Sleep Seminar 2022.09.21 Sullivan

November 28, 2022

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00:00OK. So good afternoon everyone,
00:03and welcome to sleep seminar.
00:05So just as a reminder of these
00:07lectures are available for CME
00:09credit and to receive credit,
00:10please just text the ID for
00:11the lecture to Yale Cloud.
00:13CME needs to go in by 3:15 PM today,
00:16and if you don't catch it on the slide,
00:18it will show up in the chat later.
00:20Recordings of the lecture are
00:21available within two weeks at
00:22the site noted in the chat.
00:24And if you have questions during the talk,
00:26you will be muted.
00:27So use the chat feature and we'll address
00:29them at the end or otherwise I'll give you.
00:31Permission to unmute yourself at the end
00:33as far as upcoming events for next month.
00:35Next week, Michael Grandner will be speaking.
00:38He'll be talking about behavioral measures
00:40to optimize sleep for performance.
00:42You can feel free to share these
00:44lectures widely with colleagues as
00:46invitations and just e-mail Debbie
00:47Lovejoy if you have if you need
00:50to schedule for this semester.
00:51So it is my pleasure now to introduce
00:53today's sleep seminar speaker,
00:55Doctor Shannon Sullivan.
00:56Dr Sullivan is a clinical professor in
00:59the Division of Pediatric pulmonary,
01:01asthma and sleep.
01:02Person in the Department of
01:03Pediatrics at Stanford University.
01:05Additionally,
01:06she has a courtesy appointment in the
01:08Division of Sleep Medicine at Stanford.
01:10Doctor Sullivan received her
01:11MD from University of Michigan,
01:13and while there she also did
01:15additional training in epidemiology
01:17at the University of Michigan
01:18School of Public Health.
01:19She moved to University of California,
01:21San Francisco for both pediatric residency
01:24and Pediatric Pulmonology Fellowship.
01:25She then completed a fellowship
01:27in Sleep Medicine at Stanford.
01:29She joined the faculty at Stanford in 2008
01:31and is now clinical professor in Pediatrics,
01:33and she's also a clinical science team
01:35lead of the Baseline Health study.
01:37She served as medical director
01:39of the Eval Research Institute.
01:40On Palo Alto,
01:41and she previously served as
01:43program director for the Stanford
01:45Sleep Medicine Fellowship.
01:46She is an active member of
01:48multiple organizations,
01:49including ETS,
01:50American Academy of Sleep Medicine
01:51and National Sleep Foundation,
01:53and among her many service contributions.
01:56She recently served as vice chair of
01:58the ASM COVID-19 Task Force and Chair
02:01of the ASM Public Safety Committee,
02:03and she has an active role on
02:05the National Foundation Sleep
02:06Health Technology Task Force.
02:08She's been Pi on numerous clinical studies,
02:10including.
02:11Diverse studies,
02:12novel medications for patients with insomnia,
02:15assessment of sleep education programs
02:17and importantly for this talk home
02:19based early detection of disrupted
02:21sleep in children with risk factors
02:23for sleep disorder breathing.
02:25Her work has been published in
02:27diverse journals including Journal
02:28of Clinical Sleep Medicine,
02:29Respiratory Care, Chest Neurology,
02:31Lancet respiratory Medicine,
02:33Sleep Medicine Reviews and others.
02:35So I am really pleased that doctor
02:37Sullivan is joining us today to discuss
02:39I think an important and timely topic.
02:41The best of times.
02:42The worst of times.
02:43Advances in remote assessments in
02:45pediatric sleep.
02:46So welcome,
02:47doctor Sullivan.
02:49Thanks so much, Janet.
02:50And I'm, I'm so happy to be here.
02:52Thank you for inviting me and I
02:54look forward to having some time
02:56for discussion at the end because
02:58I think this is an area that often
03:01generates quite a bit of discussion.
03:03So without further ado here is the
03:05CME disclosure and accreditation,
03:07there is the number of the text number
03:1034106 and I think Janet promised
03:12to or Debbie promised to post this
03:14number a few additional times and
03:16I'll have it again at the end so
03:18that semi credit can be claimed.
03:20I do not have any qualifying COI,
03:23but I did want to point out that
03:26I do act as a.
03:27The consultant and work with
03:28fairly Life Sciences,
03:29as mentioned on the Project
03:31Baseline Health study,
03:32and the credit for the title of my talk,
03:34of course, is Charles Dickens.
03:36It was the best of times.
03:37It was the worst of times,
03:38the age of wisdom and the age of foolishness.
03:40It was the epoch of belief.
03:42It was the epoch of incredulity,
03:43incredulity, the season of light,
03:46the season of darkness.
03:47It was the spring of hope in
03:49the winter of despair.
03:51We'll loop back around to that.
03:52So I just to kind of set the
03:54stage a little bit for what
03:56we're going to be talking about.
03:58I wanted to point to this article
04:01published last December by a number
04:03of our pediatric Sleep Medicine
04:05colleagues entitled Uncharted Territory,
04:08The Challenges and Opportunities
04:09in Pediatric Sleep Medicine during
04:11the COVID-19 pandemic and beyond.
04:13And table one in this article is
04:16around opportunities and considerations
04:18for pediatric sleep labs.
04:20In the world after the pandemic
04:23and among the opportunities and
04:25considerations are listed the
04:26use of auto CPAP for children,
04:28which we'll touch on briefly,
04:30and home sleep studies for selected
04:32groups of children and adolescents.
04:34And I wanted to dive a little
04:35bit deeper into that.
04:36As you mentioned,
04:37Janet,
04:38I served as Vice Chair and the
04:40COVID-19 task force at the American
04:42Academy of Sleep Medicine.
04:44And we and we thought a lot about.
04:46How to adapt in real time as as the
04:51COVID-19 pandemic presented new challenges.
04:53But you know,
04:54with respect to that
04:56article from last December,
04:57we have to remember that the Academy
04:59has a position paper from 2017 that
05:01really pretty clearly states that
05:03the use of home sleep apnea testing
05:05is not recommended for the diagnosis
05:08of obstructive sleep apnea in children.
05:10Now bear in mind,
05:11even though the door seems fairly
05:13well closed from that perspective,
05:15it's left open a little.
05:16Track because this particular position paper,
05:20like money from the Academy,
05:21states that the ultimate judgment
05:23regarding any specific care must
05:24be made by the clinician in light
05:26of the individual circumstances
05:27presented by the patient,
05:29available diagnostic tools,
05:30accessible treatment options and resources.
05:33And on top of that,
05:34you see that same sort of thinking in
05:36the IRS guidelines that were published
05:39the year before that Academy position,
05:41which stated that alternative
05:43methods might be considered for
05:45use and when PSG is not available.
05:47And that home or respiratory
05:49polygraphy is feasible and has been
05:52used as an alternative to inland PSG.
05:54A couple of important things about
05:56this particular set of guidelines
05:57and which we which I would love
05:59to talk about in the discussion
06:00because I don't have a lot on it
06:02in this talk is the referencing of
06:05clinical validated clinical tools,
06:07questionnaires and that sort of thing
06:09in combination with home testing which
06:12I think is really a really interesting
06:14area for study and and the IRS guidelines.
06:17Mentioned both the PSQ,
06:19the Pediatric Sleep Questionnaire as
06:21well as the sleep clinical record.
06:23Now, what are the kind of core concerns
06:26related to home sleep testing?
06:28Home sleep apnea testing,
06:29excuse me, in children?
