS/S-AHI ratio was consistent between the entire sleep period and the specific sleep stages. However, the NS/S-AHI ratios for individual patients displayed poor agreement between total sleep and the specific stages. Additionally, the weighted NS/S-AHI ratio displayed poor agreement with the original NS/S-AHI ratio, primarily due to discrepancies in patients with mild to moderate OSA.
Conclusion
. The weighted NS/S-AHI ratio may help precisely assess positional dependency.

Keyword

Diagnosis; Polysomnography; Obstructive Sleep Apnea; Sleep Stages; Supine Position

Figure

• 

  Fig. 1. Comparison of the ratio of non-supine apnea-hypopnea index (AHI) to supine AHI (NS/S-AHI ratio) during total, rapid eye movement (REM), and non-REM (NREM) sleep. The mean value of the NS/S-AHI ratio during the entire sleep period did not differ significantly from that during REM sleep (A), but the values for individual patients displayed poor agreement (Lin concordance correlation coefficient [CCC], 0.43; 95% confidence interval [CI], 0.26–0.57). Eight outliers (7.2%) were present beyond ±2 standard deviations (SDs) from the mean difference between these two ratios (B, C). Similarly, the mean value of the NS/S-AHI ratio during the entire sleep period was not significantly different from that during NREM sleep (D), but the values for individual patients also showed poor agreement (CCC, 0.81; 95% CI, 0.74–0.86). Two outliers (1.8%) were found beyond ±2 SDs from the mean difference between those two ratios (E, F). Likewise, the mean values of the NS/S-AHI ratio during REM and NREM sleep were not significantly different (G), but the patient-specific values again showed poor agreement (CCC, 0.25; 95% CI, 0.06–0.43). Six outliers (5.4%) were observed beyond ±2 SDs from the mean difference between those two ratios (H, I). R, REM sleep; NR, NREM sleep.

• 

  Fig. 2. Comparison between the overall and weighted ratio of non-supine apnea-hypopnea index (AHI) to supine AHI (NS/S-AHI ratio). The mean value of the weighted NS/S-AHI ratio did not differ significantly from the overall ratio (A). However, three outliers (2.7%) were found beyond ±2 standard deviations (SDs) from the mean difference between these two ratios (B, C). None of these outliers represented position dependency based on the overall NS/S-AHI ratio. When the weighted NS/S-AHI ratio was applied, one case (number 4.1) was identified as having positional dependency. The other two cases also demonstrated noticeable changes in their values; however, their positional dependency status did not change, according to the 0.5 criterion (C).

• 

  Fig. 3. Agreement between the overall and weighted ratio of non-supine apnea-hypopnea index (AHI) to supine AHI (NS/S-AHI ratio) ratios according to the severity of obstructive sleep apnea. In patients with mild to moderate obstructive sleep apnea (n=49), poor agreement was observed (Lin concordance correlation coefficient [CCC], 0.69; 95% confidence interval [CI], 0.52–0.81; A). In contrast, substantial agreement was found in patients with severe obstructive sleep apnea (n=62; CCC, 0.99; 95% CI, 0.98–0.99; B).

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