Comparison Between Automatic and Manual Analysis in the Diagnosis of Obstructive Sleep Apnea-Hypopnea Syndrome
Comparación entre el análisis automático y manual de la polisomnografía convencional en el diagnóstico del síndrome de apnea-hipopnea obstructiva del sueño
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array:2 [ "Iniciales" => "H" "apellidos" => "López" ] ] ] ] ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/13055460?idApp=UINPBA00003Z" "url" => "/15792129/0000003900000012/v0_201307090853/13055460/v0_201307090853/en/main.assets" ] "itemAnterior" => array:15 [ "pii" => "13055458" "issn" => "15792129" "estado" => "S300" "fechaPublicacion" => "2003-12-01" "documento" => "article" "crossmark" => 0 "subdocumento" => "fla" "cita" => "Arch Bronconeumol. 2003;39:537-43" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:2 [ "total" => 3754 "formatos" => array:3 [ "EPUB" => 145 "HTML" => 2712 "PDF" => 897 ] ] "en" => array:11 [ "idiomaDefecto" => true "titulo" => "Validation Study of a Polygraphic Screening Device (BREAS SC20) in the Diagnosis of Sleep Apnea-Hypopnea Syndrome" "tienePdf" => "en" "tieneTextoCompleto" => "en" "tieneResumen" => array:2 [ 0 => "en" 1 => "es" ] 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=> array:2 [ "Iniciales" => "J" "apellidos" => "Durán-Cantolla" ] ] ] ] ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/13055458?idApp=UINPBA00003Z" "url" => "/15792129/0000003900000012/v0_201307090853/13055458/v0_201307090853/en/main.assets" ] "en" => array:14 [ "idiomaDefecto" => true "titulo" => "Comparison Between Automatic and Manual Analysis in the Diagnosis of Obstructive Sleep Apnea-Hypopnea Syndrome" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "544" "paginaFinal" => "548" ] ] "autores" => array:1 [ 0 => array:3 [ "autoresLista" => "B Barreiro, G Badosa, S Quintana, L Esteban, JL Heredia" "autores" => array:5 [ 0 => array:3 [ "Iniciales" => "B" "apellidos" => "Barreiro" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "affa" ] ] ] 1 => array:3 [ "Iniciales" => "G" "apellidos" => "Badosa" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "affa" ] ] ] 2 => array:3 [ "Iniciales" => "S" "apellidos" => "Quintana" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "affb" ] ] ] 3 => array:3 [ "Iniciales" => "L" "apellidos" => "Esteban" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "affa" ] ] ] 4 => array:3 [ "Iniciales" => "JL" "apellidos" => "Heredia" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "affa" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Servicio de Neumología, Hospital Mútua de Terrassa, Terrassa, Barcelona, Spain." "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "affa" ] 1 => array:3 [ "entidad" => "Servicio de Cuidados Intensivos, Hospital Mútua de Terrassa, Terrassa, Barcelona, Spain." "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "affb" ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Comparación entre el análisis automático y manual de la polisomnografía convencional en el diagnóstico del síndrome de apnea-hipopnea obstructiva del sueño" ] ] "textoCompleto" => "<p class="elsevierStylePara"><span class="elsevierStyleBold">Introduction</span></p><p class="elsevierStylePara">Obstructive sleep apnea-hypopnea syndrome (OSAHS) is a disorder that affects between 1% and 4% of the general population.<span class="elsevierStyleSup">1,2</span> At present polysomnography is considered the test of choice for establishing a diagnosis of OSAHS and evaluating its severity. Traditionally, sleep stages are scored by hand according to previously established criteria.<span class="elsevierStyleSup">3</span> However there is interobserver variability in the analysis of polysomnographic data and furthermore the process consumes a great deal of time and resources. Modern polygraphs incorporate systems that automatically analyze neurological parameters and record respiratory episodes, oxygen desaturation, and respiratory movements. Such automatic systems are not sufficiently validated and lack precision in discriminating sleep stages or detecting respiratory episodes in clinical practice. Given the differences between various kinds of sleep analysis, it was decided to undertake a study comparing hand and automatic scoring of the variables obtained by the 16-channel polygraphic system Somnostar α 4100 (SensorMedics Corporation, Yorba Linda, California, USA).