06:31Well, there's a number.
06:32This again is from the 2017 Academy
06:35publication that lists out ideal
06:37home sleep apnea testing parameters.
06:39Those include things like the ability
06:42to estimate total sleep time,
06:43arousal identification, I e.g,
06:45as well as a number of other typical sensors,
06:50and as you know, a lot of Level 3.
06:54Um home sleep apnea testing equipment
06:58types really don't have these the
07:02ability to measure these ideal parameters.
07:04So I think lack of EEG is one of the
07:06more important things that's missing.
07:08This is needed to score arousals and
07:10arousals of course are important
07:12in Pediatrics for our definition of
07:14hypopnea as well as central apneas.
07:16Very importantly,
07:17total recording time is not the
07:19same thing as total sleep time and
07:22on on many types of equipment.
07:24Used for Level 3 home sleep apnea
07:26test is just isn't available.
07:29You really can't readily identify
07:31hypoventilation which is another important
07:32characteristic for many children who
07:34may have sleep disorder breathing.
07:36And finally and importantly and where
07:37I will spend a little bit of time
07:39is that we really don't know what
07:41the correct cutoff should be on on
07:44these different types of equipment.
07:45And it might vary between brands
07:47and it might vary between the type
07:49of patient that that you're testing
07:51and we really don't have a sense
07:53of algorithms for use. When?
07:55What's the what?
07:56What's the right scenario to use it in?
07:59I think additional concerns
08:01include feasibility,
08:01especially run adequate signal acquisition.
08:03We'll talk a little bit about that.
08:04And then also for younger children,
08:06whether or not the equipment is is safe,
08:08there's a lot of wires and one could
08:10become wrapped around those wires
08:12could become wrapped around an
08:13individual and if if not attended.
08:15And then finally really incomplete
08:18to absent performance testing.
08:20I prefer the term terminology
08:22performance testing to validation and
08:24that's especially true for younger
08:26children and it's especially true.
08:28For those who have comorbidities that said,
08:32you know,
08:33by 2017 by the time of that publication,
08:36authors did acknowledge that there
08:38was some available data and that
08:40according to what they had the
08:43home sleep apnea testing.
08:44These Level 3 tested tend to perform a little
08:47bit better and more severe sleep apnea.
08:49So given all of that,
08:51that laundry list of concerns,
08:53why would one ever want to consider
08:55home sleep apnea testing and in a child?
08:58While a number of reasons,
08:59I think one we already mentioned briefly,
09:02that was the sort of existential
09:04circumstances brought on by the the pandemic,
09:07but also in lab polysomnography is
09:10expensive and itself it is imperfect,
09:13it's a limited resource and I
09:16think substantial disparities and
09:18access exist and we really haven't.
09:20Um, probably been diligent enough
09:21as a field to understand just how
09:24widespread these disparities are.
09:26I mean, it's shocking there.
09:27I have one study quoted here that
09:29up to 3/4 of children on mainly
09:31public insurance who are referred
09:33for PSG are lost to follow up.
09:35And if the PSG is completed and positive,
09:38it can take twice as long to
09:40obtain treatment afterwards.
09:40I think we have to be aware that this is
09:44a test that just isn't easily available
09:46for everyone and think about what
09:48that means for our work as clinicians.
09:51I also think that first night effects
09:53of night to night variability exist and
09:56in lab hymnography they also exist.
09:58You know no matter what your
10:00venue that that that can exist.
10:02I think one advantage of home based
10:04testing is that you may have the
10:07opportunity to perform testing across
10:10multiple nights and then finally.
10:12You know, there are issues,
10:13especially in adolescents,
10:14around testing at suboptimal times.
10:16Of course,
10:17sleep Labs are expensive to operate
10:19and they're staffed by shift workers.
10:21And so sometimes early morning study
10:23termination before that last episode of
10:26RAM or in teenagers last two episodes
10:28of RAM may result in key loss of data.
10:31So it's important to consider.
10:33And then we like we talked about I think
10:35we are still dealing at least here on
10:37the West Coast with pandemic driven
10:39alterations and access to to care.
10:41You know labs are open but we continue
10:43to have quite a lot of staff shortages
10:46and thinking about what that means for
10:48how many beds we can operate is important.
10:50We also you know in the especially
10:52miss the pandemic and still have
10:54to think about infection mitigation
10:56procedures and and these things can also
10:59increase the burden of disparities.
11:02So, Umm, you know,
11:04with that kind of context in mind,
11:07the other point I want to make is that
11:08it's it is important to acknowledge
11:10heterogeneity and Pediatrics.
11:11It's a lifetime within a lifetime
11:14and the appropriateness of using home
11:16sleep apnea testing may vary with
11:18age or presentation or circumstance.
11:20So I product put up a couple of
11:23scenarios where I might take a moment
11:26and consider home based testing.
11:28These might be different than the
11:30ones that you would consider,
11:31but I think about it.
11:3213 year old child with enormous
11:35touching tonsils.
11:35Nighttime and daytime symptoms
11:37consistent with sleep apnea and a
11:40surgeon who despite the otolaryngology.
11:42Clinical practice guideline desires a
11:45positive sleep test and if the in lab
11:48testing queue were six or nine months and
11:51that child were was clearly symptomatic.
11:54You know maybe that would be a good
11:56situation in which a home sleep apnea test
11:58could be considered or a different surgeon.
11:59What about the 17 year old
12:01with daytime sleepiness,
12:02snoring and delayed sleep wake disorder?
12:06What about the seven-year old
12:07child with developmental delays who
12:09whose failed in lab testing and you
12:11would just like to get some?
12:12Idea of what might be going
12:14on for them and in sleep.
12:16So with that in mind,
12:18I wanted to review some of the
12:20recent data which might support or
12:22not support home sleep apnea testing
12:24or sleep polygraphy and Pediatrics.
12:26Overall when you look through these studies,
12:28I'm not going to go out study by
12:30study by study that the the studies
12:32are generally small,
12:33they're generally non randomized,
12:35they're generally you know open label,
12:38there's no game changers in these studies,
12:40but overall the volume is increasing and I
12:43think these studies do provide a rationale.
12:46Continue to consider each SAT and
12:48select cases and overall I look at
12:50this as kind of building a framework
12:52for incremental evidence and and
12:53you can see this just by going to
12:55pub Med and putting in the search
12:57term pediatric home sleep test.
12:58There certainly is an increase in studies
13:00that are available to to consider for review.
13:03The same with pediatric sleep polygraphy.
13:06So let's tackle a couple of those issues
13:09I mentioned earlier on like some some
13:11of like the really big areas of concern.
13:14I'm going to start with feasibility.
13:16In other words,
13:17is it reasonably possible?
13:18Well,
13:18when you look through a lot of these studies,
13:19I have some of the references here
13:21at the bottom of the slide and
13:22many more at the end of this talk.
13:23You know in most cases recordings
13:26were valid and interpretable.
13:28So 70% or more in general across
13:31these small studies and rather
13:33amazingly I'm starting at age 1 and.
13:36Generally speaking, these are an unhealthy.
13:38These are unhealthy or
13:40uncomplicated pediatric patients.
13:42By and large,
13:43failure of nasal cannula and failure
13:45of the SP O2 signal are the most
13:48common reasons for failed study.
13:50I think for sure the narrative
13:52in the literature is that it's
13:54quite helpful to have some sort of
13:57support for placement of the device.
