Original article
Diagnostic value of respiratory polygraphy in patients with low probability of obstructive sleep apnea syndrome
Valor diagnóstico de la poligrafía respiratoria en pacientes con baja probabilidad de síndrome de apneas e hipopneas durante el sueño
Ana Hernandez Voth
, Gemma Mora Ortega, Raul Moreno Zabaleta, Javier Montoro Zulueta, Maria I. Verdugo Cartas, Blas Rojo Moreno-Arrones, Vanesa Lores Gutierrez, María T. Ramirez Prieto
Corresponding author
Servicio de Neumología, Hospital Universitario Infanta Sofía, San Sebastián de los Reyes, Madrid, Spain
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Verdugo Cartas, Blas Rojo Moreno-Arrones, Vanesa Lores Gutierrez, María T. Ramirez Prieto" "autores" => array:8 [ 0 => array:4 [ "nombre" => "Ana" "apellidos" => "Hernandez Voth" "email" => array:1 [ 0 => "anahvoth@gmail.com" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "Gemma" "apellidos" => "Mora Ortega" ] 2 => array:2 [ "nombre" => "Raul" "apellidos" => "Moreno Zabaleta" ] 3 => array:2 [ "nombre" => "Javier" "apellidos" => "Montoro Zulueta" ] 4 => array:2 [ "nombre" => "Maria I." "apellidos" => "Verdugo Cartas" ] 5 => array:2 [ "nombre" => "Blas" "apellidos" => "Rojo Moreno-Arrones" ] 6 => array:2 [ "nombre" => "Vanesa" "apellidos" => "Lores Gutierrez" ] 7 => array:2 [ "nombre" => "María T." "apellidos" => "Ramirez Prieto" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Servicio de Neumología, Hospital Universitario Infanta Sofía, San Sebastián de los Reyes, Madrid, Spain" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Valor diagnóstico de la poligrafía respiratoria en pacientes con baja probabilidad de síndrome de apneas e hipopneas durante el sueño" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0010" "etiqueta" => "Fig. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1549 "Ancho" => 2303 "Tamanyo" => 153060 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Comparative results on prevalence and severity of obstructive sleep apnea syndrome between respiratory polygraphy and polysomnography in the study population. RP, respiratory polygraphy; PSG, polysomnography; OSAS, Obstructive Sleep Apnea Syndrome.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">According to the evidence derived from solid cohort studies, an increase in cardiovascular morbidity and mortality in patients with obstructive sleep apnea syndrome (OSAS) has been demonstrated, especially in those with an apnea-hypopnea index (AHI) greater than or equal to 30, but the risk is already observed with an AHI greater than 15.<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">1</span></a> These data show that the definition of OSAS should be based primarily on obtaining an abnormal AHI.<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">2</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Conventional polysomnography (PSG) is the reference method for the diagnosis of patients with suspected OSAS.<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">3</span></a> This study is conducted in a sleep laboratory, under technical surveillance and a night record of at least 3<span class="elsevierStyleHsp" style=""></span>h of continuous sleep; it is an expensive and complex technique which not all the centers have, that is why portable devices for respiratory polygraphy (RP) have been developed. However, unlike the PSG, the RP does not consider electroencephalography, electromyography or electrooculography, so the <span class="elsevierStyleItalic">arousals</span> caused by airflow limitations cannot be demonstrated.</p><p id="par0015" class="elsevierStylePara elsevierViewall">After several validation studies, it was concluded that RPs can be used as an alternative to PSG in patients with moderate or high probability of obstructive sleep apnea.<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">4</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">According to the guidelines of the Spanish Society of Respiratory Diseases (SEPAR) for the diagnosis and treatment of OSAS,<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">1</span></a> the clinical probability of the disorder is classified as:<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">-</span><p id="par0025" class="elsevierStylePara elsevierViewall">Low: patients with snoring and observed apneas, without drowsiness or cardiovascular comorbidity.</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">-</span><p id="par0030" class="elsevierStylePara elsevierViewall">Moderate: patients with snoring and observed apneas and/or score on the Epworth Sleepiness Scale<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">5</span></a> of 12–15 and/or body mass index (BMI)<span class="elsevierStyleHsp" style=""></span>≥<span class="elsevierStyleHsp" style=""></span>30 without cardiovascular comorbidity.</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">-</span><p id="par0035" class="elsevierStylePara elsevierViewall">High: patients with snoring and observed apneas, score on the Epworth Sleepiness Scale<span class="elsevierStyleHsp" style=""></span>><span class="elsevierStyleHsp" style=""></span>15, BMI<span class="elsevierStyleHsp" style=""></span>><span class="elsevierStyleHsp" style=""></span>30 and/or cardiovascular comorbidity.</p></li></ul></p><p id="par0040" class="elsevierStylePara elsevierViewall">RP confirms the suspicion of OSAS in patients with moderate or high probability. In contrast, its use in cases of low probability of obstructive sleep apnea is not validated, although it is a part of routine clinical practice.