</p><p class="elsevierStylePara"><span class="elsevierStyleBold">Materials and Methods</span></p><p class="elsevierStylePara">The study took place at the Hospital Mútua de Terrassa, a referral hospital in the town of Terrassa, near Barcelona, that serves a population of 200 000 inhabitants. Attached to its Department of Respiratory Medicine, the hospital has a sleep clinic that is equipped to carry out standard polysomnography and respiratory polygraphy.</p><p class="elsevierStylePara">Twenty-eight patients with a diagnosis of suspected OSAHS were referred from the outpatients' clinic of the Department of Respiratory Medicine and studied over a period of 3 months. All patients underwent chest x-ray, forced spirometry, and blood testing, and all completed an Epworth questionnaire. All patients then underwent attended conventional polysomnography (Somnostar α4100) in the hospital's sleep unit. Parameters from the following tests were monitored: 4 electroencephalogram (EEG) channels (EEG; C4-A1, C3-A2, O1-A2, O2-A1), electrooculogram, chin and tibial electromyograms, and electrocardiogram. Oronasal airflow was recorded using a thermistor sensor, thoracic and abdominal movements using piezoelectric sensors, and oxygen saturation in arterial blood using pulse oximetry. The nasal pressure wave was not monitored because the equipment was not available, and this represents a limitation of the study. Apnea was defined as a cessation of oronasal airflow lasting for at least 10 seconds, and hypopnea as a significant reduction of oronasal airflow and/or thoracic-abdominal movements accompanied by arousals and/or oxygen desaturation of 3% or more. Arousal was defined as an increase in the frequency of the EEG lasting for more than 3 seconds subject to certain conditions, following the guidelines of the American Sleep Disorders Association.<span class="elsevierStyleSup">4</span> OSAHS was diagnosed when the apnea-hypopnea index (AHI) obtained by standard polysomnography was greater than 10 per hour. None of the patients had previously initiated continuous positive airway pressure treatment. One member of the research team (BB) carried out manual and automatic readings of the polysomnographic variables in random order. The Somnostar α 4100 traces out its results automatically but these marks were removed before hand scoring and therefore did not influence the manual readings. Hand scoring of the different sleep stages was carried out according to the parameters previously established by Rechtscaffen and Kales.<span class="elsevierStyleSup">3</span> Automatic interpretation of the EEG was carried out by the software of the Somnostar α 4100, which uses spectral analysis. In spectral analysis a mathematical algorithm identifies the amplitude and frequency of the EEG waves and classifies them as delta, theta, alpha, or beta. The same algorithm is applied to the signal given by the electrooculogram. Respiratory episodes were analyzed and recorded automatically by the Somnostar α 4100, whose system establishes a baseline by taking the mean number of breaths in the 2 minutes preceding the event. It defines apnea as a reduction in oronasal airflow of greater than 80% from baseline, and hypopnea as a decrease in oronasal airflow of at least 50% from baseline associated with 4% oxygen desaturation. The results are expressed as means with SD between parentheses. The intraclass correlation coefficient was used to establish agreement between the 2 types of analysis. To obtain a graphic representation of the difference between the 2 types of analysis, we used the Bland and Altman<span class="elsevierStyleSup">5</span> method for assessing agreement between 2 methods of clinical measurement expected to yield the same results. The sensitivity, specificity, and positive and negative predictive values of the respiratory parameters were calculated on the basis of the manual analysis using as reference an AHI of 10 obtained by standard polysomnography. A value of <span class="elsevierStyleItalic">P<</I>.05 was considered to be statistically significant.