Distinguish Obstructive and Central Sleep Apnea by Portable
Peripheral Arterial Tonometry *
Thomas Penzel, Senior Member IEEE, Martin Glos, Ingo Fietze, Sebastian Herberger, Giora Pillar
1
Abstract— Sleep apnea has a very high prevalence in the
general population. Sleep apnea can be the cause for
cardiovascular disorders. An increased risk for suffering from
hypertension, stroke, and myocardial infarction had been shown
in large studies, like the Sleep Heart Health Study. Sleep related
breathing disorders and sleep apnea had been diagnosed in sleep
laboratories with polysomnography in the past. Today in view of
the high prevalence of sleep disordered breathing, home sleep
apnea testing (HSAT) has become the accepted test for the
diagnosis of sleep apnea, if there are no other comorbidities, and
if a high pretest probability was confirmed by a sleep physician.
For home sleep apnea testing, the number of sensors needed
should be reduced. Some methods use indirect means to derive
features to detect sleep apnea and hypopnea events. A very well
developed method is peripheral arterial tonometry (PAT). This
method records the pulse wave on a finger and derives sleep and
sleep apnea feature. The PAT method has been tested under
many conditions. As an indirect method, it was long seen as a
limitation that obstructive and central sleep apnea events could
not be distinguished. A new multicenter trial was set up to
develop algorithms, which could distinguish central and
obstructive apnea events with sufficient accuracy.
I. INTRODUCTION
Sleep disordered breathing has a high prevalence
according to epidemiological studies [1]. Sleep apnea severity
is counted by the apnea hypopnea index, which presents the
number of respiratory cessations during sleep. If a respiratory
cessation exceeds 10 seconds and occurs during sleep, it is
counted as an apnea. If the respiration is reduced by at least
50% in amplitude and a drop of oxygen saturation is found in
parallel, then the event is counted as a hypopnea. The disorder
sleep apnea is diagnosed if more than 5 events, apnea or
hypopnea, are found per hour of sleep. The apnea / hypopnea
index exceeds 5 / hour. Almost 1 billion subjects worldwide
suffer from sleep apnea based on an apnea hypopnea index
(AHI) above 5 events per hour of sleep. This corresponds to
29% of the population. If only more severe subjects are
counted, those who have more than 15 apnea / hypopnea
events per hour of sleep, then more than 424 million of
subjects are affected worldwide. This corresponds to 13% of
the population. As an essence sleep apnea presents a major
global burden to medicine [1].
Polysomnography performed in sleep laboratories
worldwide present the diagnostic reference standard for testing
for sleep disordered breathing. With the large number of
* Research partially supported by Itamar Medical, Caesarea, Israel.
T. Penzel is with the Sleep Medicine Center, Charité
Universitätsmedizin Berlin, 10117 Berlin, Germany (phone: +49-30-
450513013; fax: +49-30-450513906; e-mail: thomas.penzel@charite.de).
M. Glos is with the Sleep Medicine Center, Charité Universitätsmedizin
Berlin, 10117 Berlin, Germany (e-mail: martin.glos@charite.de). I. Fietze
978-1-7281-1990-8/20/$31.00 ©2020 IEEE
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subjects affected, new methods had been introduced
worldwide to perform home sleep apnea testing (HSAT). This
testing can be done either at home or in hospital departments
other than sleep laboratories. Therefore, these methods are
summarized as out of center testing [2]. In many countries the
required signals for HSAT include oxygen saturation, pulse
rate or heart rate, oronasal airflow, respiratory effort with
either one or two belts covering ribcage and abdominal
respiratory movement, and body position. Optional signals
include activity recording to derive estimates for sleep time
and CPAP pressure or mask pressure in case of sleep apnea
treatment follow-up studies. Then this signal picked up at the
mask is recorded as an alternative to oronasal airflow. Many
of the home sleep apnea testing devices use fewer sensors and
leads. These systems may use only oxygen saturation and
pulse rate or ECG and a single airflow sensor. Many systems
try to use indirect signal recording to assess the apnea and
hypopnea events. Indirect signal recording may be derived
from the ECG or pulse wave. Based on this concept these
devices try to count apnea and hypopnea events and relate
them to an estimated sleep duration. Then they calculate an
AHI. Based on the AHI threshold of 15 events per hour they
propose the diagnosis ‘sleep disordered breathing’ or ‘sleep
apnea’ to the user of the device.
