[ Commentary ]

Pediatric Home Sleep Apnea Testing

Slowly Getting There!
Hui-Leng Tan, MBBS; Leila Kheirandish-Gozal, MD; and David Gozal, MD, MBA, FCCP

Pediatric OSA can result in significant neurocognitive, behavioral, cardiovascular, and meta-
bolic morbidities. Prompt diagnosis and treatment are, therefore, of paramount importance.
The current gold standard for diagnosis of OSA in children is in-laboratory polysomnography
(PSG). Home sleep apnea testing has been considered as an alternative as it is potentially
more cost effective, convenient, and accessible. This review concentrates mainly on the use
of type 2 and 3 portable monitoring devices. The current evidence on the feasibility and diag-
nostic accuracy of home testing in the diagnosis of pediatric OSA was examined. Overall, the
evidence in children is limited. Feasibility studies that have been performed have on the
whole shown good results, with several reporting . 90% of their home recordings as meeting pre-
determined quality criteria regarding signal artifact and minimum recording time. The limited
data comparing type 2 studies with in-laboratory PSG have shown no significant differences
in respiratory parameters. The results pertaining to diagnostic accuracy of type 3 home sleep
apnea testing devices are conflicting. Although more research is needed, home testing with
at least a type 3 portable monitor offers a viable alternative in the diagnosis of otherwise
healthy children with moderate to severe OSA, particularly in settings where access to polysom-
nography is scarce or unavailable. Of note, since most studies have been performed in habitually
snoring healthy children, home sleep apnea testing may not be applicable to children with other
comorbid conditions. In particular, CO2 monitoring is important in children in whom there is
concern regarding nocturnal hypoventilation, such as children with neuromuscular disease,
underlying lung disease, or obesity hypoventilation, and most home testing devices do not
include a transcutaneous or end-tidal CO2 channel. CHEST 2015; 148(6):1382-1395

ABBREVIATIONS: AASM 5 American Academy of Sleep Medicine; AHI 5 apnea-hypopnea index; OAHI 5
obstructive apnea-hypopnea index; PAT 5 peripheral arterial tonometry; PSG 5 polysomnogram; RDI 5
respiratory disturbance index; RP 5 respiratory polygraphy; SCOPER 5 sleep, cardiovascular, oximetry,
position, effort, and respiratory; SCS 5 Sleep Clinical Score; TRT 5 total recording time; TST 5 total
sleep time

Pediatric OSA is characterized by intermit- tion of normal ventilation and sleep pat-
tent partial or complete obstruction of the terns.1 It can result in periodic hypoxia,
upper airways during sleep, with the disrup- hypercarbia, increases in respiratory effort,

Manuscript received June 5, 2015; revision accepted July 24, 2015;
originally published Online First August 13, 2015.
AFFILIATIONS: From the Department of Paediatric Respiratory Medi-
cine (Dr Tan), Royal Brompton Hospital, London, England; and the
Sections of Pediatric Sleep Medicine and Pediatric Pulmonology (Drs
Kheirandish-Gozal and Gozal), Department of Pediatrics, Pritzker
School of Medicine, Biological Sciences Division, The University of
Chicago, Chicago, IL.
FUNDING/SUPPORT: This work is supported by the National Institutes
of Health [Grant HL-65270 to L. K.-G. and D. G.].
CORRESPONDENCE TO: David Gozal, MD, MBA, FCCP, Section of
Pediatric Sleep Medicine, Department of Pediatrics, Pritzker School of
Medicine, Biological Sciences Division, The University of Chicago, Knapp
Center for Biomedical Discovery, Room 4100, 900 E 57th St, Mailbox 4,
Chicago, IL 60637; e-mail: dgozal@uchicago.edu
© 2015 AMERICAN COLLEGE OF CHEST PHYSICIANS. Reproduction of
this article is prohibited without written permission from the American
College of Chest Physicians. See online for more details.
DOI: 10.1378/chest.15-1365