<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">1</span></a> According to Spanish legislation, if there is clinical suspicion of OSAS and RP is negative, a PSG has to be performed to definitively rule out the diagnosis; however, according to the algorithm of action in suspected OSAS in this same legislation, a patient with a low probability that has undergone a RP that is negative, should be treated with conservative measures, sleep hygiene and weight control diets.</p><p id="par0045" class="elsevierStylePara elsevierViewall">When in doubt as to diagnosis and treatment of OSAS in a patient with clinical suspicion but low probability, we intend to study the prevalence and severity of OSAS diagnosed by PSG, in a sample of patients with low probability and RP negative, to assess the reliability of ambulatory sleep studies in this population.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Methods</span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Type of study</span><p id="par0050" class="elsevierStylePara elsevierViewall">Retrospective, observational, descriptive and analytical study on the comparison between the results of RP and PSG performed in patients with clinical suspicion of OSAS and low probability.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Population</span><p id="par0055" class="elsevierStylePara elsevierViewall">All patients evaluated by a hospital department on sleep-related breathing disorders with suspected OSAS and low pretest probability, which underwent a portable ambulatory RP and subsequently a hospital PSG. Patients whose PSG had been performed as titration for <span class="elsevierStyleItalic">continuous positive airway pressure</span> (CPAP) devices or <span class="elsevierStyleItalic">bilevel positive airway pressure</span> (BiPAP) devices were excluded.</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Study period</span><p id="par0060" class="elsevierStylePara elsevierViewall">Since the start of the operation of the Sleep-related breathing disorders (SRBD) unit in September 2008 until May 2014.</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Sleep studies</span><p id="par0065" class="elsevierStylePara elsevierViewall">All studies were performed in the sleep laboratory of the SRBD unit of the Infanta Sofia University Hospital in Madrid. Embletta<span class="elsevierStyleSup">®</span> PDS and Gold<span class="elsevierStyleSup">®</span> (ResMed), Nox T3<span class="elsevierStyleSup">®</span> (NoxMedical) and SOMNOScreen<span class="elsevierStyleSup">®</span> (SANRO) polygraphs were used for the RPs, all measure oronasal flow by thermistor and pressure cannula, bands for measuring thoracic and abdominal effort, pulse oximetry for continuous recording of oxyhemoglobin saturation, microphone to detect snoring and body position sensor. A Comet-PLUS XL<span class="elsevierStyleSup">®</span> polysomnography was used for PSG with TWin<span class="elsevierStyleSup">®</span> PSG Software (GRASS Technologies), with oronasal flow measurement by thermistor and pressure cannula, bands for measuring thoracic and abdominal movements, pulse oximetry for continuous recording of oxyhemoglobin saturation, microphone for detecting snoring, body position sensor, chin and lower limb electromyography, electrooculography and electroencephalography with 2 occipital channels (O1/O2) and 2 central channels (C3/C4). Each PSG was manually reviewed by qualified Unit personnel, based on guidelines from SEPAR<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">1</span></a> and the <span class="elsevierStyleItalic">American Academy of Sleep Medicine</span>.<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">6</span></a> The presence of an AHI<span class="elsevierStyleHsp" style=""></span>≥<span class="elsevierStyleHsp" style=""></span>10 has been considered diagnosis of OSAS. With respect to the classification by severity, it was established as follows: mild (AHI<span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>15), moderate (AHI 15–29.9) and severe (AHI<span class="elsevierStyleHsp" style=""></span>><span class="elsevierStyleHsp" style=""></span>30).</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Measurements</span><p id="par0070" class="elsevierStylePara elsevierViewall">A retrospective review of sleep studies (RP and PSG) conducted in the SRBD unit was carried out from the Unit's own databases, collecting the following data:</p><p id="par0075" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Anthropometric data:</span> age, sex, weight, height, body mass index (weight/height<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">2</span></a>) and cervical perimeter.</p><p id="par0080" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Clinical data</span>: history of hypertension, ischemic heart disease and stroke, symptoms suggestive of respiratory disorders during sleep (snoring, excessive daytime sleepiness, restless sleep, observed apneas, asphyxia, morning headaches and nocturia) and the score on the Epworth Sleepiness Scale, considering excessive sleepiness a score higher than 12.</p><p id="par0085" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">RP and PSG data:</span> number of obstructive, central and mixed apneas, hypopneas, AHI, oxyhemoglobin desaturation index (ODI), percentage of total sleep time with oxyhemoglobin saturation below 90% (TC90), and medium and minimum oxyhemoglobin saturations.