13:59I'm rather amazed at this Canadian study.
14:02562 one year olds of that group 91%.
14:06Technically acceptable data on
14:08home sleep testing.
14:09However,
14:10that is a study where the tech went
14:12to the home to set up the device,
14:14which almost certainly makes a difference.
14:18I would say we have to be really
14:19cautious about thinking about
14:21children with certain comorbidities,
14:22as in particular neuromuscular disease,
14:24and in one very small pilot with six
14:26adolescents with neuromuscular disease,
14:28there was a 50% failure rate.
14:30And in hospitalized children
14:31with certain comorbidities,
14:32there's very, very limited data,
14:34but but pretty similar success rates.
14:37Here's a feasibility study
14:39from the COVID-19 pandemic.
14:41This is out of the UK.
14:42The study is a retrospective
14:44analysis of real world data.
14:46Kind of necessity is the
14:48mother of invention type data.
14:49From 2020 it was 137 children.
14:53What I like about this
14:54report is that you know,
14:56this was a real world problem
14:58that this the sleep lab needed
15:00encountered and needed to solve
15:02for and so they overnight
15:04transition to home based testing.
15:06Respiratory polygraphy for
15:08their patient population,
15:10they just didn't have another choice.
15:12And so they had children with a lot
15:14of different comorbidities and they
15:16also measured children who are on
15:18positive airway pressure therapy
15:20or ventilator therapy in whom they
15:22were measuring effectiveness of
15:24therapy using either oximetry or CO2
15:26monitoring and very real world results.
15:29About half the time they consider the
15:31home sleep apnea test to be successful
15:34when it was a diagnostic test autism.
15:36Predicted a lower success rate,
15:38so only 29% as did age under 5.
15:41And if you look at the table here,
15:42you can see that.
15:43So if you look at ASD, ADHD children,
15:45you get the median age of seven with
15:49an interquartile range of of 4 to 16.
15:51But they have a failure rate
15:52of 71% if you read it.
15:54That's all the way on the
15:55left in that column.
15:55If you read all the way over on the
15:57right hand side of possible sleep apnea,
15:59failure rate is 25% with the
16:02average aid immediate, sorry,
16:04median age of about five years
16:06and what's really interesting.
16:07So failure rates.
16:08Power and in these less complicated
16:10children who are getting evaluated
16:12for obstructive sleep apnea.
16:14But what was really interesting to me
16:16is that from a parental point of view,
16:18it's the parents who have
16:20children with developmental,
16:22neuro,
16:22behavioral or developmental disorders
16:23who had a great preference for
16:26the home based study compared to
16:27parents of typically developing
16:29children who were referred for OSA.
16:31They had a greater preference
16:32for the INLAB study.
16:33So it's kind of a inverse,
16:35inverse relationship with
16:37success rates actually.
16:40And here's another study,
16:41you know looking at feasibility and in
16:44this one this is 40 children aged 2 to 10.
16:46I want to say the average age
16:48was five and these are children
16:50referred from general practitioners
16:52or ENT was suspected OSA.
16:54And what I love about this study is the
16:57authors presented their data in phases,
17:00kind of six months chunks of time and
17:02what happened is very real world.
17:03What happened is they weren't getting
17:05very good results from their home
17:06based test and so they started
17:08to deploy additional information
17:09out to patients.
17:10And families on what they could do
17:12to help make the studies of success.
17:14And I have some images there on
17:15the right hand side of the screen
17:16to kind of show that.
17:17And in fact it helped.
17:19So that by the end of the study with these
17:21pragmatic instructions on how to
17:23tape things and how to put the
17:25how to secure the nasal cannula,
17:26they were getting about a 2/3 success
17:29rate with with their home based test.
17:31They did survey parents and 94% felt
17:34that the home sleep apnea test was
17:37either easy or medium hard to use.
17:39But once again.
17:40Air flow and asymmetry were the main
17:43obstacles to obtaining a quality recordings.
17:47So what about if, like,
17:48just sending out a slip of paper or
17:51some instructions is not adequate?
17:52What about a hybrid model?
17:54There's one study that was just
17:56published this summer in July on this
17:59exact sort of a model from Australia.
18:02This was again retrospective analysis,
18:05230 children the age was 5 to
18:0718 with the mean age of 10.
18:09And this is interesting,
18:10about 1/4 of those children
18:12did have comorbidities,
18:14although importantly,
18:15neuromuscular disease again.
18:16Was excluded from this from this
18:18group and these children had a
18:20level two study and they had a
18:22nurse perform setup either at the
18:24clinic and then the child would
18:26drive home with their family or
18:28they had a mobile van come out to
18:30the home and do a setup at home.
18:32Either way,
18:33there was a telehealth consultation
18:34with the sleep nurse just prior to
18:36bedtime so that the parent could
18:38go through a checklist of all the
18:40technical aspects of the portable PSG.
18:42Parents were encouraged to spend the
18:44night in the same room with their child.
18:46And and what these authors found was
18:49technically successful studies 90%
18:51of the time and six or more hours of
18:53sleep about 90% of the time as well.
18:55And I have here a total sleep time
18:57from that report you can see on the Y
19:00axis and mean sleep time was almost 8
19:02hours and the median was over 8 hours.
19:04So that that's that's quite a lot
19:07of opportunity to collect quality
19:09data and I think overall this
19:12indicates that with ingenuity and
19:14with some hands on support perhaps.
19:16Unbiased testing is possible,
19:18and parental reports also sort
19:20of corroborated that this was an
19:23acceptable and even convenient
19:25way to to get testing done.
19:28So I'm going to leave feasibility
19:30aside and talk a little bit about
19:32accuracy and whether or not we can how
19:34do we even think about the results of
19:36home based testing and in children?
19:39So this is a study that looked at like
19:42like if we had to back calculate what
19:45a home test result or respiratory
19:47polygraphy test would be like,
19:49what would that look like?
19:50So,
19:51so in this study the researchers
19:53took PSG based data,
19:54they removed all the data that
19:56wouldn't be available on respiratory
19:58polygraphy and then they took a
19:59look at how would that change the
20:01results of the of the analysis.
20:04Children who are aged 2 to 16 clinically
20:07referred for OSA were included.
20:10And oops sorry about that and the
20:12and what they found is that there was
20:15a rest respiratory polygraphy had
20:17a sensitivity of of 82.5% and a
20:19specificity of 90% if you used a cutoff
20:23of a PSG drive HI of one or greater.
20:26Now this is important because what
20:29I want to what I want to kind of
20:31review based on the reports that
20:33we have in the literature is that
20:35the HI cut off to use on the home
20:38based device is not always clear.
20:40This was a study published in
20:432017 comparing home sleep apnea
20:45testing versus laboratory based
20:47polysomnography for the diagnosis of
20:49obstructive sleep apnea in children.
20:51And one of the things I like about
20:53this test is that they are they are.
20:55This study is that they included
20:57children all the way down to age of
20:59two and then all the way up to 17.
21:01Very typical for studies of this
21:04nature is a very small #33 children
21:06are reported upon and they did a three
21:08night pilot and the the type of testing.
21:11Equipment.
21:11They used risen blood of gold.
21:13So the first night that got in lab
21:15polysomnography and then they did
21:17two nights of home based testing
21:19and what they found number one.
21:21So a couple of interesting findings.
21:22Number one that the home sleep
21:24apnea test were 2/3 of them
21:27were successful recordings.