1382 Commentary [ 148#6 CHEST DECEMBER 2015 ]

intrathoracic pressure changes, and sleep fragmentation.2
OSA is now recognized as a very common childhood
health problem with a reported prevalence ranging
from 1% to 5%, depending on the population studied
and the stringency of the diagnostic criteria used.
Crucially, if left untreated, it can lead to adverse neuro-
cognitive/behavioral, cardiovascular, and metabolic
consequences.1-5 It is, therefore, of utmost importance
that accurate diagnosis is made in a timely manner so
that appropriate treatment can be initiated and potential
resultant morbidities minimized.
The currently accepted gold standard for diagnosis of
OSA is an in-laboratory polysomnogram (PSG), as it
provides an objective measure of disturbances in respi-
ratory parameters and sleep architecture.1 However,
PSGs may not be readily available in all countries.
Furthermore, PSGs have their attendant disadvantages:
They are labor intensive, requiring in-laboratory moni-
toring of the patient by skilled staff overnight and subse-
quent scoring and analysis. This is expensive, both in
terms of time and resources, not insignificant consider-
ations in the current economically constrained times.
Moreover, PSGs are also poorly predictive of OSA-
associated morbidities.6
Home sleep apnea testing is, thus, of considerable interest,
as it has the potential to measure a more typical night’s
sleep, as the child is sleeping at home, and could be
substantially less expensive and potentially accessible
to more children. The critical questions that need to be
answered are the following: (1) Is it possible to obtain
high-quality recordings from unattended home testing
in children? (2) What is the diagnostic accuracy of the
different types of home testing? and (3) Are there spe-
cific populations where home testing is not appropriate?
In 1994, the American Academy of Sleep Medicine
(AASM) Portable Monitoring Task Force classified
portable monitoring into four types, of which types 2
through 4 are applicable to home testing.7 Type 1 studies
are fully attended PSG (seven or more channels) in a
laboratory setting. Type 2 studies are unattended PSG
(seven or more channels). Type 3 consist of studies
using more limited channel devices (usually using four
to seven channels), also referred to by many as respira-
tory polygraphy (RP) studies. Type 4 studies include
only one or two channels, with oximetry traditionally
but not exclusively being used as one of the measure-
ments. Here, we critically appraise and summarize the
most recent available literature on the use of home
testing in the diagnosis of pediatric OSA. As there
already is extensive literature concerning overnight
journal.publications.chestnet.org
oximetry,8-10 we will predominantly focus on type 2 and
3 portable monitoring devices in children. Studies that
have examined pediatric home sleep apnea testing using
these two types of devices are summarized in Tables 1
and 2,11-19 including the sleep, cardiovascular, oximetry,
position, effort, and respiratory (SCOPER) designa-
tions of the devices used. This refers to a more specific
classification proposed in 2011 which categorizes
out-of-center testing devices based on measurement
of SCOPER parameters20 (see Table 3 for explanation of
the SCOPER categorization system).
Home PSG (Type 2 Portable Monitoring)
Of the first 162 children recruited for the Tucson
Children’s Assessment of Sleep Apnea study (TuCASA)
who had home PSGs performed, 91% of the studies
were technically acceptable on first pass.11 This was
defined as “respiratory channels (airflow or either
band), oximetry, and one EEG were good for . 4 h.” This
increased to 97% when nine children who failed the first
night recording had it successfully repeated. These find-
ings suggest that high-quality, unattended PSGs can be
performed on children aged 5 to 12 years in the research
setting. The nasal pressure transducer and thermistor
signals were the ones that were most frequently lost.11
Five children also had in-laboratory PSGs, and there
was no statistically significant difference in respiratory
disturbance index (RDI) between the in-laboratory and
home PSGs.11 RDI was defined by the investigators as
the number of respiratory events (apneas and hypop-
neas) per hour of total sleep time. Apneas were scored
if the amplitude of the thermistor decreased below 25%
of baseline lasting for . 6 s or two breaths. Hypopneas
were scored if the amplitude of any respiratory signal
decreased below 70% of baseline.11
More recently, Marcus et al12 reported similar findings
in 201 children aged 5 to 12 years from four centers
in Canada and Australia who had PSGs performed at
home. These studies were also conducted in the con-
text of a research setting (the Caffeine for Apnea of
Prematurity Trial). Artifact-free signals were obtained
for ⱖ 75% of recording time in . 92% of subjects. The
only exception was the nasal pressure transducer signal,
which was satisfactory for ⱖ 75% of recording time
in only 67% of subjects.12 A total of 91% of the initial
studies were deemed technically satisfactory, and a fur-
ther 14 studies were satisfactory when repeated (ie, over-
all, 98% of the studies were successful). In-laboratory
PSGs were compared with home PSGs in four children.12
The children slept longer in the home environment,
with a trend toward more consolidated sleep. Respiratory
1383
 TABLE 1 ] Summary of Studies of Pediatric Home Sleep Apnea Testing Using Type 2 and 3 Portable Monitoring Devices
Type of Portable Nasal SCOPER Setup
Study/Year No. of Participants Age, y Objective Device Monitoring CO2 Cannula Designation Performed by
Goodwin 162 (157 of whom 100 children To determine the Compumedics PS-2 Type 2 No Yes S2 Trained staff
et al11/2001 had successful 5-8 y, feasibility of obtaining (Abbotsford, Victoria, C3

1384 Commentary
recordings used 57 children quality unattended Australia) O1x
for analysis) between PSGs in TuCASA study P2
9-12 y E1
R1
Marcus 201 (197 of whom 9.2 ⫾ 2, To evaluate the Compumedics Siesta 802 Type 2 No Yes S1 Trained staff
et al12/2014 had successful mean ⫾ SD feasibility of system (Charlotte, NC) C3
recordings used ambulatory PSG O1x
for analysis) in school-aged P2
children in the home E1
environment R1
Jacob 24 (21 of whom 7 (3.8-9.2), To determine the Developed by research Type 3 No No S3 Trained staff
et al13/1995 had home and median (IQR) accuracy and institute, channels include home RP C3
in-laboratory practicality of home ECG, pulse rate, SaO2, pulse O1x
recordings that sleep apnea testing waveform, thoracic, and P1
could be with home RP device abdominal excursions, and E1
compared) their sums as obtained from R5
RIP, audiovisual recording
Zucconi 12 4.0 ⫾ 0.8, To compare portable POLY-MESAM, MAP, Type 3 No No S0 Trained staff
et al14/2003 mean ⫾ SD RP with in-laboratory (Martinsried, Germany) home RP C2
PSG for diagnosis of O1x
OSA in children P2
E1
R3