</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Statistic analysis</span><p id="par0090" class="elsevierStylePara elsevierViewall">Arithmetic means were calculated for numerical variables with standard deviations and medians with ranges for variables with normal distribution and not normal, respectively. Data were analyzed using parametric statistical tests. The tests used were contingency tables, Chi square and Pearson correlation. The statistical program used was SPSS<span class="elsevierStyleInf">®</span> 17.0 (SPSS Inc., Chicago, IL, USA). A <span class="elsevierStyleItalic">p</span> value <0.05 was considered statistically significant.</p></span></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Results</span><p id="par0095" class="elsevierStylePara elsevierViewall">During the study period PSG was performed to 306 patients who had already undergone RP. Between the RP and the PSG, we leave a mean time of about 6 months. After excluding from this group those who had undergone PSG titration for CPAP or BiPAP treatment, and those with suspected OSAS with medium or high probability, we ended up with a group of 82 patients evaluated in the SRBD unit as clinical suspicion of OSAS with low probability (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). The general characteristics of this population are described in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>; in general, they were patients with snoring and/or demonstrated apneas, without apparent daytime sleepiness according to the score on the Epworth Sleepiness Scale or history of hypertension, ischemic heart disease or stroke.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0100" class="elsevierStylePara elsevierViewall">The PSG were performed as second diagnostic study of sleep-related disorders, due to persistent clinical suspicion of OSAS primarily by significant snoring and observable apnea pauses, although the results for AHI in RP were low and the Epworth Sleepiness Scale score was also low.</p><p id="par0105" class="elsevierStylePara elsevierViewall">The comparative results between RP and PSG in this population are described in <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>. A higher number of obstructive, central and mixed respiratory events were observed in the PSG compared to the RP. This difference is statistically significant in hypopneas and AHI. The parameters relating to saturation of oxyhemoglobin, such as mean and minimum saturation, ODI and CT90 were similar in both studies.</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0110" class="elsevierStylePara elsevierViewall">The prevalence and severity of OSAS differ between the RP and PSG, as outlined in <a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>. The prevalence of OSAS increased by 17% in the PSG compared to the RP; cases of severe OSAS increased by 35%, the moderate OSAS grew by 6%, and mild OSAS decreased by 41%.</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0115" class="elsevierStylePara elsevierViewall">The distribution of diagnoses obtained by PSG compared to RP in patients of this population is shown in <a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>. Of the 82 patients studied, 31 (87.8%) demonstrated the presence of severe OSAS through PSG; these patients were previously classified by RP as without OSAS (16.2%), mild OSAS (35.5%) and moderate OSAS (45.2%). Only one patient was correctly classified as severe OSAS.</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Discussion</span><p id="par0120" class="elsevierStylePara elsevierViewall">According to the results of this study, RP underestimates statistically significant hypopnea type obstructive respiratory episodes and AHI in patients with clinical suspicion of OSAS but low pretest probability, and therefore also underestimates the prevalence of OSAS in this population.</p><p id="par0125" class="elsevierStylePara elsevierViewall">Not only are there differences regarding syndrome diagnosis prevalence, but also the severity of the same, underestimating the severe and moderate forms and overestimating mild cases.</p><p id="par0130" class="elsevierStylePara elsevierViewall">There are several reasons that might justify these differences between RP and PSG; probably the most important is the ability of PSG to detect <span class="elsevierStyleItalic">arousals</span>. The determination of these episodes allows to record hypopneas as associated respiratory events in the sleep log, thereby increasing the AHI. In addition, in the RP, the total sleep time is estimated, as the absence of the electroencephalogram makes it impossible to determine for sure whether or not the patient is asleep, while in the PSG, sleep time is accurate. Overestimation of total sleep time can decrease the AHI. Finally, in the PSG, the percentage of time in dorsal decubitus position is usually higher than in the RP; this difference could affect the results, since a higher number of obstructive episodes are usually observed in this position.<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">7</span></a></p><p id="par0135" class="elsevierStylePara elsevierViewall">The importance of proper OSAS diagnosis for patients is indisputable, both to explain the cause of their symptoms and to provide adequate treatment. The possibility of false negative results for OSAS with RP has already been described, but they seem to be mild cases.<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">8</span></a> However, in this study we observed severe OSAS undiagnosed in 35% of patients studied.</p><p id="par0140" class="elsevierStylePara elsevierViewall">These results are similar to those obtained by other authors,<a class="elsevierStyleCrossRefs" href="#bib0095"><span class="elsevierStyleSup">7,9</span></a> who describe a weak correlation and poor concordance between the RP and PSG results. The RP has shown good diagnostic performance compared to PSG only in patients with high pretest probability of moderate or severe OSAS.