The Laryngoscope

Published 2020. This article is a U.S.

Government work and is in the public
domain in the USA.

The Value of Oxygen Desaturation Index for Diagnosing Obstructive

Sleep Apnea: A Systematic Review

Nur HA Rashid, MD; Soroush Zaghi, MD ; Marcelo Scapuccin, MD; Macario Camacho, MD ;
Victor Certal, MD, PhD; Robson Capasso, MD

Objectives: Intermittent hypoxemia is a risk factor for developing complications in obstructive sleep apnea (OSA) patients.
The objective of this systematic review was to identify articles evaluating the accuracy of the oxygen desaturation index (ODI) as
compared with the apnea–hypopnea index (AHI) and then provide possible values to use as a cutoff for diagnosing adult OSA.
Study Design: Systematic Review of Literature.
Methods: PubMed, the Cochrane Library, and SCOPUS databases were searched through November 2019.
Results: Eight studies (1,924 patients) met criteria (age range: 28–70.9 years, body mass index range: 21.9–37 kg/m2, and
AHI range: 0.5–62 events/hour). Five studies compared ODI and AHI simultaneously, and three had a week to months between
assessments. Sensitivities ranged from 32% to 98.5%, whereas specificities ranged from 47.7% to 98%. Significant heterogeneity
was present; however, for studies reporting data for a 4% ODI ≥ 15 events/hour, the specificity for diagnosing OSA ranged from
75% to 98%, and only one study reported the positive predictive value, which was 97%. Direct ODI and AHI comparisons were not
made because of different hypopnea scoring, different oxygen desaturation categories, and different criteria for grading OSA severity.
Conclusion: Significant heterogeneity exists in studies comparing ODI and AHI. Based on currently published studies,
consideration should be given for diagnosing adult OSA with a 4% ODI of ≥ 15 events/hour and for recommending further
evaluation for diagnosing OSA with a 4% ODI ≥ 10 events/hour. Screening with oximetry may be indicated for the detection of
OSA in select patients. Further study is needed before a definitive recommendation can be made.
Key Words: Obstructive sleep apnea, review, systematic review, apnea-hypopnea index, oxygen desaturation index.
Laryngoscope, 131:440–447, 2021

INTRODUCTION contributing to multiorgan comorbidity.1 Undiagnosed OSA

Obstructive sleep apnea (OSA) forms a significant part
of the spectrum of sleep-related breathing disorders and is
characterized by recurrent episodes of airflow obstruction
caused by a total or partial collapse of the upper airway.
These repetitive episodes of apneas and hypopneas are asso-
ciated with recurrent cycles of intermittent hypoxemia
(IH) or cyclical desaturation–reoxygenation.1 It is thought
that IH leads to oxidative stress, systemic and vascular
inflammation with endothelial dysfunction, increased sym-
pathetic activation, and blood pressure elevation, thus
From the Unit of Otorhinolaryngology, Department of Surgery,
Faculty of Medicine and Health Sciences (N.H.R.), Universiti Putra
Malaysia, Serdang, Malaysia; University of California Los Angeles
(UCLA) Medical Center, Santa Monica (S.Z.), Santa Monica, California,
USA; Department of Otorhinolaryngology-Head and Neck Surgery (M.S.),
Santa Casa School of Medicine, Sao Paulo, Brazil; Division of Sleep
Surgery and Medicine, Department of Otolaryngology-Head and Neck
Surgery (M.C.), Tripler Army Medical Center, Honolulu, Hawaii, USA;
Department of Otorhinolaryngology (V.C.), Sleep Medicine Centre, Hospital
CUF Porto, Porto, Portugal; and the Division of Sleep Surgery (R.C.),
Department of Otolaryngology-Head & Neck Surgery, Stanford University
School of Medicine.
Institution where work was performed: Stanford Hospital and
Clinics, Redwood City, California, U.S.A.
Editor’s Note: This Manuscript was accepted for publication on
March 13, 2020.
The authors have no funding, financial relationships, or conflicts of
interest to disclose.
Send correspondence to Macario Camacho, MD, Division of Sleep
Surgery and Medicine, Department of Otolaryngology–Head and Neck
Surgery, Tripler Army Medical Center, Honolulu,
HI. E-mail: drcamachoent@yahoo.com
DOI: 10.1002/lary.28663
is known to be associated with neurocognitive impairment 2
and cardiovascular morbidity,3–5 and is a well-recognized
public health issue.6
The apnea–hypopnea index (AHI) is the most common
measurement of OSA diagnosis and severity and is defined
as the number of apneas and hypopneas per hour of
sleep. It is derived from the gold-standard level 1 poly-
somnography (PSG) and is used for disease identification,
disease severity quantification, and definition of the preva-
lence of this condition in normal and clinical populations.7
However, this diagnostic modality has limitations that
include: 1) the “first night effect” (adaptation to sleep labo-
ratory environment characterized by increased sleep onset
latency, increased rapid eye movement latency, and lower
sleep efficiency8; 2) inherent night-to-night variability; and
3) over- or underestimation of events depending on the spe-
cific monitoring channels used (e.g., use of thermistors com-
pared with nasal cannulas).9–14 Moreover, there is
controversy in defining hypopnea, for which classification
of abnormal severity and extent of reduction in airflow is
still in dispute.15,16 Studies have shown that these discrep-
ancies yield different estimates of AHI, which may alter
disease identification and prevalence, treatment decisions,
and comparability of research and clinical results.7,17–19
Additionally, some articles have reported that the AHI
derived from polysomnography has a lower predictive value
for determining the risk of OSA-related complications as
compared to measurements of intermittent hypoxemia.20