21:28And the second thing is that for
21:31this particular study and for this
21:33particular equipment you needed to
21:35use an HMI cutoff on the home base
21:38test of 0.75 to be able to predict
21:41the diagnosis of sleep apnea made by.
21:43CSG and that improved a little
21:46bit in older children.
21:48So it was a the performance of this
21:50particular of that cut off did not
21:52work as well in younger children.
21:53And so up here these Roc curves,
21:56it's the one on the right that is the one
21:59that describes children aged 6 or older.
22:02And you can see there that if you use
22:06a home based AH set HDI of 0.75 you
22:09get you have a very sensitive test.
22:13And your and your Type 1 error is is .4.
22:18Well what's really interesting is
22:19that if you look at other studies,
22:22they do not suggest that you use a
22:24lower threshold on your home based test.
22:26They you might need to use a higher
22:28threshold on your home base test.
22:29So this was a study.
22:32Of 35 children again typical small study
22:35using apnea link mean age was older,
22:39it was 11 and sleep to sort
22:41of breathing was diagnosed.
22:43And just about half of of these
22:45children they did do manually manual
22:47scoring of the apnea link data
22:49and determined that actually an
22:51apnea link HI of greater than five
22:54events had a sensitivity in 94% of
22:57specificity of 61% to detect any
22:59sleep disorder breathing on PSG.
23:02So another words,
23:03the home based test generated a higher
23:05HDI than the in lab test and you can
23:08see this here on the bland Altman that
23:10there's there's quite a lot of biasing.
23:14Above to have a higher a higher HIV test at
23:17home. And and how much higher?
23:19About about four.
23:20So an HI of about four.
23:23So what gets even more difficult
23:25about this area is it seems that
23:28performance of home based testing
23:30relative to a set threshold could vary
23:32depending on the age of the patient
23:35and also depending on the severity
23:37of the sleep disorder breathing.
23:39So here's the study also looking at
23:41apnea link compared to polysomnography
23:43in both children and adolescents
23:44and you can see there's so little
23:47bit bigger study population,
23:4960 children and you can see
23:51here some of their.
23:52Subject Characteristics
23:53these children tended to be.
23:57But actually they broke it down
23:59into younger children up to 10 years
24:00of age and then pre adolescent and
24:02adolescent children and they they also
24:04had a few greater than 18 year olds.
24:0620% of these kids were obese
24:08and they have pretty substantial
24:09sleep disorder breathing.
24:10So the mean HI and PSG was 11 but
24:13with the with very big confidence
24:15interval and on the home sleep apnea
24:17testing it was it was 10.3 and what
24:20they found in this study is that
24:22they needed to use an apnea link HI
24:24threshold if they wanted to diagnose.
24:27Any sleep apnea is defined by
24:29one an HIV one or higher on PSG
24:31of 3.5 on the apnea link.
24:34But if they wanted to go for a
24:35moderate to severe pediatric sleep
24:37apnea if if we although we don't
24:39have perfect consensus about that,
24:40if we use a cutoff of greater than
24:42five events per hour on the 8 the
24:44PSG HI that then they could use
24:46an apnea link threshold of 5.5.
24:48And what's interesting is that
24:50the authors pointed out that if
24:52you just look at the children who
24:55are aged under 10 years,
24:57the performance in terms of.
24:58Such as sensitivity and specificity
25:00of using up those thresholds
25:02is a little bit different,
25:04and arguably not quite as good.
25:08Especially in terms of specificity.
25:10So this is the sort of thing
25:11where like you may decide,
25:13well you know this test might be
25:14able to rule in somewhere that
25:16I have prior suspicion of having
25:18sleep disorder breathing,
25:19but it might not be so successful
25:22it it it ruling them out.
25:24Now as I think about it from
25:27a clinical perspective,
25:27sort of the group of patients that
25:29I might like to approach 1st and
25:32thinking about home based testing
25:33might be #1 post pubertal adolescent
25:36and #2A child who's overweight or obese.
25:38So I wanted to point out this
25:40particular study also from last year
25:42looking at portable sleep monitoring
25:44to diagnosis obstructive sleep apnea.
25:47This study did use apnea link.
25:49They did the apnea link one night
25:51alongside probably sonography in
25:53the lab and then a second night
25:54at home which was the HST night.
25:56And what you find is that you
25:58know kind of like what I've been
26:00arguing based on the literature
26:01is that there's over diagnosis,
26:03there's overestimate and underestimate
26:04of home based testing compared to
26:07PSG, which makes this a really.
26:09Really a little bit more nuanced to be
26:11able to adopt into clinical thinking.
26:14But what these authors pointed out is
26:15that overall in this particular group
26:17there was a high degree of diagnostic
26:19agreement so as as if what you wanted
26:21to understand was whether or not your
26:24child you know yes no binary just
26:26does the does your adolescent have
26:28sleep disorder breathing home based
26:31testing might be might be appropriately
26:33appropriately used to answer that question.
26:36But overall again that portable monitoring.
26:39They tend to underestimate PSG
26:41in terms of HIV.
26:43Well, what about watch Pat I again,
26:47I'm I'm not sure what you
26:48guys are using there,
26:49but in our neck of the woods we saw
26:51just a huge increase in watchpad
26:52over the course of the pandemic
26:54because of the disposability option.
26:56And so I wanted to point out that
26:58there are two studies in Pediatrics
27:00looking at this and one from.
27:022018, actually both of them are from 2018.
27:05And then very interestingly just
27:08last month there's a a review of
27:11peripheral arterial tonometry devices,
27:13a systematic review across the boards
27:15for both Pediatrics and adults.
27:17There are only 74 pediatric patients
27:19that that that the systemic review
27:22reported upon they call the results
27:25excellent based on these two studies again
27:28mainly adolescents and I would point out.
27:32That these issues of what's the correct
27:36threshold to use are not fully resolved.
27:38So you know I think that's like a little
27:41bit of a positive perspective to say that
27:44that results for watchpad are excellent.
27:47But I do think that there could be a
27:49role and some utility depending on as
27:52long as you're framing the the clinical
27:54question correctly and you know the I
27:57think the the one of the two studies
27:59from from 2018 pointed out that an HIV.
28:03On the PAT,
28:04if you use a cutoff of 3.5
28:06events an hour on the PAT device,
28:07that can provide a about 77% sensitivity
28:11and 78% specificity compared to PSG.
28:17Leaving that topic behind,
28:19just a few words on reproducibility.
28:21So this was a study that evaluated night
28:24tonight variability of the Type 3 device.
28:27That's the Knox T3 HI again,
28:29small study, 30 children in adolescence,
28:31median age is a little bit older, 14.
28:33And you know, so a couple of interesting
28:40things #137% of participants had an
28:42HIV difference of greater than two
28:44events per greater than or equal to.
28:45Two events per hour between the nights
28:47it what 1 interesting finding is that
28:50if you were going after trying to
28:53identify cases of moderate to severe
28:55sleep apnea these were rarely missed but
28:5820% of patients did change diagnostic
29:00category between the nights and 50% of
29:03patients change severity care category.
29:05So diagnostic category would be like yes,
29:07no and then you know half the patients
29:10are shifting between severity category.
29:12So again it speaks to sort of limitations
29:14of home based testing to be able to.
29:16To get to that level of details to
29:18be able to say I'm confident that
29:21you have moderate obstructive sleep
29:23apnea again in children if if we say
29:25we're going to define that as an HI
29:27between 5:00 and 10:00 for example.