[
Rosen 850 Term birth To evaluate extent to PT-2 system, SensorMedics, Type 3 No No S0 Not stated
et al15/2003 group, which SDB varies (Yorba Linda, CA) home RP C1
9.6 ⫾ 0.7; with demographic O1x
preterm and medical risk P2
birth group, factors and to E1
9.3 ⫾ 0.8; estimate prevalence R0
mean ⫾ SD of SDB in 8-11-y-olds
Poels 24 4.2 ⫾ 1.6, To evaluate feasibility Embletta PDS Medcare, Type 3 No Yes S0 Caregivers
et al16/2003 mean ⫾ SD of using home RP (Reykjavik, Iceland) home RP C4
device in children O1x
P2
E1
R2

148#6 CHEST DECEMBER 2015

(Continued)

]
journal.publications.chestnet.org
TABLE 1 ] (continued)
Type of Portable Nasal SCOPER Setup
Study/Year No. of Participants Age, y Objective Device Monitoring CO2 Cannula Designation Performed by
Moss 54 (50 of whom 10.1 ⫾ 0.7 To determine reference Embletta PDS (Flaga, Iceland) Type 3 No Yes S2 Trained staff
et al17/2005 had successful values for respiratory home RP C4
recordings used variables obtained O1
for analysis) using home RP device P2
in healthy primary E1
schoolchildren R1
Brockmann 101 (75 home, 2.8 (0-15.4), To investigate Embletta Gold III Type 3 No Yes S0 Caregivers
et al18/2013 26 hospital) median technical feasibility of (Broomfield, CO) home RP C3
(range) unattended home RP O1x
for diagnosis of OSA in P2
children E1
R2
Alonso-Álvarez 50 5.3 ⫾ 2.5, To evaluate the eXim Apnea Polygraph Type 3 home No Yes S0 Trained staff
et al19/2015 mean ⫾ SD diagnostic reliability (Bitmed, SIBEL group) RP C4
of home RP in O1
children with clinical P2
suspicion of OSA E1
R1

IQR 5 interquartile range; PSG 5 polysomnogram; RIP 5 respiratory inductance plethysmography; RP 5 respiratory polygraphy; SaO2 5 arterial oxygen saturation; SCOPER 5 Sleep, Cardiovascular, Oximetry,
Position, Effort, and Respiratory; SDB 5 sleep-disordered breathing; TuCASA 5 Tucson Children’s Assessment of Sleep Apnea.

1385
 TABLE 2 ] Summary of Studies of Pediatric Home Sleep Apnea Testing Using Type 2 and 3 Portable Monitoring Devices (Continued)
Criteria for Definition of Technically Validity Against
Study/Year Diagnosis of OSA Hypopnea Definition Initial Failure Rate Acceptable Study Patient Population Laboratory PSG Comments
Goodwin RDI ⱖ 1/h TST 30%-75% decrease 9% Respiratory channels Children in the 5 children had 10 children had
et al11/2001 in amplitude of (airflow or either TuCASA study in-laboratory second night study,

1386 Commentary
any respiratory band), oximetry, recruited PSG, no which showed high
signal from and at least 1 EEG from selected statistical degree of
baseline for . 6 s good for . 4 h elementary difference in reproducibility
or 2 breaths schools in the RDI between
Tucson Unified the 2 methods
School District (P . .13)
Marcus N/A “Scored using the 9% Study failure defined Subset of children 4 children had Artifact-free signals
et al12/2014 AASM pediatric as , 4 h total enrolled in in-laboratory obtained for ⱖ 75%
scoring rules” recording time and follow-up studies PSG, similar of recording time in
major signals (ie, for Caffeine for respiratory . 92% of subjects
arterial oxygen Apnea of parameters with exception of
saturation, both Prematurity trial, obtained nasal pressure,
respiratory effort an international compared with which was
channels, both trial with United home studies satisfactory for
airflow channels or States, Australia, ⱖ 75% recording
all EEG channels) and Canadian time in 67% of
displaced for most participants. subjects
of the night Study included
6 children with
cerebral palsy.
Jacob et al13/1995 Different 50%-80% decrease 17% Not defined, but Children referred to Using an AHI Experience with a
definitions in amplitude of 4 initial failures Montreal Children’s cutoff of . 1/h further 62 children
examined: summation were due to Hospital for TST, the who had home RPs
AHI . 1/h TST channel and a computer investigation of sensitivity of also reported, all
AHI . 3/h TST decrease in malfunction, OSA diagnosing OSA were successful

[
AHI . 5/h TST saturation of ⱖ 4% electrical power was 100%,
failure, and 1 child specificity 62%;
unplugging the with an AHI
computer cutoff of . 3/h
TST, the
sensitivity was
88%, specificity
77%; and with
an AHI cutoff of
5/h TST the
sensitivity and
specificity were
both 100%

148#6 CHEST DECEMBER 2015

(Continued)

]
 TABLE 2 ] (continued)
Criteria for Definition of Technically Validity Against
Study/Year Diagnosis of OSA Hypopnea Definition Initial Failure Rate Acceptable Study Patient Population Laboratory PSG Comments
Zucconi Different Reduction of . 50% 0% Not defined Children with clinical With RDI . 5 as Small study, 75% of
et al14/2003 definitions in thermistor suspicion of OSA cutoff, 89% subjects had RDI . 5,
examined: signal (for min sensitivity, 0% 41.7% had RDI . 10,
RDI . 5 of 8 s) associated specificity. With performed in
RDI . 10 with oxygen RDI . 10 as laboratory setting
desaturations . 4% cutoff, 100%
sensitivity,