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440
 Other means of assessing OSA have been investigated,
such as clinical evaluation and questionnaires,21–23 radio-
logic studies,24 cardiovascular system analyses (i.e., heart
rate variability and peripheral arterial tonometry25–27),
acoustic investigations of snoring, and the nocturnal pulse
oximeter (NPO) as a stand-alone diagnostic tool.28–35 As the
name implied, the oxygen desaturation index (ODI) is a
measure of the number of times per hour that oxygen satu-
ration decreases per hour. The value of ODI is independent
of the duration of the desaturation and is strictly a count of
the number of times that the oxygen desaturates by a cer-
tain percentage (such as 3% or 4%). Useful oxymetric mea-
sures that can be extracted from NPO include lowest
oxygen saturation (SpO2 nadir), mean oxygenation satura-
tion (mean SpO2), and time spent below 90% oxygenation,
as well as the ODI. However, because NPO does not include
a thermistor, electrocardiogram, or chest leads, it is not pos-
sible to accurately assess for the incidence of apnea,
hypopnea, or arousals during sleep. Moreover, the NPO
cannot differentiate central apnea from obstructive apnea.
There is interest in NPO because it is portable, eco-
nomical, widely available, simple to use, and potentially
could be used as an affordable option for diagnosis and
chronic management for OSA sufferers. However, the
Fig. 1. Flow chart for search strategy, study identification, and study selection.
Laryngoscope 131: February 2021 Rashid et al.: Oxygen Desat Index in Diagnosing OSA: Systematic Review
updated Practice Parameters for the Indications for
Polysomnography and Related Procedures in 2005 states
that oximetry lacks the specificity and sensitivity to be
used as an alternative to polysomnography or an
attended cardiorespiratory (level III) sleep study for
diagnosing sleep-related breathing disorders.14 Because
pulse oximeter devices have developed improved resolu-
tion in recent years, we conducted a systematic review
to study the diagnostic accuracy of ODI derived from the
nocturnal pulse oximeter compared to AHI derived from
the level 1 PSG in adult OSA. To our knowledge, a sys-
tematic review evaluating the international literature
comparing AHI and ODI has not been performed. The
objective of this review was to identify articles evaluat-
ing the accuracy of the ODI as compared with the AHI
and then provide possible values to use as a cutoff for
diagnosing OSA.
METHODS
Search Strategy
We performed a comprehensive literature search for several
months, finalized in November 2019 using PubMed, the Cochrane
441
 TABLE I.
Quality Appraisal of the Included Studies Using the QUADAS-2 Tool.
Risk of Bias Applicability Concerns
Study Patient Selection Index Test Reference Standard Flow and Timing Patient Selection Index Test Reference Standard

Alvarez et al., 200728 Low risk Unclear Unclear Low risk Low risk Low risk Low risk
Chiner et al., 199929 Low risk Low risk Low risk Low risk Low risk Low risk Low risk
Golpe et al., 199930 Unclear Low risk Low risk High risk Low risk High risk Low risk
Gyulay et al. 199331 Low risk Low risk Low risk Low risk Low risk Low risk Low risk
Hang et al., 201532 High risk High risk Unclear Unclear Low risk Low risk Low risk
Lin et al., 200933 Low risk High risk Low risk Unclear Low risk Low risk Low risk
Series et al., 199334 Low risk Low risk Low risk Low risk Low risk Low risk Low risk
Takeda et al., 200635 Unclear Unclear Unclear Low risk Low risk Low risk Low risk

QUADAS-2 = Quality Assessment for Diagnostic Accuracy Studies-2.