Because so many different methods were developed a new
grading system to categorize indirect sensing and an indirect
assessment of the physiological functions, such as HSAT, was
introduced. This new grading system for diagnostic purposes
is called the SCOPER system and criteria [2]. The SCOPER
grading system had been introduced in 2011 but has not been
applied much until now to portable system for the diagnosis of
sleep apnea. The criteria define Sleep, Cardiovascular,
Oximetry, Position, respiratory Effort, and Respiratory flow
and take care of the reference standard as highest level to
surrogate signals as the lowest level. With this system, the
peripheral arterial tonometry can be classified. Here,
actigraphy is a surrogate for sleep. Pulse rate is a surrogate for
cardiovascular functions. Tonometry derived oscillations are a
surrogate for respiratory effort.
In the diagnostic assessment of patients with sleep
disordered breathing, first a clinical interview with symptom
assessment is performed. This will assess sleepiness, usually
with the Epworth Sleepiness Scale, a popular questionnaire.
is with the Sleep Medicine Center, Charité Universitätsmedizin Berlin,
10117 Berlin, Germany (e-mail: ingo.fietze@charite.de). S. Herberger is
with the Sleep Medicine Center, Charité Universitätsmedizin Berlin,
10117 Berlin, Germany (e-mail: Sebastian.herberger@charite.de). G.
Pillar is with the Technion Faculty of Medicine, Sleep Laboratory, Carmel
Medical Center, Haifa, Israel (e-mail: gpillar@technion.ac.il).
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 Then snoring, and observed apneas are assessed. Arterial
hypertension is recorded, and work and social life performance
problems are recorded. Common questionnaires are the Berlin
Questionnaire and the STOP-BANG questionnaire. Only
thereafter an overnight test is performed. While this used to be
a polysomnography, today this is mostly replaced by
polygraphy, or home sleep apnea testing. Usually home sleep
apnea tests include the recording of respiratory flow,
respiratory effort, oxygen saturation, heart rate, and body
position, as specified by the SCOPER criteria. Some
alternative methods try to derive respiratory parameters from
other signals. One popular method for this approach is the
recording of peripheral arterial tone (PAT) with a device
introduced by the company Itamar [3]. Using this signal, only
one company is currently producing recording devices. Due to
the large body of publications [3] and validation studies this
specific method is mentioned by the SCOPER criteria as well
[2]. The commercially available device is called WatchPAT.
The device is manufactured by Itamar Medical (Caesarea,
Israel) and has a stiff finger probe with optical sensors inside
(see figure 1 below).

Figure 2. A parallel recording of the arterial tonometry signal and

polysomnography is shown here. In this recording the attenuation of the
PAT waveform in parallel to apnea events as shown by nasal thermistor is
clearly visible. In addition, this recording example shows arterial blood
pressure. From that it can be seen, that arterial tonometry does not reflect
blood pressure, but mirrors different physiological regulation. The trace
below blood pressure shows snoring and below that, oxygen saturation and
pulse rate are plotted.

One limitation, until recently, was, that many indirect

Figure 1. The WatchPAT system is depicted. The wrist watch includes the
recording unit and an actigraphy. The blue finger sensor represents the
arterial tonometry sensing single use probe. The white finger sensor is a
standard oxymetry probe. The white round extra sensor is an optional
sensor to be placed on the chest to record snoring sounds and body position
of the chest.