<a class="elsevierStyleCrossRefs" href="#bib0110"><span class="elsevierStyleSup">10,11</span></a> It has been shown that patients with high probability of obstructive sleep apnea can be diagnosed and treated on an outpatient basis at a considerably lower cost than in a hospital setting.<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">12</span></a> According to national and international guidelines, the RP is not recommended as a diagnostic method in patients with low pretest probability of obstructive sleep apnea.<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">1,3</span></a></p><p id="par0145" class="elsevierStylePara elsevierViewall">An important limitation of this study emphasize that this is a retrospective analysis using information from databases SRBD unit; a bias to consider is that the RP were performed with 3 different polygraphs, so the values obtained in safely polygraphs are not entirely coincident with each other.</p><p id="par0150" class="elsevierStylePara elsevierViewall">Finally, the RP is an affordable, often used, easy, quick and for diagnosis of OSAS, cost-effective diagnostic technique so its use is recommended; PSG, however, is less available and more expensive and demanding of resources but detects breathing disorders during sleep in patients with “normal” RP. Proper classification process pretest risk of the patient to indicate the most appropriate diagnostic test is necessary, and when a RP is “normal” in a patient with clinical suspicion but low probability of obstructive sleep apnea, it is advisable to perform a standard PSG for a correct diagnosis.</p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Conflict of interests</span><p id="par0155" class="elsevierStylePara elsevierViewall">The authors declare no conflicts of interest related directly or indirectly with the contents of this manuscript.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:10 [ 0 => array:3 [ "identificador" => "xres676842" "titulo" => "Abstract" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Introduction and objective" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Material and methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusion" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec682883" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres676843" "titulo" => "Resumen" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Introducción y objetivo" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Material y métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusión" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec682882" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:3 [ "identificador" => "sec0010" "titulo" => "Methods" "secciones" => array:6 [ 0 => array:2 [ "identificador" => "sec0015" "titulo" => "Type of study" ] 1 => array:2 [ "identificador" => "sec0020" "titulo" => "Population" ] 2 => array:2 [ "identificador" => "sec0025" "titulo" => "Study period" ] 3 => array:2 [ "identificador" => "sec0030" "titulo" => "Sleep studies" ] 4 => array:2 [ "identificador" => "sec0035" "titulo" => "Measurements" ] 5 => array:2 [ "identificador" => "sec0040" "titulo" => "Statistic analysis" ] ] ] 6 => array:2 [ "identificador" => "sec0045" "titulo" => "Results" ] 7 => array:2 [ "identificador" => "sec0050" "titulo" => "Discussion" ] 8 => array:2 [ "identificador" => "sec0055" "titulo" => "Conflict of interests" ] 9 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2015-07-17" "fechaAceptado" => "2015-10-01" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec682883" "palabras" => array:4 [ 0 => "Polygraphy" 1 => "Polysomnography" 2 => "Low probability" 3 => "Obstructive sleep apnea syndrome" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec682882" "palabras" => array:4 [ 0 => "Poligrafía" 1 => "Polisomnografía" 2 => "Baja probabilidad" 3 => "Síndrome de apneas obstructivas de sueño" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:3 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Introduction and objective</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Polysomnography (PSG) is the gold standard technic for the diagnosis of obstructive sleep apnea syndrome (OSAS). It is an expensive, complex and not always available technic, meaning that respiratory polygraphy (RP) has become usual. Although RP is not validated in low probability patients, Spanish guidelines recommend conservative treatment in patients with negative RP. We intended to study the prevalence and severity of OSAS through PSG in a sample of patients with low probability and negative RP.</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Material and methods</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Retrospective, observational, descriptive and analytic study of low probability OSAS patients with negative RP in whom a PSG was performed. Anthropometric, clinical and sleep data were collected.</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Eighty-two patients were included. After PSG, a greater number of hypopneas (137.8<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>70.1 vs. 51.2<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>38.4 [<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>0.05]) and apnea hypopnea index (27.8<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>15.6 vs. 11.7<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>7.1 [<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>0.05]) was observed, as well as an increment in OSAS prevalence of 17%, which was 35% in severe OSAS. In mild OSAS, there was a decrement of 41%.