29:29Well,
29:29let's take a step back and ask the question,
29:32are there any event are are are there
29:36a sort of types of testing equipment
29:38that are approved for children?
29:39There are some.
29:40This is not meant to be a comprehensive list,
29:43but I will point out that Knox T3
29:45does have approval from 2009 and ages
29:482 plus the watch PAT got approval on
29:512016 for age 12 plus they also have
29:54a weight limitation of a 29.5 kilos.
29:57So no or greater.
29:59And then some to screen plus does
30:02have did in 2020 have an expansion to
30:05ages 2 plus and they have a number
30:09of different kind of configurations
30:10and one of those is a home suggesting
30:13configuration.
30:16So lots of unknowns in this space.
30:19We we don't and I think these unknowns
30:22limit sort of widespread use,
30:24at least in my mind.
30:25One is that we really don't know the
30:27minimum age for utility and safety.
30:29We don't have, you know,
30:32clear protocols and what do you do?
30:34We mentioned that oximetry and air flow
30:37are the two most common missing signals.
30:40Do you repeat, do you advance?
30:42What are the best pathways for parental
30:44training and involvement in sensor?
30:45Basement, what are the different
30:47pathways in terms of in person versus
30:50remote support leading up to the
30:52test and and even during the test,
30:54what are the best indications for testing?
30:56What's the base subgroup of pediatric
30:58patients for whom you might think about this?
31:00What are the optimal cut offs for the
31:03home based HIV and very importantly
31:05what are the device brand or equipment
31:08differences that might exist.
31:10This area is really just kind
31:12of like don't ask,
31:13don't tell right now in the
31:14literature I think it's really.
31:16Important to understand that
31:17and understand the specific
31:18characteristics of of your device
31:20and then finally how do you handle
31:22false positives and false negatives.
31:23So you know it's clear that there are
31:26both and so really thinking through
31:29an overall framework and algorithm
31:31in order to be able to navigate a
31:33variety of scenarios is is quite an
31:35important thing and and I I think
31:37it's a field we haven't done that
31:38it certainly at the center level
31:40some of that work can be engaged in
31:42and then I wanted to point out this
31:44study this was published in 2021.
31:46Some methods paper about pediatric
31:48home respiratory polygraphy study
31:50for the diagnosis of obstructive
31:52sleep apnea and the main goal of that
31:55study is to establish the diagnostic
31:57and therapeutic decision validity
31:59of simplified home respiratory
32:01polygraphy approach compared to PSG
32:02among children at risk for OSA.
32:04This is exactly the question at hand.
32:07And then secondary outcome is to look
32:09at the cost effectiveness of home
32:11respiratory polygraphy versus in lab
32:13cost effectiveness for outcome like that.
32:15One of the things that I think
32:16is really special.
32:17About this particular methods
32:19methodological approach is focusing
32:21on the outcome for the patient rather
32:24than looking at HIV equivalents which
32:26at best might be a leading indicator,
32:29really looking at what did it mean
32:31in terms of clinical outcome for
32:33that particular pediatric patient.
32:35And so I think that I think that
32:38is the appropriate way to approach
32:40these sorts of questions.
32:42And the other,
32:43the other things I like about
32:44this particular study,
32:46number one is the age range.
32:472 to 14 and then finally the sample
32:50size estimates are are quite
32:52ambitious at 320 children and I
32:54think I think that would be helpful.
32:57I wanted to point out that while
32:59we struggle with home sleep apnea
33:01testing and Pediatrics you know
33:03technology is zipping ahead and
33:05I so I wanted to point out
33:07a couple of of papers in this space.
33:10This is a paper looking at cloud
33:12algorithm driven oximetry based
33:14diagnosis of obstructive sleep apnea.
33:16This is using a smartphone.
33:18A Bluetooth smart tone,
33:20a smartphone oximeter in habitually
33:23snoring children again ages 2 to 15,
33:26but the mean was six years of age
33:28and it's a big sample of 432 children
33:30and what they found using this
33:32this Bluetooth based oximeters and
33:34accuracy at all estimated HIS of 79%
33:37and a false negative rate for the
33:39diagnosis of sleep apnea 4.7% which.
33:42You know, gives one pause considering
33:44the types of performance data that we
33:47saw for home sleep apnea testing overall.
33:50And then there's this study looking
33:52at a software generated HI derived
33:55from Photoplethysmography signal.
33:56So this this utilizes cardio pulmonary
33:58coupling analysis from the PPG signal.
34:01And and these researchers use the
34:03chat database which includes 1244
34:06habitually snoring children aged 5 to 10.
34:08And they were able to calculate HI with
34:1191 and 98% agreement of HI classes.
34:14So they class of lesson one,
34:16one to five,
34:17five to 10 and greater than and
34:19greater than 10.
34:20So again I think being open minded
34:23to advancement of technologies is,
34:25is something we have to keep our
34:27finger on the pulse of this and
34:28that's no pun intended.
34:29This next study is around Pulse transit
34:33time which again if you add pulse
34:36transit time to respiratory polygraphy,
34:39can that add anything overall
34:41to the device performance,
34:42the home based test device performance
34:45and for the diagnosis of sleep
34:47apnea and you can see here that
34:49that generally speaking.
34:50The respiratory polygraphy and and
34:53polysomnography results are fairly
34:55similar with no significant difference,
34:58although close with the total hypopneas.
35:03So leaving diagnostic testing I wanted
35:06to very briefly touch on empiric APAP.
35:09This talk is not really devoted to
35:11that but it I think it's I think it's
35:14relevant it was brought up again and
35:17and the considerations article from
35:18last December and I so I wanted to
35:20point out a couple of papers here.
35:22This is a paper looking at auto
35:24titrating CPAP for the treatment of
35:25obstructive sleep apnea in children.
35:27What's interesting about this I use
35:29this sometime in my own practice
35:30I typically use it in typically.
35:32Developing children.
35:33But what was interesting about this
35:35report is that these children did,
35:37they did have a pretty broad spectrum
35:39of pediatric patients including
35:41some with cerebral palsy,
35:43musculoskeletal problems,
35:44other neurological problems,
35:45chromosomal abnormalities and the
35:47children were a little bit older
35:50at 13 years and but what they found
35:52is that the compared to titration
35:55based pressures that using the
35:57P90 these were Phillips devices.
35:58You can see over there on the
36:01left using the P90.
36:02It was a pre performed pretty well
36:05in this group of older children
36:08or adolescent age children in
36:10terms of treatment.
36:11And then I wanted to point out this study.
36:14This was published by my
36:15colleagues at Stanford,
36:16Carolina Corey and and Marian Tablazo.
36:18It's a smaller study.
36:20They looked at 19 children and again
36:22these these children had fairly
36:25pronounced sleep disorder breathing
36:27with a PSGOHI of 12.3 per hour.
36:30But what you could see is the titrated.
36:33Pap pressure was fairly similar
36:36to the pressures reported on an
36:39auto titrating CPAP with this
36:41with with some differences,
36:43relatively small amount of differences.
36:47I'm going to take a breath there
36:49and I'm going to switch again
36:50and I want to talk a little bit
36:52about actigraphy and wearables.
36:54Again, this kind of falls into the
36:56space of home based assessment.
36:57Well, why would I even need to go there?
37:00One reason is that again,
37:02Actigraphy is recommended in the
37:05evaluation of certain sleep disorders.
37:07It's suggested.