</span></p><p class="elsevierStylePara"><span class="elsevierStyleBold"> Results</span></p><p class="elsevierStylePara">Twenty eight patients (21 men, 7 women) with a mean age of 50 took part in the study. The anthropometric and lung function characteristics in Table 1 show that they were moderately obese patients with excessive daytime sleepiness. The final diagnosis established by manual analysis was OSAHS in 20 cases. Eight patients did not have OSAHS. There was moderate agreement between automatic and manual analysis on sleep parameters and on most respiratory parameters (Table 2). Automatic analysis tended to underestimate the duration of the stages of REM sleep (<span class="elsevierStyleItalic">P</span><.007) and deep sleep (<span class="elsevierStyleItalic">P</span><.3) but there was moderate agreement for light sleep (stages 1 and 2). Agreement between the 2 kinds of analysis on respiratory parameters was high, both for the final AHI (<span class="elsevierStyleItalic">P</span><.0001) and for the apneas (<span class="elsevierStyleItalic">P</span><.0001). However, agreement was low for hypopneas, which were underestimated by automatic analysis. The graphic representation showed substantial differences between the 2 methods in recording sleep stages, due fundamentally to lack of precision in the automatic analysis (Figures 1 and 2). Comparison of respiratory episodes showed few differences with regard to the AHI (Figure 3). However there was a definite reduction in agreement as the number of episodes (mostly hypopneas) increased.</p><p class="elsevierStylePara"><img src="260v39n12-13055459tab01.gif"></img></p><p class="elsevierStylePara"><img src="260v39n12-13055459tab02.gif"></img></p><p class="elsevierStylePara"><img src="260v39n12-13055459tab03.gif"></img></p><p class="elsevierStylePara">Figure 1. Comparison of the standardized difference between manual (m) and automatic (a) analyses for stage 1 with the standardized mean for stage 1. The horizontal lines represent the upper and lower limits of agreement (95% confidence interval).</p><p class="elsevierStylePara"><img src="260v39n12-13055459tab04.gif"></img></p><p class="elsevierStylePara">Figure 2. Comparison of the standardized difference between manual (m) and automatic (a) analyses for stage 3 with the standardized mean for stage 3. The horizontal lines represent the upper and lower limits of agreement (95% confidence interval).</p><p class="elsevierStylePara"><img src="260v39n12-13055459tab05.gif"></img></p><p class="elsevierStylePara">Figure 3. Comparison of the standardized difference between the apnea-hypopnea index (AHI) in manual (m) and automatic (a) analyses with the standardized mean. The horizontal lines represent the upper and lower limits of agreement (95% confidence interval).</p><p class="elsevierStylePara">When the data was stratified by AHI for analysis, manual analysis provided few new diagnoses among patients with an AHI over 30. However, for patients with an AHI between 15 and 30, manual analysis gave 7 more positive diagnoses, 25% of the 28 cases studied (Figure 4).</p><p class="elsevierStylePara"><img src="260v39n12-13055459tab06.gif"></img></p><p class="elsevierStylePara"> Figure 4. Stratification of respiratory episodes by automatic and manual analyses. AHI indicates apnea-hypopnea index.</p><p class="elsevierStylePara">If we take manual analysis as the gold standard, automatic analysis at an AHI cut point greater than 10 had a sensitivity of 55%, a specificity of 100%, a positive predictive value of 100%, a negative predictive value of 47%, and an overall diagnostic yield of 67.8%.</p><p class="elsevierStylePara"><span class="elsevierStyleBold"> Discussion</span></p><p class="elsevierStylePara">This study confirms that the automatic analysis of respiratory and neurological variables carried out by the Somnostar α 4100 is less sensitive than manual analysis. Agreement between the 2 types of analysis is good for the AHI but poor for sleep stages, especially deep sleep and REM.</p><p class="elsevierStylePara">Automatic methods of analysis of respiratory variables can be useful as they provide information about additional variables such as the duration of respiratory episodes, mean and minimum saturation, and the percentage of recording time with oxygen saturation less than 90%. They also measure snoring and body position. Compared with manual analysis, automatic methods tend to underestimate AHI, mostly because they fail to recognize hypopneas.