Library, and SCOPUS electronic databases. We combined the fol-
lowing keywords and Medical Subject Headings terms: ((((“oxygen
desaturation index”) OR (oximetry) OR (“transcutaneous blood gas
monitoring”)) AND (apnea OR apnoea OR hypopnea OR
hypopnea)) AND (“Sleep Apnea Syndromes”)). We limited our sea-
rch to English-language studies but without time restrictions.
Selection Criteria, Study Quality Assessment,
and Data Extraction
We only included studies that directly compared ODI (derived
from pulse oximetry data) with AHI (derived from level 1 poly-
somnography). The primary outcome measure was the degree of diag-
nostic agreement and accuracy between ODI (such as that from NPO)
and AHI (from polysomnography) cutoffs to diagnose obstructive sleep
apnea. Secondary outcome measures included a comparison of other
oxymetric measurements (SpO2 nadir, mean SpO2, time spent below
90% oxygenation) to those derived from level 1 polysomnography.
Studies carried out in sample populations with comorbidities such as
chronic obstructive pulmonary disease, congestive heart failure, hypo-
ventilation, and central apneas were excluded.
Two reviewers (M.S. and N.H.A.R.) independently screened
titles and abstracts to identify potential studies for inclusion in
the study while discrepancies were resolved by a third reviewer
(S.Z.). Two authors (V.C. and R.C.) also independently assigned the
Quality Assessment for Diagnostic Accuracy Studies-2
(QUADAS-2) tool to each article. Disagreements were resolved
by consensus. Studies comparing NPO with level 1 sleep test
involving adults were included if they reported on diagnostic
accuracy and/or agreement. Therefore, the study inclusion
criteria were as follows using the PICOS acronym: 1) patients:
adult patients (≥ 18 years old) with obstructive sleep apnea; 2)
intervention: nocturnal pulse oximeter and polysomnography; 3)
comparison: polysomnography data that can be compared; 4) out-
comes: diagnostic accuracy and/or agreement between nocturnal
pulse oximetry and polysomnography; 5) study design: any study
design from case series through randomized controlled trials.
Data were reported as mean/standard deviation (range)
values for continuous variables and frequency and percentage
values for categorical variables.
RESULTS
Search Results and Quality Assessment
A flow chart of the process of the study identification
and inclusion/exclusion is shown in Figure 1.
In total, 881 articles were identified using the search
strategy and listed sources. Among these, 845 articles
were excluded either because NPO was not used in the
study, the article was a review without original data, or
the study involved the pediatric population. The
remaining 36 articles were retrieved for more detailed
full-text evaluation, and another five were included after
a manual search of references of the included studies.
Thirty-three articles were excluded for the reasons sum-
marized in Figure 1.
We used the QUADAS-2 tool to assess the quality of
the included studies, shown in Table I. This tool evalu-
ates internal validity (bias) and external validity (applica-
bility) in the following domains: patient selection, index
test, reference-standard test, flow, and timing.36
Included Studies
Eight studies with 1,924 patients met the criteria to
be included in this review. The characteristics of these
studies are shown in Table II. 82.4% of the patients were
male; age range was 28 to 70.9 years; body mass index
(BMI) range was 21.9 to 37 kg/m2; and AHI range was
−0.5 to 62 events/hour. Six studies28–31,34,35 used a sepa-
rate oximeter to collect ODI data to make comparisons
with the reference device, and in two studies32,33 the oxim-
etry data was acquired from the reference instrument.
Five studies28,29,32,33,35 acquired ODI and AHI data simul-
taneously during the same sleep study event, whereas in
three studies30,31,34 the comparison intervals between the
acquisition of the ODI data (via NPO) and AHI data (via
level I PSG) were between 1 week and 22 months.
All studies but one33 sought to investigate diagnostic
accuracy and agreement between ODI and AHI by conser-
vative statistical analyses such as receiver operator curves
construction, area under the curve measurements, and
Bland–Altman plot compositions. Lin et al33 carried out
predictive modeling to study the diagnostic accuracy and
agreement of ODI and AHI and concluded that ODI pro-
vided a high level of diagnostic sensitivity and specificity
at different degrees of OSA severity. However, a very high
inconsistency was seen among the sensitivities and speci-
ficities reported in the included studies; sensitivities