The blue rigid finger probe placed on the middle finger is
very useful to provide stability on the finger and thus reduces
movement artifacts from the pulse signal (see figure 2). In
addition, the single-use finger probe applies some pneumatic
pressure on the finger when applied first. The pressure is lower
than diastolic pressure, somewhere near 40 mmHg. This preset
pressure attenuates the pulse wave which improves signal to
noise ratio when analyzing pulse waveform. The sensor
derives both, pulse wave and oxygen saturation.
The PAT technology is available for many years (see
figure 2) and has been upgraded and improved over the last
years with new features.
methods, such as peripheral arterial tone, were not able to
distinguish between central and obstructive sleep apnea
episodes. It is important to distinguish these episodes, because
central apnea events are more often associated with cardiac
disorders such as heart failure whereas obstructive apnea
events are more associated with upper airway narrowing and
metabolic disorders. Central apnea events may occur in
patients with cardiac problems, but also in patients with
problems in respiratory regulation. Treatment of patients with
obstructive sleep apnea and central sleep apnea may differ,
based on the underlying additional disorder. Some ventilation
modes are more effective in central sleep apnea than in
obstructive sleep apnea. In order to study systematically the
ability to distinguish central and obstructive sleep apnea
events, a multi-center study has been conducted [4].
II. METHODS
A multi-center study was initiated. Altogether 84 patients
were studied in 11 participating sleep centers. All patients with
suspected sleep disordered breathing were studied with
polysomnography in the sleep laboratory and the WatchPAT
system applied in parallel.
The validation set of data consisted of 84 subjects. Out of
these there were 54 male and 30 female subjects. Patient
medication was considered as it might have an impact on the
pulse wave. Patients with alpha blockers and short-acting
nitrates were excluded. According to polysomnography mean
sleep time was 5.65 hours.

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 Mean apnea index (AHI) was 24.2 ± 21.2 events/h. Mean
number of central apneas in terms of apnea index was 5.9 ±
11.8 events/h.
The visual scoring of the polysomnography was performed
centrally at one site to derive sleep stages and sleep apnea
events with a minimum of inter- and intra-scorer variability.
American Academy of Sleep Medicine (AASM) scoring
criteria were applied for the scoring of sleep stages and
respiratory events. The scoring of polysomnography was
performed independent and blinded to the PAT results.
In order to have a sufficient number of central apnea
events, the sleep centers were advised to selectively recruite
patients with heart failure and suspected Cheyne-Stokes
breathing. Previous studies reported that 33 to 40% patients
with heart failure showed Cheyne-Stokes breathing during
sleep.
Out of the 84 patients recruited for this study, 50 had
cardiac problems such as heart failure (n=33) or atrial
fibrillation (n=9) or both conditions (n=8). Recruited patients
were between 17 and 90 years old. Patients did sign an
informed consent as agreed by the Ethics review board. Only
patients willing to join the study with the additional
WatchPAT device were included.
The WatchPAT device as used for the study records the
finger pulse, oximetry, and actigraphy with an optional
additional sensor for body position and snoring (see figure 1).
This particular device is no longer available. Instead a newer
version of the recording device now combines the two finger
sensors into one sensor, to improve patient comfort and
reduce the number of sensors and wires. Wrist actigraphy,
incorporated in the watch like system, is used to estimate
sleep and wake times based on previously approved
algorithms. The finger pulse signal is used to derive pulse rate
and respiration by analyzing different properties (compare
figure 2 pulse wave). An algorithm, see figure 3, uses new
properties derived from the upstroke of the finger pulse
signal.
The PAT signal can be used to identify apnea events [5] as
well as REM sleep because it reflects sympathetic tone
changes which accompany sleep apnea and sleep stages [6].
Sympathetic tone is reflected because PAT amplitude reflects
peripheral vasoconstriction. PAT amplitude changes follows
apnea events (compare figure 2).
New additional signal properties from the finger pulse
(beside amplitude and rate), combined with more parameters
derived from the other signals, such as movement recording,
were used to classify respiratory events as being either central
or obstructive type [4]. A new algorithm was developed using
a training set and the algorithm was then validated using a test
set. The new algorithm uses several parameters extracted
from the pulse waveform. The difference of the upstroke of
the pulse waveform is depicted in figure 3.