</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusion</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">According with the results of this study, RP significantly underestimates the prevalence and severity of OSAS in low probability patients. While it is necessary to adequately stratify the OSAS probability in order to correctly indicate diagnosis tests, we recommend performing a PSG in low probability patients with negative RP.</p></span>" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Introduction and objective" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Material and methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusion" ] ] ] "es" => array:3 [ "titulo" => "Resumen" "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Introducción y objetivo</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">La polisomnografía (PSG) es el método estándar para el diagnóstico del síndrome de apneas e hipopneas del sueño (SAHS). Es una técnica cara, compleja y de poca disponibilidad, por lo que la poligrafía respiratoria (PR) es de uso habitual. La PR no está validada en casos de baja probabilidad; sin embargo, la normativa vigente contempla el tratamiento conservador en caso de PR negativa. Nos hemos propuesto estudiar la prevalencia y gravedad del SAHS mediante PSG, en una muestra de pacientes con baja probabilidad y PR negativa.</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Material y métodos</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Estudio retrospectivo, observacional, descriptivo y analítico de pacientes con baja probabilidad de SAHS y PR negativa a los que se les realizó posteriormente una PSG. Se registraron datos antropométricos, clínicos y características del sueño.</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Ochenta y dos pacientes fueron incluidos. En el registro de la PSG se observó un incremento de hipopneas (137,8<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>70,1 frente a 51,2<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>38,4 [p<span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>0.05]) y del índice de apneas e hipopneas (27,8<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>15,6 frente a 11,7<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>7,1 [p<span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>0,05]), así como un aumento del 17% en la prevalencia de SAHS, de un 35% de casos graves y una disminución de un 41% de los casos leves.</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusión</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">De acuerdo con los resultados de este estudio, la PR subestima de forma estadísticamente significativa la prevalencia y gravedad del SAHS en pacientes con baja probabilidad. Es necesario un adecuado proceso de estratificación de riesgo para la correcta indicación de pruebas diagnósticas, y recomendable realizar una PSG cuando se ha realizado una PR con resultado negativo en estos pacientes.</p></span>" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Introducción y objetivo" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Material y métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusión" ] ] ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Hernandez Voth A, Mora Ortega G, Moreno Zabaleta R, Montoro Zulueta J, Verdugo Cartas MI, Rojo Moreno-Arrones B, et al. Valor diagnóstico de la poligrafía respiratoria en pacientes con baja probabilidad de síndrome de apneas e hipopneas durante el sueño. Med Clin (Barc). 2016;146:194–198.</p>" ] ] "multimedia" => array:5 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1165 "Ancho" => 1603 "Tamanyo" => 122693 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Diagram of sleep studies and clinical probability of obstructive sleep apnea syndrome in the patients studied. BiPAP, <span class="elsevierStyleItalic">bilevel positive airway pressure</span>; CPAP, <span class="elsevierStyleItalic">continuous positive airway pressure</span>; RP, respiratory polygraphy; PSG, standard polysomnography; OSAS, Obstructive Sleep Apnea Syndrome.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Fig. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1549 "Ancho" => 2303 "Tamanyo" => 153060 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Comparative results on prevalence and severity of obstructive sleep apnea syndrome between respiratory polygraphy and polysomnography in the study population. RP, respiratory polygraphy; PSG, polysomnography; OSAS, Obstructive Sleep Apnea Syndrome.</p>" ] ] 2 => array:7 [ "identificador" => "fig0015" "etiqueta" => "Fig. 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 1436 "Ancho" => 2225 "Tamanyo" => 172422 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Distribution of results in respiratory polygraphy of patients diagnosed with severe and moderate obstructive sleep apnea syndrome by polysomnography. RP, respiratory polygraphy; PSG, polysomnography; OSAS, Obstructive Sleep Apnea Syndrome.</p>" ] ] 3 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at1" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">SD, standard deviation; F, female; BMI, body mass index; M, Male.