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 TABLE II.
Characteristics of Included Studies.
Outcome
No. Study Study Characteristics Patient Characteristics Measure Method

1 Alvarez Design: cohort Index device: 1- Criticare 504, N: 187 58.0  12.9 2
BMI (kg/m ): Diagnostic
et al., Criticare Technologies Inc 29.5  5.5 accuracy and
Reference device: Ultrasom Men: 147
200728 CSI Waukesha, WI agreement
Network , Nicolet, Madison, Age (years): AHI:
WI, U.S.A Comparison interval: *40.1  19.6
simultaneous
Central tendency measure
2 Chiner Design: cohort Index device: 1- Nellcor N200, N: 275 BMI (kg/m2): †32  5 Diagnostic Linear
et al., Nellcor Inc, Pleasanton,CA accuracy regression,
Reference device: Somnostar Men: 246 AHI: †42  20
199929 between ROC analysis
SensorMedics Z4 Comparison interval: Age (years):
†
Polysomnography simultaneous 53  10
Diagnostic Sleep Lab Study
System, Vyaire Medical, Inc,
Mettawa, IL
3 Golpe Design: retrospective cohort Index device: 1- Pulse Ox 7 N: 116 BMI (kg/m2): 29.6  6.4 Diagnostic Linear
et al., Konica Minolta, Tokyo, (excluded if >10% BMI accuracy and regression,
Reference device: level I PSG, Men: 104
199930 Japan change) agreement ROC analysis
name NR Age (years):
Comparison interval: 50  13 AHI: 23.7  24.2
2–22 months
‡
4 Gyulay Design: cohort Index device: model 1- N: 98 50.0  2.5 BMI (kg/m2): Diagnostic
et al., Ohmeda 3700 Pulse 30.2  1.2 accuracy
Reference device: level I PSG, Men: 77
199331 Oximeter Biox, Boulder
name NR Age (years): AHI: NR
Colorado
Comparison interval:
2 weeks–3 months
Linear regression, ROC analysis
5 Hang Design: retrospective cohort Index device: part of reference N: 616 45.2  12.7 BMI (kg/m2): Diagnostic
et al., device 26.7  4.2 accuracy and
Reference device: Respironics Men: 475
201532 agreement
Alice 4 Diagnostic Sleep Comparison interval: Age (years): AHI: NR
Study, Kennesaw, GA simultaneous
Support machine technique
vector
6 Lin et al., Design: retrospective cohort Index device: part of reference N: 257 42.7  12.3 BMI (kg/m2): Diagnostic
200933 device 26.3  3.9 accuracy and
Reference device: 1- Men: 209
agreement
Respironics Alice 4 Comparison interval: Age (years): AHI: 37.6  23.6
Diagnostic Sleep Study, simultaneous
Kennesaw, GA
Predictive analysis
model
7 Series Design: cohort Index device: Biox IVA, N: 240 BMI (kg/m2): 31.7  0.8 Diagnostic Linear
et al., Ohmeda, Tokyo, Japan accuracy and regression,
34 Reference device: Grass Men: 216 AHI: 38.1  2.5
1993 agreement ROC analysis
Instruments, Quincy, MA Comparison interval: Age (years):
1–4 weeks (Range
28–68)
8 Takeda Design: cohort Index device: 1- Apnomonitor N: 135 54.0  15.6 BMI (kg/m2): Diagnostic
et al., Reference device: Alice 3, III: AP, Chest Co., Tokyo, Men: 112 25.8  3.9 accuracy and
200635 Respironics Diagnostic Japan Age (years): AHI: 37.2  22.7 agreement
Sleep System, Kennesaw, Comparison interval:
GA simultaneous

Linear regression, ROC analysis

*In 111 patients positive for OSA.