37:09So it actually the Academy and its
37:13practice guide clinical practice
37:14guidelines suggest the use of actigraphy
37:16for the assessment of pediatric insomnia.
37:17Disorder and circadian rhythm disorders.
37:20And in this I actually particularly
37:24like this paper because it explicitly
37:27calls out that actigraphy has pretty
37:29wide mean differences with sleep logs
37:31and with PSG for wake after sleep onset,
37:35for total sleep time,
37:36for sleep onset latency,
37:37and there's very few studies in Pediatrics.
37:40Nonetheless,
37:41the paper does promulgate clinical
37:44significance thresholds for maximum
37:46allowable differences in the 95th percentile.
37:49Confidence intervals between Echography
37:51versus PSG for total sleep time,
37:54sleep onset,
37:54latency and and wake after sleep onset
37:57and you can see there's fairly big.
37:59You know, the windows are fairly wide.
38:00It's 50 minutes or 40 minutes
38:03depending on the metric.
38:04Well,
38:04there are a number of papers that have
38:07come out in recent years looking at
38:09consumer consumer sleep wearables you
38:11know which I think is fascinating.
38:12I get questions all the time
38:13on this from from my patients.
38:15Maybe that's because I'm Silicon Valley,
38:17I'm not sure you guys can tell me.
38:19And so just a couple words of caution
38:22risk Warren consumer devices are
38:24you know largely not validated in
38:26patient or clinical populations
38:28are generally validated at all or
38:30performance tested in healthy sleepers.
38:32The training data sets for sleep
38:34disorders typically do not.
38:35Include children,
38:35these are not cleared by the FDA,
38:37these devices and they can't
38:39be manually scored.
38:40They use the black box although
38:43almost algorithm almost universally.
38:45And I will point out that a little bit
38:47of data that we have does definitely
38:50demonstrate that proportional biases
38:51exist and these can vary by disorder.
38:53So I'll show you a little bit
38:54of data about that.
38:55Nonetheless,
38:56they are very widespread among my
38:58patients and in the market generally
39:00and they do have a couple of advantages
39:02like a tiger fee they can they can measure.
39:05Possible nights over different circumstances.
39:07And they may have certain advantages
39:09over sea flags in children,
39:11especially in adolescents who may
39:13have recall bias or missing us.
39:15You know,
39:16as a parent of two teens and a preteen,
39:18trying to encourage them to fill
39:21out a sleep log every morning
39:23could be a little challenging.
39:24So, you know,
39:26different different elements of of value.
39:28And I constructed this earlier in
39:30the year based on studies looking
39:32at these consumer wearables that
39:33did have a ground source of.
39:35Truth that included hymnography
39:37and that's not the only way to
39:39do it but but I think that's a
39:40pretty important truth measure and
39:42so looking at these studies they
39:44all have certain trends in
39:46common so and the devices that
39:48were studied were Fitbit charge,
39:50the Ulta, the Ora Ring,
39:51the polar restore and wearable device
39:53and and most and then all of these
39:55there was also actigraph or active
39:57watch some some measure of actigraphy
39:59is a real world alternative measure.
40:01And all of these studies,
40:04the wearable devices tend to underestimate
40:07turtle sleep time and overestimate wake
40:10after sleep onset where measure the
40:12sensitivity for sleep tends to be high.
40:15Again, these are going
40:16to be typical sleepers,
40:17so that's not surprising.
40:19And the specificity for sleep,
40:21in other words wake detection is is quite a
40:23bit lower and you can see that over here.
40:25So sensitivities for sleep tend
40:27to be right around 90% plus minus,
40:29sometimes a little bit lower
40:31for actigraphy like.
40:32And the peasant pesonen study and then
40:35specificity meaning wake detection
40:36tends to be quite a bit lower.
40:39So in the polar device from 31 to 98%,
40:43that's a really big range up to 88 to
40:4690% in in one of the Fitbit studies.
40:49And all of those fall within the range.
40:52By the way if you look at the,
40:53let me go back, if you look at sort of.
40:56The underestimate overestimate bounds.
40:58They're falling within the range
41:00that that generally speaking,
41:02that's that's been established by
41:05the academies clinical practice
41:07guideline for actigraphy.
41:08So my kind of my own conclusion from
41:11this is that consumer sleep trackers
41:13can perform pretty imperfectly for sure,
41:16but as about as well as actigraphy for
41:18sleep wake in children and adolescents.
41:20This is not to.
41:21Please don't confuse that with staging,
41:24which I think is a different kettle of fish.
41:26I do think it's important to
41:28be aware of proportional bias,
41:29which means that depending on like
41:32if your measure is total sleep time
41:35or like actually in this study you
41:37can see this is true for staging
41:40if you're measure is light sleep
41:42that the more the more.
41:46Sleep,
41:46you have measured in that category
41:48on your ground truth measure that
41:51the that your wearable detection
41:53changes based on how much is is
41:55present on that recording.
41:57And so this is a big deal because
41:59it really limits our ability to be
42:02able to use wearables in the field.
42:04By the way,
42:05a trigger fee is not necessarily
42:06better or worse than the consumer
42:08wearables in this space and that's
42:10shown in this particular study,
42:11which again demonstrates this one
42:13demonstrates proportional bias even
42:14with total sleep time and sleep.
42:15Efficiency.
42:16Not just staging,
42:17but the the column on the left is
42:20that evaluation of where consumer,
42:22wearable,
42:22Fitbit and the consumer and the column
42:24on the right is looking at active graphs.
42:27You can see the biases are relatively
42:29similar between the two types of devices.
42:32And this is just to remind us
42:35all that we have to be really,
42:37really cautious and how we approach
42:40consumer wearables because their
42:41training data sets or validation
42:43data sets do not include
42:45sleep disorders.
42:46This paper is an exception.
42:48This paper actually went after sleep
42:50disorders in their validation data set.
42:53Unfortunately,
42:53most of the sleepers were adult sleepers,
42:56but they did include some children.
42:58The other thing to point out about this,
43:00which I think is something to look for.
43:02If you're interested in reviewing this
43:04literature is that Cohen's Kappa that
43:05defines and you can see that up here.
43:07This Kappa value here which you can
43:10see it looks different than the
43:12accuracy measure and the Cohens Kappa
43:15describes a level of agreement for
43:17categorical data between 2 scores and
43:18so typically one would be like one is
43:20the wearable and the other is a ground
43:22truth measure like like like PSG but
43:24but the kappas generally more robust
43:27than accuracy because it includes the
43:30possibility of agreement by chance.
43:32Which which which is important and
43:34generally speaking capus between .6 and
43:37.8 indicates substantial agreement.
43:39Moderate agreement would be
43:40.4 to .6 and .8 to one.
43:43It would be near perfect agreement.
43:45Then finally,
43:46I wanted to point out this paper.
43:48This is just from this summer in July.
43:51It is a.
43:53Review of sleep wearables
43:54and disease outcomes.
43:56Now this is really interesting
43:58I mentioned before is wearables
44:00are they're everywhere and of
44:01course it doesn't take very long
44:03before they turn up and chronic
44:06disease management evaluations.
44:07And so in the peer reviewed literature
44:09we see sort of consumer wearables as
44:12predictors of clinical disease outcomes.
44:15And and much like when we're
44:16talking about home sleep apnea
44:17testing where maybe it's not just
44:19about comparing 1 to one the HIV,
44:21maybe we need what we need to do
44:22is incorporate into our thinking.