</p>" "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Sex, n (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">F: 28 (34); M: 54 (66) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Age, (years)<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>SD \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">51.9<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>12.3 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">BMI, average<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>SD \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">30.8<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>6.02 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Cervical circumference (cm), mean<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>SD \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">38.55<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>4.46 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Score on the Epworth scale, mean<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>SD \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">7.7<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>2.7 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Snoring, n (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">82 (100) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Observed apneas, n (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">63 (77) \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1110597.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">General characteristics of the study population.</p>" ] ] 4 => array:8 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at2" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "<p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">CT90, proportion of total sleep time with oxyhemoglobin saturation lower than 90%; SD, standard deviation; AHI, apneas and hypopneas index; ODI, oxyhemoglobin desaturation index; NS, not significant; RP, respiratory polygraphy; PSG, polysomnography; SpO<span class="elsevierStyleInf">2</span>, Oxyhemoglobin saturation.</p>" "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Parameter \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">RP \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">PSG \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">p</span> \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Obstructive apneas, median (range) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">6 (0–157) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">14 (0–413) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">NS \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Central apneas, median (range) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0 (0–30) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">2 (0–81) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">NS \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Mixed apneas, median (range) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0 (0–18) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1 (0–19) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">NS \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Hypopneas, mean<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>SD \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">51.2<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>38.4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">137.8<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>70.1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top"><0.05 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">AHI, mean<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>SD \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">11.7<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>7.1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">27.8<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>15.6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top"><0.05 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">ODI, median (range) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">12<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>7.9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">12.3<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>11.6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">NS \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">CT90, median (range) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1 (0–88) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1 (0–97) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">NS \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">SpO<span class="elsevierStyleInf">2</span> mean, mean<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>SD \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">94.2<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>2.4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">93.5<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>2.3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">NS \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">SpO<span class="elsevierStyleInf">2</span> minimum, mean<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>SD \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">84.7<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>6.6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">83.6<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>6.8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">NS \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1110596.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">Comparative results between respiratory polygraphy and polysomnography in the study population.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:12 [ 0 => array:3 [ "identificador" => "bib0065" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Diagnosis and treatment of sleep apnea-hypopnea syndrome. 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