†
In 194 patients positive for OSA.
‡
Results reported only for evaluable patients, that is, those who completed the test, had their records analyzed, and started CPAP treatment.
BMI = body mass index (weight (kg)/height (m2)); CPAP = continuous positive airway pressure; NR = not reported; ODI = oxygen desaturation index;
OSA = obstructive sleep apnea; PSG = polysomnography; RDI = respiratory disturbance index; ROC = receiver operator curve; SaO2 = blood oxygen saturation;
SVM = support vector machine.

ranged from 32% to 98.5%, whereas specificities ranged
from 47.7% to 98%.28–35 We tabulated the main variables
used in each study, as shown in Table III. For studies
reporting data for a 4% ODI ≥ 15 events/hour, specificity
for diagnosing OSA ranged from 75% to 98%, and only one
study reported the positive predictive value, which was
97% (see Table IV). Only three studies31–33 followed the
definitions recommended by the American Association of
Sleep Medicine (AASM), whereas another three29,34,35 used
their own cutoffs and guidelines. Definitions of apnea, oxy-
gen desaturation, baseline airflow, baseline saturation,
and OSA were different for each of the eight studies.
Takeda et al35 found that the diagnostic value of ODI was
better than the apnea index, although there were possible
inappropriate settings of the NPO device used, as well as
underestimation of the apnea measurement.

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 TABLE III.
Definitions of Apnea, Oxygen Desaturation, Baseline Airflow, Baseline Saturation, and OSA in the Included Studies.
No. Study Apnea Oxygen Desaturation Event Baseline Airflow Baseline Oxygen Desaturation OSA

1. Alvarez et al., Cessation of (i) Fall in SaO2 ≥ 4% from baseline NR Mean saturation in the first 3 min of AHI
200728 airflow for ≥ 10 recording ≥10
(ii) Fall in SaO2 ≥ 3% from baseline
secs
(iii) Fall in SaO2 ≥ 2% from baseline
2. Chiner et al., Cessation of (i) Fall in SaO2 > 4% from baseline Value of Mean saturation in the previous minute of AHI
199929 airflow for ≥ 10 immediately recording ≥15
(ii) Fall in SaO2 ≥ 4% in the interval of 90%–
secs preceding
100% of SaO2
breaths
3. Golpe et al., Cessation of Fall in SaO2 of ≥ 4% NR NR AHI
199930 airflow for ≥ 10 ≥ 10
secs
4. Gyulay et al., A cessation of i) Fall in SaO2 of ≥2% from baseline until NR Mean SaO2 level in the first 3 min of AHI
199331 oronasal airflow resaturation of ≥ 2% or lasting 3 min recording ≥ 15
> 10 sec
(ii) Fall in SaO2 of ≥ 3% from baseline until
resaturation of ≥ 3% or lasting 3 min
(iii) Fall in SaO2 of ≥ 4% from baseline until
resaturation of ≥ 4% or lasting 3 min
5. Hang et al., Cessation of (i) Fall in SaO2 ≥ 4% from baseline Preceding period (i) mean of all-night saturation AHI > 5
201532 airflow for ≥ 10 of normal
(ii) Fall in SaO2 ≥ 3% from baseline (ii) mean of the top 20% of oxyhemoglobin
secs breathing
saturation values over the 1 min
preceding the scanned oxyhemoglobin
value
6. Lin et al., Cessation of (i) Fall in SaO2 ≥ 4% from baseline lasting Preceding period (i) mean of all-night saturation AHI > 5
200933 airflow for ≥ 10 1 sec of normal
(ii) mean of the top 20% of oxyhemoglobin
secs breathing
(ii) Fall in SaO2 ≥ 4% from baseline lasting saturation values over the 1 min
3 sec preceding the scanned oxyhemoglobin
(iii) Fall in SaO2 ≥ 4% from baseline lasting value
5 sec
(iv) Fall in SaO2 ≥ 3% from baseline lasting
1 sec
(v) Fall in SaO2 ≥ 3% from baseline lasting
3 sec
(vi) Fall in SaO2 ≥ 3% from baseline lasting
5 sec
7. Series et al., A cessation of Transient desaturation followed by a rapid NR NR AHI
199334 oronasal airflow return to the baseline SaQ2 level using ≥15
> 10 sec no minimum decrease in SaQ2 level and
no threshold
8. Takeda et al., A sustained airflow Fall in SaO2 > 3% from the previous score NR NR RDI
200635 reduction lower ≥20
than 50% below
baseline, lasting
more than
10 sec

AHI = apnea–hypopnea index; NA = not applicable; NR = not reported; OSA = obstructive sleep apnea; RDI = respiratory disturbance index; SaO2 = blood
oxygen/hemoglobin saturation.