journal.publications.chestnet.org
57% specificity
Rosen et al15/2003 Different Respiratory efforts 6% At least 4 h of Population-based In-laboratory PSGs
definitions were accompanied respiratory effort cohort of children performed in
examined: by a 25%-50% signals with aged 8-11 y from 121 children.
(1) OAHI ⱖ 5/h reduction in concurrent reliable Cleveland In subgroup
estimated estimated tidal oximetry data of 55 children
sleep time volume and who had the
(2) OAHI ⱖ 1/h accompanied by at in-laboratory
estimated least 3% oxygen PSG and home
sleep time desaturation or RP performed
Combination when clearly within 3 mo of
of 1 and 2 discernible each other,
decreases in OAHI 2.6 ⫾ 8
estimated tidal (in-laboratory)
volume were and 2.9 ⫾ 7.5
associated with (home) ICC: 0.85.
similar Using threshold of
desaturation OAHI ⱖ 5/h TST,
sensitivity of
home RP 88%,
specificity 98%
Poels et al16/2003 Mild OSA: Reduction in airflow 25% (though 6 (25%) failed Children 2-7 y Not studied 45% participation
AHI 1-5; signal to below only 29% of as technically scheduled for rate, participants
moderate 50% baseline for recordings unacceptable. adenotonsillectomy older and had
OSA: AHI at least 10 s were classified Successful to treat habitual higher Brouillette
6-25; as successful) study defined as snoring and/or OSA score
severe OSA: ⱖ 390 min of possible OSA in
AHI . 25 artifact-free signal The Netherlands
present in 3 tracings
simultaneously
of TST

(Continued)

1387
 TABLE 2 ] (continued)
Criteria for Definition of Technically Validity Against
Study/Year Diagnosis of OSA Hypopnea Definition Initial Failure Rate Acceptable Study Patient Population Laboratory PSG Comments
17
Moss et al /2005 N/A Reduction in 11% A minimum of Study was part of Not studied Interobserver and
amplitude of nasal corrected estimated a population- intraobserver

1388 Commentary
airflow to ⱕ 50% sleep time (without based cross- variability showed
of the average movement or sectional study reasonable
amplitude of artifactual/ on prevalence, agreement overall
the 2 preceding uninterpretable risk factors, and (Cohen k range,
breaths, oxygen periods) of 4 h consequences of 0.29-0.83)
desaturation of at required SDB in children in
least 4% occurring Germany
within 30 s of the
onset of the event
Brockmann N/A Decrease in 7% Failed study Children referred Not studied Number of failed
et al18/2013 nasal flow of at defined as , 4 h to sleep unit for studies did not
least 50% with of artifact-free investigation differ significantly
corresponding recording time, or of clinically between home and
decrease in , 4 h SpO2 signal, suspected OSA hospital RPs
SpO2 ⱖ 3% or more or loss of ⱖ 2 of the in Chile. One child
following channels: had congenital
nasal flow or cyanotic heart
thoracoabdominal condition.
belts
Alonso-Álvarez Several cutoffs Decrease . 50% in 0% Data were excluded Children 2-14 y If ORDI-PSG ⱖ 3 is Flow limitation events
et al19/2015 examined amplitude of from analysis referred to the used as cutoff for were included in
(eg, RDI ⱖ 1, nasal pressure or if . 60% of the sleep unit in OSA diagnosis, the RDI, and these
RDI ⱖ 3, alternative signal airflow signal was Spain for clinical the optimal were defined as
RDI ⱖ 5, compared with uninterpretable suspicion of OSA ORDI cutoff for discernible drops in
baseline amplitude of cannula

[
ORDI ⱖ 1, HRP was ⱖ 5.6,
ORDI ⱖ 3, lasting ⱖ 90% which gave a signal , 50% of
ORDI ⱖ 5, of the entire sensitivity of baseline and/or
OAHI ⱖ 1, respiratory event 90.9% and flattening of nasal
OAHI ⱖ 3, and accompanied specificity of pressure waveform,
OAHI ⱖ 5) by an SpO2 94.1% accompanied by
decrease ⱖ 3% snoring, noisy
breathing, or visual
evidence of
respiratory effort
lasting at least
2 breaths

AASM 5 American Academy of Sleep Medicine; AHI 5 apnea-hypopnea index; HRP 5 home respiratory polygraphy; ICC 5 intraclass coefficient of correlation; N/A 5 not applicable; OAHI 5 obstructive apnea-hypopnea
index; ORDI 5 obstructive respiratory disturbance index; RDI 5 respiratory disturbance index; SpO2 5 oxygen saturation by pulse oximetry; TST 5 total sleep time. See Table 1 legend for expansion of other abbreviations.

148#6 CHEST DECEMBER 2015

]
TABLE 3 ] SCOPER Categories, From Collop et al20
Sleep Cardiovascular Oximetry Position Effort Respiratory
S1: Sleep by C1: . 1 ECG O1: Oximetry P1: Video or E1: 2 RIP bands R1: Nasal
3 EEG channels lead (finger/ear) with visual position pressure
(frontal, central, recommended measurement transducer
occipital) with sampling (ie, 3-s and thermistor
EOG and chin averaging and a
EMG minimum 10-Hz
sampling rate)
S2: Sleep by C2: Peripheral O1x: Oximetry (finger/ P2: Nonvisual E2: 1 RIP band R2: Nasal
, 3 EEG with arterial ear) that does not position pressure
or without EOG tonometry fulfill recommended measurement transducer
or chin EMG sampling (or if
sampling not stated)
S3: Sleep C3: 1 ECG lead O2: Oximetry from … E3: Derived R3: Thermistor
surrogate such alternate site effort
as actigraphy (eg, forehead)
S4: Other sleep C4: Derived O3: Other oximetry … E4: Other effort R4: End-tidal
measure pulse measure CO2
(usually from (including
oximetry) piezo bands)
… C5: Other … … … R5: Other
cardiac respiratory
measure measure