<span class="elsevierStyleSup">6</span> The sensitivity and specificity of automatic analysis varies according to what is being measured. In this study automatic analysis underestimated AHI, especially if the number of respiratory episodes was low (less than 30) and hypopneas predominated. In addition, when the AHI was greater than 10, sensitivity and negative predictive values were 55% and 47%, respectively. This is probably tied to the failure to detect hypopneas, the reason why a manual analysis of respiratory variables is necessary. Similar results were published in a study by Zucconi et al,<span class="elsevierStyleSup">7</span> in which automatic and/or semi-automatic analysis of respiratory variables had high sensitivity and specificity for high AHI cut points but not for low ones. However, some authors have found good correlation for AHI calculated by the 2 kinds of analysis.<span class="elsevierStyleSup">8</span> Correlation has largely depended on the type of automatic system used. Authors who have evaluated systems of analysis that are less complex than conventional polysomnography have found that assisted manual analysis in such simplified systems does not have a higher diagnostic yield than automatic analysis.<span class="elsevierStyleSup">9</span> Other authors have seen that manual analysis is better than automatic scoring.<span class="elsevierStyleSup">10,11</span></p><p class="elsevierStylePara">Automatic systems of sleep analysis have improved over the past few years. However they underestimate total and stage 2 sleep time, mostly due to difficulty identifying the K-waves and spindles. They also overestimate stage 1, but stage 3 and REM readings are little affected.<span class="elsevierStyleSup">12</span> In this study agreement between the 2 types of analysis was moderate for the stages of light sleep and low for the deep sleep and REM stages.</p><p class="elsevierStylePara">There are various ways of analyzing EEGs using a spectral frequency index.<span class="elsevierStyleSup">13</span> The main advantage of spectral analysis over visual analysis is that the stages of deep sleep are assessed continuously and more objectively.</p><p class="elsevierStylePara">Certain computerized methods detect sleep spindles automatically by quantifying the frequency and amplitude of EEG waves.<span class="elsevierStyleSup">14</span> With this type of analysis there is also a reduction in the number of artifacts. It is therefore a very flexible method.</p><p class="elsevierStylePara">Philip-Joet et al<span class="elsevierStyleSup">15</span> achieved 81% total agreement, 11% partial agreement, and 8% disagreement between spectral analysis of EEGs and manual analysis. With spectral analysis the reliability of the EEG reading can be estimated rapidly. However in this study we found low agreement between the 2 types of analysis for sleep stages, especially deep sleep and REM. Probably the program for automatic analysis did not correctly identify spindles and K-waves. Nor did the program correctly identify the REM stage, which is sometimes confused with stage 1 because eye movements are interpreted incorrectly.</p><p class="elsevierStylePara">Several factors can modify the characteristics and interpretation of the EEG. First, the so-called "first night effect" causes an increase in the amount of time spent awake, a decrease in total sleep time, a reduction in sleep efficiency, and a reduction in REM stage sleep.<span class="elsevierStyleSup">16</span> Second, interobserver variability, with a level of agreement between different technicians of between 82% and 88%, also affects interpretation.<span class="elsevierStyleSup">17,18</span> Interobserver variability was not taken into account in the present study because the same researcher recorded all the readings. Third, intraobserver variability may slightly affect the manual readings of polysomnographic results and the fact that we did not assess it represents a limitation of our study.</p><p class="elsevierStylePara">At present, systems of automatic analysis used by polygraphic screening devices have limited sensitivity and specificity as they provide inadequate readings of some respiratory episodes (hypopneas) and of sleep stages.