Alvarez et al.28 applied nonlinear analysis to their
data to assess diagnostic accuracy and agreement, spe-
cifically the approximate entropy and central tendency
measures to construct second-order difference plots.
They suggested that using this analysis could improve
the diagnostic ability of SpO2 signals from NPO. Hang
et al.32 employed the support vector machine technique,
a useful method for data classification and regression
that in recent years has become an important tool for
machine learning and data mining in medicine. The
SMV models that were designed based on ODI provided
a high sensitivity, specificity, and area under the curve
compared to conservative analysis.
Other oxymetric measures that have been compared to
AHI for the diagnosis of OSA include the cumulative time
spent below an oxyhemoglobin saturation of 90%30,31,37 and
delta index, which is a measure of the variability of the oxy-
hemoglobin saturation.38–40 None of the studies reported
mean oxygen saturation or percent of the time spent < 90%
oxygen saturation.
DISCUSSION
Intermittent hypoxemia is one of the two general
patterns of hypoxia that is most characteristic of patients
with OSA. IH is manifested as a short, intermittent,
high-frequency cyclical pattern of oxygen desaturation
lasting 15 to 60 seconds, followed by re-oxygenation,
which occurs for 8 to 9 hours per night during sleep in a
process that can last for weeks to months or even longer.1
In comparison, sustained or low-frequency hypoxemia is
manifested as oxygen saturation ranging between 80%
and 85%, which lasts from a few minutes to hours and
can be seen during rapid ascent and descent from alti-
tude, as well as among patients with chronic lung disease
during sleep.1 The main differentiation between IH and

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 TABLE IV.
Sensitivity, Specificity, Positive Predictive Value, and Negative Predictive Value for a 4% Oxygen Desaturation Index.
No. Study OSA Comparison 4% ODI Sensitivity 4% ODI Specificity 4% ODI PPV 4% ODI NPV

1. Alvarez et al., 2007 28

AHI ≥ 10 58.7% 94.3% 92.5% 65.8%
ODI ≥ 13
2. Chiner et al., 199929 AHI ≥ 15 62% 93% 97% 40%
ODI ≥ 15
3. Golpe et al., 199930 AHI ≥ 10 32% 97% 95% 46%
ODI ≥ 31.4
4. Gyulay et al., 199331 AHI ≥ 15 40% 98% NR NR
ODI ≥ 15
5. Hang et al., 201532 AHI ≥ 15 85.7% 89.7% NR NR
ODI ≥ 7.3
6. Lin et al., 200933 AHI ≥ 15 85.3% 85.3% 94.1% 68.1%
ODI as below*
7. Series et al., 199334 AHI ≥ 10 98.2% 47.7% 61.4% 96.9%
ODI ≥ 10
8. Takeda et al., 200635 AHI ≥ 20 74.7% 75.0% NR NR
ODI ≥ 15

*ODI ≥ 13 was combined with data for ODI ≥ 15 for calculating average specificity (90% based on study averages) and positive predictive value (95%
based on study averages); 3% ODI using the mean of the top 20% of oxyhemoglobin saturation values over the 1 min preceding the scanned oxyhemoglobin
value.
AHI = apnea–hypopnea index; NPV = negative predictive value; NR = not reported; ODI = oxygen desaturation index; OSA = obstructive sleep apnea.