EMG 5 electromyogram; EOG 5 electrooculogram. See Table 1 legend for expansion of other abbreviations.

parameters were similar in both. Challenges faced by
the staff included interference from siblings during the
setup, lack of electricity outlets near the child’s bed,
artifacts in the signals from the use of laptops and other
equipment in the home, and insufficient battery life if
the unit was unplugged when the child woke up to go
to the bathroom and the device was not plugged in on
return. In some instances, the caregivers noticed that
a lead had become displaced, but only one-third attempted
to replace it. Caregivers were mostly satisfied with the
home study experience, with the median parental satis-
faction rating being 1 (best) on the Likert scale.12
These two studies11,12 performed direct comparisons of
home PSG with in-laboratory PSG in only nine children
combined; inasmuch as the results are promising, it is
difficult to draw any firm conclusions from such
limited numbers. However, the main aim of these two
studies was to demonstrate that it is feasible to obtain
high-quality PSGs at home. Another salient feature of
these studies was that trained staff went to the child’s
home to apply the sensors in both these studies, which
may explain the high success rates. The children stud-
ied were school-aged children, who may be more
compliant, and failure rates may be higher in younger
children. Furthermore, these studies were population
studies, and it is possible that children with more restless
sleep, such as those with OSA, may have higher failure
rates from signal loss secondary to their tossing and
turning.
The main limitations of home PSGs are that they are
still quite labor intensive and expensive, as patient’s
home setup requires personnel travel, and scoring is
no different from in-laboratory PSGs. Video recordings
often provide useful information, but not all portable
PSGs include a video channel. Home CO2 monitoring is
also less commonly available and may be important for
detecting obstructive alveolar hypoventilation. End-
tidal or transcutaneous CO2 results are particularly
important in children in whom there is concern regarding
nocturnal hypoventilation, such as children with neuro-
muscular disease, underlying lung disease, or obesity
hypoventilation.
Key Message
Two large studies have so far demonstrated that it is
possible to perform high-quality home PSGs in chil-
dren ⱖ 5 years old in the research setting. No significant
differences in the respiratory parameters of the nine
children who had both home-PSG with in-laboratory
PSG were reported, but clearly more data are needed.
Home RP (Type 3 Portable Monitoring)
The majority of the published studies on home sleep
apnea testing in children have used type 3 home RP