<span class="elsevierStyleSup">6</span> However, as automatic analysis can simplify sleep assessment, automatic polygraphy during sleep followed by manual analysis is now recommended.<span class="elsevierStyleSup">19</span></p><p class="elsevierStylePara">In conclusion, conventional manual polysomnography is the most sensitive and specific method for correctly stratifying sleep stages and recording respiratory episodes. It is important to assess new automatic systems for use in day-to-day clinical practice and in this way increase available resources.</p><p class="elsevierStylePara"><span class="elsevierStyleBold"> Acknowledgments</span></p><p class="elsevierStylePara">The authors would like to thank Dr. F. Barbé, from the Hospital Universitari Son Dureta for his help in writing this article.</p><p class="elsevierStylePara"></p><hr></hr><p class="elsevierStylePara">Correspondence: Dr. B. Barreiro López.<br></br> Servicio de Neumología. Hospital Mútua de Terrassa.<br></br> Pza. Dr. Robert, 5. 08221 Terrassa. Barcelona, España.<br></br> E-mail: <a href="pneumologia@mutuaterrassa.es" class="elsevierStyleCrossRefs"> pneumologia@mutuaterrassa.es</a></p><p class="elsevierStylePara">Manuscript received March 5, 2003. Accepted for publication July 1, 2003.</p>" "pdfFichero" => "260v39n12a13055459pdf001.pdf" "tienePdf" => true "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec191239" "palabras" => array:3 [ 0 => "Obstructive sleep apnea-hypopnea syndrome" 1 => "Polysomnography" 2 => "Diagnosis" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec191240" "palabras" => array:3 [ 0 => "Síndrome de apnea-hipopnea obstructiva del sueño" 1 => "Polisomnografía" 2 => "Diagnóstico" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:1 [ "resumen" => "Objective: To compare automatic and manual analysis of neurological and respiratory variables obtained with the SomnoStar α 4100, a 16-channel polysomnographic system. Patients and method: Twenty-eight patients suspected of obstructive sleep apnea-hypopnea syndrome were enrolled and given conventional polysomnographic tests. The order of automatic and manual reading of respiratory episodes, sleep stages, and arousals was randomized. We assessed agreement with the intraclass correlation coefficient and plotted standardized differences against standardized means, using the Bland-Altman method. Results: Poor agreement was observed between the 2 types of analysis of sleep stages, especially for REM and deep sleep stages. Agreement was good for apneic episodes among the respiratory variables; however, automatic analysis underestimated hypopneas. If manual analysis is considered the gold standard at the apnea-hypopnea index cut point greater than 10, automatic analysis obtained a sensitivity of 55%, a specificity and positive predictive value of 100%, a negative predictive value of 47%, and an overall diagnostic yield of 67.8%. Conclusions: The automatic analysis of the SomnoStar 4100 system provides an unsatisfactory reading of sleep stages and respiratory episodes, especially hypopneas." ] "es" => array:1 [ "resumen" => "Objetivo: Comparar el análisis automático y manual de las variables neurológicas y respiratorias obtenidas por el polisomnógrafo de 16 canales Somnostar α 4100. Pacientes y método: Se incluyó en el estudio a 28 pacientes con sospecha de síndrome de apnea-hipopnea obstructiva del sueño a los cuales se les practicó una polisomnografía convencional. Se decidió de forma aleatoria el orden de las lecturas automática y manual de los episodios respiratorios, fases de sueño y arousals. Se realizó un análisis de concordancia (coeficiente de correlación intraclase), así como una representación gráfica de las diferencias utilizando el método de Bland y Altman. Resultados: Se observó una mala concordancia entre los dos tipos de análisis respecto a las fases de sueño, sobre todo REM y las fases de sueño profundo. Respecto a los parámetros respiratorios la concordancia fue buena para las apneas. Sin embargo, el análisis automático infraestimó las hipopneas. Si se considera el análisis manual como patrón de referencia para un punto de corte de índice de apneas-hipopneas mayor de 10, el análisis automático obtuvo una sensibilidad