the latter is the cycles of re-oxygenation, which is compa-
rable to ischemia–reperfusion injury and may result in
oxidative stress that has been shown to contribute to the
production of reactive oxygen species and inflammatory
mediators, thereby triggering upper airway and systemic
inflammation.1,41
At sleep onset, wake-related excitatory stimuli are lost
and mechanoreceptor reflex responses may be significantly
blunted, requiring greater predominance of chemoreflexive
control of ventilation during sleep.42 Elevated loop gain,
that is, a hypersensitive chemo-reflex feedback loop in this
control, is a primary nonanatomical cause of OSA.43 IH is
thought to also play a significant part in elevating loop gain
by inducing neuroplastic changes in the carotid bodies,
brainstem, and cervical spinal cord, inducing increased
hypoxic sensitivity and long-term facilitation of various
ventilatory nerves, manifesting as a sustained increase in
neural output to a given stimulus.42
Currently, AHI is promoted as the primary measure
to evaluate the severity of OSA, whereas lowest oxygen
saturation, ODI, and other indices are regarded as second-
ary measures; however, the oxygen metrics such as the
ODI may prove to be at least as useful a tool to screen,
diagnose, and quantify OSA because there is reasonable
evidence of the following: 1) Hypopnea with at least a 4%
decrease in oxyhemoglobin saturation has been found to be
associated with an increased risk of cardiovascular disease;
2) hypopnea characterized by arousal or less than a 4%
desaturation is not associated with a similar outcome5; 3)
the recent Sleep Apnea Definitions Task Force of the
American Academy of Sleep Medicine has established that
the majority of studies have not found an association
between arousal frequency and adverse cardiovascular out-
comes (independent of arterial oxygen desaturation)44; 4)
an ODI greater than 5 per hour has been found to be a pre-
dictor of developing diabetes after adjusting for age, BMI,
and hypertension at baseline, as well as change in BMI
and years with continuous positive airway pressure during
long-term follow-up in a community-based sample45; and
5) hypoxia with oxyhemoglobin saturation less than 90%
for more than 9 minutes has also been found to be a stron-
ger predictor for cardiovascular events over AHI.46
The primary finding of the present review is that prior
studies reporting ODI have had a large discrepancy in terms
of sensitivities and specificities when compared to the refer-
ence AHI; this has prevented the authors from proceeding
with a pooled quantitative analysis. However, for the studies
reporting data for a 4% ODI ≥ 15 events/hour, the specificity
for diagnosing OSA ranged from 75% to 98% and the posi-
tive predictive value was 97%. Therefore, in patients who
have an ODI <15 events/hour, consideration could be given
for an attended sleep study. Some of the reasons that may
account for the large variations between the various studies
include: 1) different methods of statistical analysis; 2) differ-
ent definitions of main variables in the studies, namely
hypopnea, oxygen desaturation, baseline airflow, baseline
saturation; and 3) different criteria for grading OSA severity.
Even two decades ago, AASM has seen the need to standard-
ize terminology in the field and has undergone several
updates with continuous evaluation of current research.
However, there are still only a limited number of studies
that look into the relationship of oxymetric measures against
the current gold standard level 1 PSG. The recent research
trend is to compare NPO with level 3 PSG,47–51 which is
more readily available. Although the results have been
promising, the same issues persist (i.e., significantly different
and inconsistent definitions for the various outcome mea-
surements). The application of newer mathematical analyses
to investigate the relationship between ODI and AHI include
approximate entropy,28,52 support vector machine,32,53 spec-
tral analysis technique,54 and predictive modeling33,51; expla-
nations of each are beyond the scope of this review.

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Limitations
This study has limitations: A major limitation of this
review is the significant heterogeneity in the included
studies, impeding a pooled quantitative analysis (meta-
analysis) from being carried out. It is important, however,
to emphasize the growing number of studies comparing
ODI and AHI, thereby highlighting the awareness and
common need for better, simpler, more straightforward
index to screen, diagnose, and grade the severity of OSA.
Yet, the quality of these studies is poor, and there is a
large discrepancy in the definitions of almost all of the
variables used in the studies, which prevents a more
detailed statistical analysis. Additionally, a sensitivity
analysis cannot be performed; therefore, there are only
two studies with similar enough cutoffs for AHI and ODI
that would allow for combining, which would provide no
additional benefit. Another significant limitation is that
five studies compared ODI and AHI simultaneously, and
three had a week to months between assessments. It is
very possible that the severity of the AHI and ODI values
could change between the two studies. Another limitation
is that we only included studies in English language in
this review; therefore, it is possible that relevant studies
in other languages were excluded.
CONCLUSION
Significant heterogeneity exists in studies comparing
ODI and AHI. Five studies compared ODI and AHI
simultaneously, and three had a week to months between
assessments. However, based on currently published
studies, we propose that consideration should be given for
diagnosing OSA with a 4% ODI of ≥ 15 events/hour and
for recommending further evaluation for diagnosing OSA
with a 4% ODI ≥ 10 events/hour. Screening is rec-
ommended for the detection of OSA associated with car-
diovascular risk in middle-aged men without
comorbidities including chronic obstructive pulmonary
disease, significant heart disease, and morbid obesity.
Further study is needed before a definitive recommenda-
tion can be made.
ACKNOWLEDGMENT
Disclaimer: The views expressed in this article/manu-
script are those of the author(s) and do not reflect the offi-
cial policy or position of the Department of the Army,
Department of Defense, or the U.S. Government.
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