The parameters derived and being most descriptive remain
the assets of the company and had been protected by the
company.
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Figure 3. The features for pulse waveform are illustrated to show the
differences between central apnea and obstructive apnea. See [4] for
algorithm details depicted in this figure as well.
The training set of data was used to optimize parameters.
Then, the full set of recorded data with the annotations of
obstructive and central apnea events was used for the
validation of the new detection algorithm.
III. RESULTS
Comparing the detection of subjects with an AHI ≥ 15
events/h by polysomnography and WatchPAT yielded a
sensitivity of 85% and a specificity of 70% and a positive
predictive value of 90%. The area under the curve was 0.867
(p<0.001). Comparing central AHI ≥ 15 events/h by
polysomnography and WatchPAT yielded a sensitivity of
66% and a specificity of 100% and a positive predictive value
of 100%. The area under the curve was 0.866 (p<0.001).
IV. DISCUSSION
A limitation of the study is that usually in sleep centers, the
number of patients with central sleep apnea is low. Patients
with central sleep apnea predominately suffer from heart
failure and do not complain about sleepiness. As such, they
usually go to cardiology units and are not investigated much
in sleep centers. As a result we have only a low central AHI
and a relatively low number of central apnea events in total.
Another important limitation of the study is, that patients
with alpha blockers and short-acting nitrates were excluded.
These drugs are largely used in heart failure patients. And
these were exactly the target population for this study.
Patients with these drugs were excluded because of the known
impact on the peripheral vascular system. It would be good to
quantify the effect of these drugs on the parameters extracted
here. Until now, it is unknown in how far these vasoactive
drugs influence the shape of the pulse wave. Certainly some
parameters of the pulse wave are changed but others may
remain unaffected. If this is studied more carefully, then the
specific drug effects on the pulse wave could be identified as
well and may contribute to the understanding of pulse wave
 and to the diagnosis of patients with heart failure.
A strength of the study is the estimation of sleep stage
surrogates not further studied in this specific paper. It may be
possible to investigate the obstructive and the central apnea
events as they occur in non-REM and REM sleep. To do this,
a larger number of events is needed. As such a limitation of
this study is, again the low number of central sleep apnea
events in total recorded in the population investigated.
A prospective study performed in cardiology based sleep
centers may overcome these limitation in the future. Such a
study should document types of sleep disordered breathing
and should track vasoactive drugs as well.
A final limitation of this study is, that the device is
available by only one company and thus details of the
algorithms for distinguishing central and obstructive sleep
apnea events were protected and were not open to the
investigators or the public.
Changes of the specific detection algorithms as used in this
validation study may improve system performance but may
be not visible to the average user in a hospital or a sleep
medicine center.
V. CONCLUSION
The new algorithm appears to be reliable and could detect
and differentiate central and obstructive sleep apnea events.
The algorithm proved to be effective in patients according to
the characteristics in this testing and validation sample. As a
learning objective, the study did also show, that the different
pathophysiology behind central and obstructive apnea events
expresses itself in different signal properties as picked up by
a plethysmographic signal on the finger. More properties
might be identified and may help to estimate mortality and
morbidity differences among patients with sleep disordered
breathing.
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ACKNOWLEDGMENT
The short list of authors of this paper wants to
acknowledge the contributors to the multicenter study being
the basis for this work. These were Giora Pillar, Murray
Berall, Richard Berry, Tamar Etzioni, Noam Shrater, Dennis
Hwang, Marai Ibrahim, Efrat Litman, Prasanth Manthena,
Nira Koren-Morag, Anil Rama, Robert P. Schnall, Koby
Sheffy, Rebecca Spiegel, Riva Tauman, and Thomas Penzel.
The original results of this multi-center trial had been
published in [4]. This presentation gives the original results
and a couple of additional illustrations and comments as
received in the meantime.
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