44:24How how use of these devices impacts outcome,
44:28that's a little bit what this paper
44:30is about and what's really amazing,
44:31whether it's whether it's asthma
44:34or whether it's seizure disorder
44:36or whether it's quality of life,
44:39these wearables are being worn and
44:41in a third, if you can believe it,
44:43this isn't.
44:43This is specifically for Pediatrics
44:45for children and adolescents.
44:47A third of these reports include
44:50sleep based metrics,
44:51which is pretty surprising based
44:52on that based on on the.
44:54Yeah, it's it's a fairly imperfect
44:56and exact assessment of sleep.
44:58So the conclusion of these authors
44:59is that while Fitbit devices may
45:01be beneficial for those interested
45:03in improving physical health,
45:04discretion is advised for those
45:06seeking to collect accurate and
45:08or medically necessitated data.
45:10And I think you know it's important
45:12to have these sorts of assessments
45:13and as as the field evolves and then
45:16finally before we open it up to questions,
45:18I just.
45:21I wanted to to take a second and sigh and
45:23and talk a little bit about what's missing.
45:26You know, it's in the title
45:28home sleep apnea test.
45:30It's look, it's a very directed,
45:32very focused assessment that
45:34can be performed in the home.
45:36But actually with polysomnography,
45:38these tests are so rich and
45:41there's so much data to be gained
45:43beyond simply an AHI metric.
45:46For me, I'm really interested
45:48in craniofacial development.
45:49And oral breathing is a very
45:51important part of that and we
45:53measure oral breathing in the lab
45:54we ended in addition to the nasal
45:56pressure transducer in the nose,
45:58we use an oral scoop and directly
46:00measure oral breathing and we can
46:02calculate the percent of time spent
46:04in oral breathing across the night
46:07and that's that's an important,
46:09that's a value to us and we don't,
46:11we're not able to do that
46:12simply on the home test.
46:14And then again, of course,
46:16polysomnography allows us to be able to
46:19measure things like respiratory effort,
46:21both inspiratory effort
46:22and expiratory effort.
46:24And if you spend the time to measure
46:26this and look at the signals,
46:27they can tell you something about
46:30that patterns of breathing and
46:32about and about how sleep may be
46:35affected by breathing abnormalities.
46:37And then finally, and these are sea lions.
46:40I took this photo last fall.
46:42These are sea lions in Santa Cruz
46:44out at one of the public docks.
46:46And I took one look at these
46:47guys and thought, Oh my goodness,
46:49this looks like a couple of
46:50my patience when I'm watching
46:52the video on play sonography.
46:53And in fact,
46:54I did go home and do a Google search
46:55to sea lions have sleep apnea.
46:57I would encourage you to do that,
46:59especially if you're getting bored.
47:00You could do it now,
47:01but you know a picture can
47:03be worth 1000 words.
47:04I have had children who
47:05sleep with their neck and.
47:07Extension and they're back arched
47:08and it does make a difference.
47:10It makes you,
47:11it makes you question whether or not
47:12this child might have reflux disease,
47:14whether or not they might be positioning
47:16their airway in such a position in
47:18order to open it up to improve breathing.
47:20It's important to remember
47:21that when we have pyrography,
47:22we look at all the signals,
47:24not just the HIV.
47:26So in conclusion I think you know
47:29remote sleep assessment and Pediatrics
47:31depending on where you fall on this
47:34spectrum it can be the the best.
47:36It can be a source of wisdom of light
47:38of hope for how we can democratize
47:40sleep evaluation for children be
47:42able to be more patient focused and
47:45at the and and on the other hand
47:47you might you might be thinking
47:49right now this is the work I'm
47:52completely incredulous and this is
47:53this is this is darkness and despair.
47:55Think of everything that I've lost.
47:57And small Chris.
47:59So now you you might have,
48:02you might have guessed by
48:04Janice introduction.
48:04I'm not a spring chicken,
48:06so this is a band from the 90s.
48:08I do have a point here.
48:10If you know who it is,
48:10please put it in the chat.
48:12I'll think of some prize to
48:15send out to Janet to give you,
48:17if you know who it is.
48:20The band is Diamond Rio.
48:23And this song is me in the middle there.
48:25They're indelible 1991 classic.
48:26I think that's what the field
48:28of Sleep Medicine will be doing.
48:30When it comes to remote
48:31assessment and Pediatrics,
48:32I think we've got to meet
48:33somewhere in the middle.
48:34This is William Mayo,
48:35who's who has a quote that I just love,
48:38that the glory of medicine is that
48:40it's constantly moving forward
48:41and there's always more to learn.
48:43And this is very much the way I feel,
48:44I feel about this area.
48:46I think we've all learned
48:48a lot from the pandemic.
48:50And importantly,
48:50that necessity really is
48:52the mother of invention.
48:53We clearly need larger studies that
48:55are focused not just on HI equivalents
48:57but also on outcomes equivalents
48:59and I think we were resources time,
49:01money clinic or staff availability
49:03or strained and an appropriate
49:05clinical circumstances and
49:06with appropriate patients.
49:08I I do think that there one could
49:09argue that there's a role for
49:11home sleep apnea testing as part
49:13of a multi step pathway but it's
49:14really important to select both
49:16patients and devices wisely.
49:18I definitely would like to reiterate
49:20that I don't think that home sleep
49:22apnea testing is extensively.
49:24Conclusively validated for all children.
49:27But then again,
49:28even the academies 2017 statement
49:30would would support the notion that
49:32it's not contraindicated altogether.
49:35So I'm emerging technologies
49:36may be able to assist us,
49:38but it's really I,
49:40in my mind anyway,
49:41unlikely to replace the need for ongoing
49:44clinical judgment and perceptiveness.
49:46Some final thoughts.
49:47I think we need to better define who's
49:49appropriate for this technology,
49:50these types of technologies,
49:52and understand the role of remote assessment.
49:54In combination with validated
49:56questionnaires in particular,
49:57remember that ERS statement from 2016,
49:59I really feel like a potential
50:02pathway forward might be being able
50:04to combine our different sources of
50:06truth to be able to really provide
50:09a rigorous clinical assessment.
50:11And I and I feel like too that one
50:14can argue that defining success
50:16or failure based on clinical
50:17outcomes rather than simply that
50:19score of HIV is pretty important.
50:21I it is my opinion that integration
50:23does not mean replacement.
50:25Nonetheless,
50:25I think that scaling and sustainability
50:28models that reward excellent
50:30clinical care and excellent outcomes
50:32rather than procedures per se is
50:34where we need to go as a field.
50:35And and so I I will stop there
50:37with those final thoughts and
50:39I have a bunch of references.
50:41I'm happy to share these slides
50:42and I'm just going to put up
50:44the same disclosure number again
50:46and I'll stop talking.
50:48Thank you, doctor.
50:50Salon, that was really a wonderful
50:52overview really terrific and I'm,
50:54I totally agree with you.
50:56I, you know we, we all love polysomnography.
50:59We get tons of data.
51:00I think is a field you know we just
51:02steal everything down to the HIV.
51:03That's probably a mistake.
51:04And there's so much more we can
51:06get by integrating the video and
51:07some of the other signals you know.
51:09But I hear you.
51:10You know necessity is the mother
51:12of invention and with the pandemic
51:14so many of us in the adult world
51:16have been using HST's and patients
51:18we never would have before.
51:19So some.
51:19Sort of complicated pulmonary sleep
51:21overlap and using a capping those people
51:23with oximetry and you know what it,
51:25it works.