journal.publications.chestnet.org 1389
testing. These abbreviated studies are even performed
in-laboratory in several European countries, as they are
much less time consuming to set up and score. In fact,
Spain has incorporated in-laboratory RPs into their
national consensus guidelines for diagnosis for pediatric
OSA, which are also followed in several countries in
South America.21 Alonso Alvarez et al22 showed that
when an obstructive apnea-hypopnea index (OAHI) ⱖ 3
on PSG or RDI ⱖ 3 on RP was used as the diagnostic
cutoff, the rate of diagnostic agreement between the
two was 84.9%. Furthermore, Alonso-Álvarez et al23
have also shown that in-laboratory RPs are a useful tool
in assessing effectiveness of surgical treatment. This
experience contrasts with the results of a small study of
12 children suspected to have OSA who spent two con-
secutive nights in-hospital undergoing a PSG and RP.14
The in-laboratory RP underestimated the number of
obstructive hypopneas, and although the sensitivity of
RPs was satisfactory, the specificity was poor.14
Another study similarly comparing 100 in-laboratory
PSG with in-laboratory RP showed that although there
was good correlation between the apnea-hypopnea
index (AHI) of PSG and RP. Bland-Altman analysis
showed that RPs tend to underestimate the AHI, because
hypopneas causing arousals are missed, and the total
sleep time based on video is less accurate than when
determined by EEG.24 There is also the concern that if
the child has a poor night’s sleep with reduced rapid
eye movement sleep, this will not be recognized in an
RP study, and since obstructive upper airway events
tend to cluster during rapid eye movement sleep in chil-
dren, the severity of OSA may be underestimated.
There are significant differences between home and
in-laboratory RPs. The total recording time (TRT) rather
than the total sleep time (TST) is usually used as the
denominator in home RPs, whereas for in-laboratory
RPs, the TST is estimated from sleep technician and
video monitoring data. In-laboratory RPs also tend to
use the same equipment and software as PSGs (the dif-
ference being that EEG, electromyogram, and electro-
oculogram signals are not included in the montage).
In contrast, home RP equipment is often specifically
designed to be portable and, albeit qualitatively similar,
is not exactly the same as in-laboratory PSG equipment.
In particular, not all home RPs include video and CO2
monitoring. Furthermore, home RPs may be set up
either by trained staff who visit the child’s home or by
the child’s caregivers, but are then unattended over-
night, whereas it is always trained staff who set up
in-laboratory RPs and they are present to troubleshoot
1390 Commentary
and replace any sensors in the event that signals are lost
during the study.
Moss et al17 reported the normal reference values for
home-based RP in 50 healthy primary school children
who did not have OSA. The mean number of central
apneas was 1.5/h, obstructive apneas 0.1/h, mixed apneas
0.01/h, and hypopneas 0.02/h. The corresponding cut-
off values (mean 1 2 SD) were, therefore, as follows:
3.7/h (central apneas), 0.7/h (obstructive apneas), 0.1/h
(mixed apneas), and 0.2/h (hypopneas).
However, studies of the diagnostic accuracy of home
RPs have shown discordant results. One of the earliest
studies looking at home RP testing for pediatric OSA
was by Jacob et al,13 who studied 21 children aged 2 to
12 years referred to their hospital for investigation of
OSA. They developed a portable system that allowed
them to perform home RP studies, including audio-
video recordings to enable determination of sleep and
wake, and compared the results obtained with the child’s
in-laboratory PSG results. Study duration, AHI, oxygen
desaturation index, and oxygen saturation correlated rea-
sonably well between the home RPs and the in-laboratory
PSGs. Using an AHI cutoff of . 1/h TST, the sensitivity
of diagnosing OSA was 100%, specificity 62%; with an
AHI cutoff of . 3/h TST, the sensitivity was 88%, speci-
ficity 77%; and with an AHI cutoff of 5/h TST, the sensi-
tivity and specificity were both 100%. The authors
suggested that sleep efficiency was greater at home than
in the sleep laboratory (91.1% ⫾ 13.3% [mean ⫾ SD])
compared with 86.1% ⫾ 7.2%) and was most likely attrib-
utable to the child sleeping in the home environment.13
However, as the assessment of sleep and wake of the
home studies was based on video recording and not
EEG, sleep duration could have been overestimated.
Following these findings, the authors started performing
home RPs as part of their clinical practice and reported
their experience in 62 children. None of these studies
failed from signal loss. Two children were re-evaluated
with in-laboratory PSGs as their clinical history sug-
gested significant OSA, whereas their home studies were
normal or mild OSA (AHI, 0.6/h TRT and AHI, 2.2/h
TRT, respectively). The in-laboratory PSG confirmed
the home study findings (AHI, 0.4/h TST and 2.2/h TST,
respectively).
In contrast, out of the 24 home RP recordings Poels et al16
performed, six completely failed (two due to technical
problems, two because the children did not tolerate the
sensors, and two cases because the caregiver turned the
recording off prematurely), and only seven (29%) were
successful (as defined by ⱖ 390 min of artifact-free
[ 148#6 CHEST DECEMBER 2015 ]
signal present in three tracings simultaneously). Most
artifactual interference occurred in the nasal flow
signal. There were problems with the oximetry sensor
in seven cases, the connection between the sensor and
sensor adaptor was lost in three cases, and the respira-
tory band used for assessing chest movement moved to
the abdomen over the course of the night in three cases.
These results may be because the children studied were
slightly younger than in other studies and because the
caregivers set up the RP rather than trained staff, even
though they had been given instructions on how to
place and remove the sensors.
A different experience was reported by Brockmann et al,18
who recruited 101 children and performed 75 home
RPs and 26 in-hospital RPs. The authors found that only
four home and three in-hospital recordings were nonin-
terpretable and needed to be repeated.18 The children
studied were similarly relatively young (median age,
2.8 years), but their initial setup was performed in the
laboratory by the staff, and the caregivers were taught
how to check if the sensors were placed adequately and
how to replace them if they moved overnight. A hotline
number was also provided so they could call if any
problems occurred. There was no difference in the
number of failed studies at home and in-hospital; how-
ever, the in-hospital studies do not appear to have been
performed in a sleep laboratory, as they report that the
procedure needed to be explained to the night shift
nursing staff with the same hotline number provided to
them in case any problems arose. Thus, this study was
not a true comparison between home and in-laboratory
RPs where trained sleep technicians would normally be
monitoring the subjects.
The success rate of Rosen et al15 in 850 children who
had home RPs performed was also high at 94%. A sub-
group of 55 children had in-laboratory PSG and home
RP performed within 3 months for comparison, and
