Sleep Seminar 2022.09.21 Sullivan
November 28, 2022ID9179
To CiteDCA Citation Guide
- 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.