51:26And so sometimes we actually find it
51:28works because we're forced into it.
51:29And I will say with in the
51:31adult medicine world,
51:32part of the part of the reason many
51:33of us were forced into HST was the
51:35insurance change and the fact that
51:37all of a sudden this is the test
51:39that was going to be required,
51:40you know,
51:40and that's true and a lot of
51:41it at least to the adult world.
51:43So my thought for you is I think
51:46a Sleep Medicine,
51:46adult Sleep Medicine physicians
51:47were much more comfortable with HT
51:49because we've been using it more.
51:51We've been forced into it and in
51:52the in the pediatric community,
51:55are people getting more familiar
51:56with using HT or is it still
51:58kind of not being used and what's
52:00happening if you have any idea,
52:02I know you're in California,
52:03but what's happening with insurance
52:05for for pediatric studies?
52:07Yeah. Thank you for that, Janet.
52:09There's a lot there.
52:10I definitely agree with you.
52:11I I practice with adults
52:12and children as well.
52:13I'm because I'm interested in
52:15craniofacial growth and characteristics.
52:17I often see multiple
52:18generations in the same family.
52:20So I might be seeing grandparents,
52:21parents and children.
52:23And it definitely helps to sort of have
52:27that Scooby sense on on where HST fits.
52:30And yeah, we have our guidelines,
52:31but the clinical Scooby sense
52:32of of what are the limitations,
52:34what do you need to worry about,
52:36what what's not being reported
52:37and I feel like.
52:39Um, at least in my neck of the woods.
52:40Folks on the adult side of Sleep
52:42Medicine seem to have a little more
52:44comfort with that and and know what
52:46boundaries are pushing when they're pushing.
52:48You know,
52:49just not knowing what you don't
52:51know is always a big danger.
52:52I do think, at least in my area,
52:55there's not very much.
52:59Sort of acceptance of home based testing.
53:02I I I see it more and that's why I wove in
53:04a little bit around consumer wearables #1.
53:06My patients all come in right there.
53:08They all want me to take a look at their
53:09apps with their consumer wearable data.
53:11No, what does this mean?
53:14But I also see that like as a ticker fee
53:17replacement we I think there is more
53:20acceptance there than with home based testing
53:22again and that that's my local feedback.
53:25It's interesting because I was approached
53:27a couple of years ago about doing some.
53:29Work for a different coverage determination
53:32area for public insurance to look at
53:36coming up with guidelines for home
53:39home based testing in Pediatrics
53:42for for a government payer.
53:44And I think that probably is coming one
53:47way or another because of the expense
53:50of and and limited limitation other
53:52limitations related to polysomnography.
53:55So I do think it would serve the field
53:59to to drive research in this space
54:01and and to drive that discussion a
54:03little bit so that it's not sort of a
54:07matter of payers making the decision.
54:09This is not payers making decisions
54:10is not really a good way to practice
54:12medicine like we all know and I
54:14think the more we can engage.
54:15And like here's the data and this This is
54:18why this particular group of individuals
54:20definitely needs and lab probably sonography.
54:23Like we need to be able to tell
54:24that story with the science.
54:25And so I do think engaging a
54:26little bit is an important thing.
54:28But I'd love to hear from you
54:30guys what's happening there.
54:31I can say here in the peace lab at
54:33Stanford they're they're not sending
54:34out any home sleep apnea testing.
54:36So if I want to get home sleep
54:38apnea testing and an adolescent,
54:39which,
54:39which I don't commonly do but even
54:41when if I needed to consider that that
54:43would be done through the adult lab.
54:46So I have a I have a question.
54:48Sure. Doctor Krieger,
54:49Dr krieger. Hello, Shannon.
54:52That was a great presentation.
54:54So in in the last three or four years,
54:57there's been a lot of stuff
54:59in the adult literature about
55:02racial bias and oximeters.
55:04Has that been studied in
55:06the pediatric population?
55:07I'm only aware of one study in
55:10premature babies and that's it.
55:14Not to my knowledge and I think it's a
55:16huge deal and not just for Pediatrics,
55:18but as you said across the boards,
55:20I think that Fitzgerald,
55:22so they're so skin tone because
55:24these because a lot of oximetry but
55:27also other wearable type sensors
55:29rely on a light signal getting
55:32transmitted through the skin.
55:33Depending on what your skin tone is,
55:34you may have changes in the way the
55:37signal is reported and to my knowledge
55:39there is no literature on that in
55:41Pediatrics and still kind of underdeveloped.
55:44There are still emerging literature
55:46even in the adult world,
55:48but I think it's a huge issue.
55:51I do have one question in the chat so
55:53far on how do you report oral breathing
55:55breath. Yeah, so I'm breathing.
55:58So there is no standardized
56:00way to do it unfortunately.
56:02So we provide if if that's measured,
56:05we can provide that window
56:06just like I showed you.
56:07That actually gives you a subjective sense,
56:11not an index, but a subjective sense of how
56:14common oral breathing was across the night.
56:16And I have at least one colleague who has
56:19traditionally reported out an estimate I.
56:21I observed oral breathing for approximately
56:2475% of the study or that kind of thing.
56:25I to me and that's sort of a situation
56:27the picture is worth 1000 words.
56:29I think what's interesting about it is
56:31to know that it exists at all because
56:34you know it can be hard without an oral
56:37scoop to assess for oral breathing,
56:39especially if your video might be a
56:41little blurry or the patients turned
56:42away from you and you can't really
56:43see clearly in the video because
56:44of course we have nasal pressure
56:46transducer and then we have a sum
56:48signal for for oral and nasal,
56:50so those those.
56:51She alone don't don't provide the most
56:53sensitive signal for oral breathing.
56:55Great, thank you. Yeah, we try
56:56to look at the video and it's,
56:58it's very difficult to tell.
57:01Move the sheets a little bit,
57:03you know, yeah, I do.
57:05I mean, I will say that's a pitch
57:07to looking at all the data that
57:08you're provided when you're when
57:10you're reading applies tomography.
57:11I do think it's on the field.
57:13Overall, but especially in Pediatrics
57:15to make the case that what we're
57:18measuring has value because if we,
57:20you know, dump it all down,
57:22if we like lump it all together
57:24that the only thing really
57:25coming out of this study is the
57:27HI or maybe the HI and the PMI.
57:29We've missed an opportunity to
57:31to tell the story of why the why
57:33these studies are so important and
57:35how they're clinically helpful.
57:37So I do think again I think
57:39it's important for the field.
57:41My my opinion is that it's important
57:42for the field to be part of that.
57:43Conversation.
57:45Alright, terrific. I'm not
57:46seeing anything else in the chat.
57:48Anybody need to unmute themselves,
57:50we have, we're just at time now.
57:54Yeah, here I'm in a PC sandwich.
57:57Critical care sandwich. Be the salami
58:00in the middle of the sandwich here.
58:02All right. Well, anyway,
58:03Doctor Sullivan,
58:04this is really fabulous.
58:05Thank you so much.
58:06You may get some questions by e-mail.
58:08I'm not sure, but really
58:10appreciate your time today
58:11and all your expertise.
58:12And thanks everybody.
58:13Thank you for having me.
58:14And I'm happy to get any questions.
58:15And again, I'll PDF out this
58:17this deck to you, Janet,
58:18so you feel free to send it around.
58:21Thank you. All right. Great day, everybody.
58:23Bye, bye. Bye, bye.