when using an AHI . 5/h TST as cutoff for the diagnosis
of OSA, the sensitivity of home RPs was 88% and the
specificity was 98%.15
A recent study by Alonso-Álvarez et al19 compared home
RP with in-laboratory PSG in 50 children with a mean
age of 5.3 years, who were clinically suspected to suffer
from OSA. All of the home RP studies were technically
acceptable and had good agreement with in-laboratory
PSGs. The area under the curve for home RP was consis-
tently good at . 90%, when various PSG cutoff values
such as OAHI ⱖ 1, 3, and 5/h TST were used. Although
it was not possible to score cortical arousals in the home
RPs, the Bland-Altman plot did not show any significant
journal.publications.chestnet.org
bias. A trained nurse went to the child’s home for the
setup and initiation of the recordings. These results are
very promising, but the authors do emphasize that more
research is required, especially for the diagnosis of mild
OSA using home RP.
One of the disadvantages of home studies is the risk of
failed studies due to movement of sensors or signal
loss. The use of real time telemonitoring may provide a
potential solution. Indeed, a pilot study in adults has
shown encouraging results: Bruyneel et al25 devised a
prototype dual-port wireless system, enabling short-
range communication with the home PSG kit, and
Internet communication through a Wi-Fi/3G interface.
It is equipped with a digital day/night camera with infra-
red leads and with a speaker/microphone system for
bidirectional audio/video communication.25 Twenty-one
patients were recruited, and a nurse performed remote
discontinuous hourly monitoring of the home PSG.
There were problems with the overload of computer
capacity for data transmission and internet connection
issues, leading to a 10% failure rate, but when sensor
loss was noted (EEG and nasal cannula), the nurse
managed to contact the patient, and the sensor was suc-
cessfully replaced by the patient. This preliminary study
shows proof of concept that telemonitoring of home
PSGs is possible. Furthermore, as technology improves,
it is likely to become more robust and reliable and,
therefore, could be implemented in the pediatric setting.
Key Message
Most of the interest in home sleep apnea testing has
been in the use of type 3 devices, reflecting what adult
sleep medicine has selected as preferred option. In chil-
dren, the signal most at risk for disruption is the nasal
flow signal. The majority of studies report that it is fea-
sible to perform home RPs in children who are being
investigated for OSA, even in young preschool children.
The percentage of successful recordings may be higher
if the studies are set up by trained staff. Though results
have been discordant, on the whole, the sensitivity and
specificity of home RP appear to be reasonably good
for the diagnosis of moderate and severe OSA in chil-
dren who have a high pretest probability of having the
condition.
Home Oximetry Studies (Type 4 Portable
Monitoring)
It is now well recognized that nocturnal pulse oximetry
has a high specificity but low sensitivity in the diagnosis
of pediatric OSA.1,26 A positive result is helpful, as it
likely confirms the diagnosis of OSA, but a negative
1391
result does not rule out OSA, and further investigation,
namely a PSG, is warranted.8,27 Oximetry alone is cer-
tainly not adequate for the universal diagnosis of OSA,
since a proportion of children may have OSA with resul-
tant arousals and sleep fragmentation, but oxygenation
may be preserved, whereas other children may have
very restless sleep resulting in movement artifacts that
may be mistaken for desaturations.28 However, overnight
oximetry could help in the prioritization of treatment
and clearly has a major role in resource-poor countries
where PSGs are not available.10 There have been attempts
to combine oximetry with other clinical data to develop
more accurate scoring algorithms. An example is the
Sleep Clinical Score (SCS), a composite score derived
from physical examination, subjective symptoms, and
clinical history, which has been shown to correlate well
with AHI-PSG. When a positive test result was defined
as a SCS ⱖ 6.25, the sensitivity was 96.05% and speci-
ficity was 67% (OSA being defined as OAHI . 1/h on
PSG).29 There is current ongoing research studying
whether the combination of the SCS with home oxim-
etry may improve the diagnostic specificity. In addition,
the development of smart phone-based oximetry may
provide unique opportunities for alternative diagnostic
algorithms in the near future.30
Key Message
Nocturnal pulse oximetry has a high specificity but low
sensitivity in the diagnosis of pediatric OSA. Its sensi-
tivity can be improved if other clinical data are also
incorporated into the diagnosis algorithm. Overnight
oximetry can help in the prioritization of treatment and
also has an important role in countries where PSGs or
RPs are not commonly available.
Minimal Contact Devices
There has been interest in minimal contact devices for
the diagnosis of OSA for some time. Two systems that
have previously been trialed include a capacitor-based
system that detects static charges contained within bed-
ding material and bedclothes from which body and
breathing movements are discernible,31 and a sheet con-
taining . 150 pressure sensors, which is placed on a
mattress.32 These approaches have thus far met with
limited success in diagnosing OSA in children. They
have been found to be useful in the detection of central
apneas but not for detecting obstructive events, likely
because they do not have a measure of airflow.
Several novel minimal contact devices have been devel-
oped more recently but have only been validated in
adults.33,34 For example, there has been development of a
1392 Commentary
mat containing several vibration/sound sensors that can
record breathing movement and airflow.33 The subject
sleeps on this mat (placed on the mattress under the
bedsheet) overnight. Simultaneous PSG and mat record-
ings were made in 62 adult subjects. The AHI from the
mat correlated well with that derived from the PSG. Bland-
Altman analysis showed that the mat slightly underesti-
mated the AHI by 1.4 events/h. This may be due to less
accurate estimation of TST. Area under the curve for
AHI ⱖ 5/h TST was 0.939, AHI ⱖ 15/h TST was 0.966,
and AHI ⱖ 30/h TST was 0.998. It is currently being
validated in children. Another example is a noncontact
bio-motion sensor, which uses radio waves to measure
movement and respiration and is placed on the bedside
table. Seventy-four adult subjects referred to a sleep
clinic for assessment of OSA underwent simultaneous
in-laboratory PSG and bio-motion sensor assessment.34
The AHI-bio-motion sensor correlated well with the
AHI-PSG. Area under the curve for AHI ⱖ 15/h TST
was 0.97, although it performed less well for lower AHI
cutoffs.
There has also been interest in the use of peripheral
arterial tonometry (PAT) in the diagnosis of OSA. PAT
devices measure peripheral arterial volume changes as
a surrogate measure of obstruction-induced transient
elevations of sympathetic tone associated with arousals
from sleep. An example of such a device uses PAT
(using a finger-mounted plethysmograph), in conjunc-
tion with pulse oximetry and actigraphy, analyzed by
an automated algorithm to determine sleep indices such
as AHI and RDI. A meta-analysis of 14 adult studies
concluded that PAT technology consistently demonstrates
a relatively high degree of correlation in sleep variables
when compared with in-laboratory PSG.35 Pediatric
studies are awaited. Should these newer technologies
constitute accurate and reliable approaches in children
in the future, they may prove particularly useful in those
children who do not tolerate sensors, such as those suf-
fering from autism spectrum disorder.
Key Message
Some minimal contact devices show promise but need
to be validated in the pediatric population. These devices
may be particularly helpful in the subgroup of children
who do not tolerate having sensors attached to them
overnight.
What Can We Learn From the Adult
Experience?
In adults, the portable monitoring task force of the
AASM recommended in 2007 that for patients with a
[ 148#6 CHEST DECEMBER 2015 ]
high pretest probability of moderate to severe OSA,
portable monitoring may be used as an alternative to
in-laboratory PSGs for the diagnosis of OSA.36 The
following year, the US Centers for Medicare and Medicaid
Services released a statement allowing the use of por-
table monitoring to diagnose OSA and prescribe CPAP,
opening the door to the widespread use of these devices.
Sleep medicine in adults has changed significantly
since; even when allowing for regional variability, up
to 75% of sleep studies are now performed in the home
setting.37
Results from adult studies should not be directly extrap-
olated to pediatric settings, as the AHI threshold as to
what is considered abnormal, and, thus, necessitates
therapy, is considerably lower in children. This reflects
the unique differences in upper airway function between
children and adults, as well as the potentially greater
susceptibility of children to develop morbid consequences
of OSA. This is particularly important, as it is in the
diagnosis of moderate to severe OSA in the adult popu-
lation where portable monitoring results are the most
robust, such that extrapolation to children is not linear.
However, there are still elements of the AASM guide-
lines35 worth highlighting, as they are likely to be perti-
nent when devising future guidelines in children: (1)
The adult guidelines recommend that home testing may
be used as an alternative to in-laboratory PSG in patients
with a high pretest probability of moderate to severe
OSA, and home testing is not appropriate for the
screening of asymptomatic patients. (2) Home testing
needs to be performed in conjunction with a compre-
hensive sleep evaluation, and, at a minimum, recordings
need to include airflow, respiratory effort, and oxygen
saturations. (3) Portable monitoring should not be used
in patients with significant comorbid medical condi-
tions and patients suspected of having comorbid sleep
disorders. The latest clinical practice guideline on the
diagnosis and management of childhood OSA by the
American Academy of Pediatrics was published in 2012
and concluded that the limited data on home-based
studies precluded any firm recommendations, although
if in-laboratory PSG is not available, clinicians may
order alternative diagnostic tests, such as home sleep
apnea testing.1 However, they should be aware of the
sensitivity and specificity of the test used and consider
proceeding to full PSG if the test results are inconclusive.1
Future Research
Up until now, different studies have used different crite-
ria in both scoring of respiratory events and defining
disease severity. Standardization of both is required for
journal.publications.chestnet.org
true head-to-head comparisons of different SCOPER
home sleep apnea testing devices. Integral to this,
research to establish the minimum number of channels
and the duration of recording necessary for accurate
diagnosis of pediatric OSA is urgently needed; further-
more, direct comparisons of in-laboratory PSG with
home PSG would also be of interest. It is important to
understand that the diagnosis of OSA is not solely
dependent on a number such as the AHI, obtained
from a single investigation, whether this be in-laboratory
PSG or home sleep apnea testing. It is imperative to
interpret study findings in light of other factors, such
as symptoms, examination findings, and risk factors.38
Thus, development and validation of clinical algorithms
incorporating these factors alongside results from home
sleep apnea testing are needed to help physicians decide
on appropriate clinical management strategies. Well-
designed, randomized, multicenter, prospective studies
are, therefore, required to provide more definitive
answers regarding the usefulness of home sleep apnea
testing in children. Furthermore, it is now recognized
that in-laboratory PSGs are poorly predictive of OSA
morbidities. Patients with the same AHI on PSG can
have markedly different clinical presentations and end-
organ morbidity. The way to circumvent and address
this problem may lie in more detailed biochemical and
genetic phenotyping provided by metabolomic and pro-
teomic analysis, such as urinary biomarkers.39,40
Conclusions
There has been increasing interest in moving toward
home testing for diagnosing OSA in children. This
drive is in part economic, as home monitoring is
assumed to be more cost effective but also reflects the
desire to improve the patient experience and indeed
improve validity, with home testing possibly being more
representative of a typical night’s sleep. However, home
testing has its attendant challenges, namely being unat-
tended with higher risk of signal loss and failed studies.
Moreover, the AHI can potentially be underestimated in
home RP studies for several reasons: (1) the denomi-
nator of the AHI is the total recording time and not
total sleep time, (2) hypopneas resulting in an arousal
and not a desaturation will not be scored, and (3) infor-
mation concerning sleep architecture will not be avail-
able. As such, home RP emerges as a potentially useful
and valid approach in the diagnosis of children with
moderate to severe OSA.
Several feasibility studies have demonstrated good-
quality recordings from home testing. However, com-
parison of home sleep apnea testing with in-laboratory
1393
PSGs in children is limited, and the findings are discor-
dant. Some of this discordance may result from the
inherent difference in sensitivity and specificity of the
considerable variety of portable monitors available on
the market, for which no head-to-head comparisons
exist. Taking a pragmatic approach, home testing using
at least a type 3 portable monitor appears to be a rea-
sonable alternative in countries where in-laboratory
PSGs are either not available or very scarce. Finally, the
studies thus far have been limited to otherwise healthy
children referred for investigation of OSA, and results
therefore may not be immediately applicable to children
who have other health conditions. More research is
needed in children with underlying comorbidities, and
the development of more portable, reliable CO2 moni-
toring may be necessary.
Acknowledgments
Conflict of interest: None declared.
Role of sponsors: The sponsors had no role in the design of the study,
the collection and analysis of the data, or the preparation of the
manuscript.
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