del 55%, una especificidad y un valor predictivo positivo del 100%, un valor predictivo negativo del 47% y una eficacia diagnóstica global del 67,8%. Conclusiones: El análisis automático del sistema Somnostar 4100 proporciona una lectura inadecuada de las fases de sueño así como de los episodios respiratorios, fundamentalmente de las hipopneas." ] ] "multimedia" => array:12 [ 0 => array:8 [ "identificador" => "tbl1" "etiqueta" => "TABLE 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:1 [ "tablaImagen" => array:1 [ 0 => array:4 [ "imagenFichero" => "260v39n12-13055459tab01.gif" "imagenAlto" => 234 "imagenAncho" => 384 "imagenTamanyo" => 10841 ] ] ] ] ] "descripcion" => array:1 [ "en" => "Anthropometric and Spirometric Characteristics of the 28 Patients With Suspected Obstructive Sleep Apnea-Hypopnea Syndrome*" ] ] 1 => array:8 [ "identificador" => "tbl2" "etiqueta" => "TABLE 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:1 [ "tablaImagen" => array:1 [ 0 => array:4 [ "imagenFichero" => "260v39n12-13055459tab02.gif" "imagenAlto" => 221 "imagenAncho" => 383 "imagenTamanyo" => 10778 ] ] ] ] ] "descripcion" => array:1 [ "en" => "Agreement Between Manual and Automatic Analyses of Polysomnographic Data*" ] ] 2 => array:8 [ "identificador" => "tbl3" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:1 [ "tablaImagen" => array:1 [ 0 => array:4 [ "imagenFichero" => "260v39n12-13055459tab03.gif" "imagenAlto" => 299 "imagenAncho" => 384 "imagenTamanyo" => 5214 ] ] ] ] ] "descripcion" => array:1 [ "en" => "Comparison of the standardized difference between manual (m) and automatic (a) analyses for stage 1 with the standardized mean for stage 1. The horizontal lines represent the upper and lower limits of agreement (95% confidence interval)." ] ] 3 => array:8 [ "identificador" => "tbl4" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:1 [ "tablaImagen" => array:1 [ 0 => array:4 [ "imagenFichero" => "260v39n12-13055459tab04.gif" "imagenAlto" => 297 "imagenAncho" => 381 "imagenTamanyo" => 5036 ] ] ] ] ] "descripcion" => array:1 [ "en" => "Comparison of the standardized difference between manual (m) and automatic (a) analyses for stage 3 with the standardized mean for stage 3. The horizontal lines represent the upper and lower limits of agreement (95% confidence interval)." ] ] 4 => array:8 [ "identificador" => "tbl5" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:1 [ "tablaImagen" => array:1 [ 0 => array:4 [ "imagenFichero" => "260v39n12-13055459tab05.gif" "imagenAlto" => 300 "imagenAncho" => 381 "imagenTamanyo" => 5470 ] ] ] ] ] "descripcion" => array:1 [ "en" => "Comparison of the standardized difference between the apnea-hypopnea index (AHI) in manual (m) and automatic (a) analyses with the standardized mean. 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"idioma" => "en" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "Young T" 1 => "Palta M" 2 => "Dempsey J" 3 => "Skatrud J" 4 => "Weber S" 5 => "Badr S." ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "N Engl J Med" "fecha" => "1993" "volumen" => "318" "paginaInicial" => "1230" "paginaFinal" => "5" ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib2" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:3 [ "titulo" => "Obstructive sleep apnea-hypopnea and related clinical features in a population-based sample of subjects aged 30 to 70 years." "idioma" => "en" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "Durán J" 1 => "Esnaola S" 2 => "Ramón R" 3 => "Iztueta A." ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1164/ajrccm.163.3.2005065" "Revista" => array:6 [ "tituloSerie" => "Am J Respir Crit Care Med" "fecha" => "2001" "volumen" => "163" "paginaInicial" => "685" "paginaFinal" => "9" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/11254524" "web" => "Medline" ] ] ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib3" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "referenciaCompleta" => "A manual of standardized terminology techniques and scoring system for sleep stages of human subjects. Washington DC: Public Health Service, US Government Printing Office, 1963." "contribucion" => array:1 [ 0 => array:3 [ "titulo" => "A manual of standardized terminology techniques and scoring system for sleep stages of human subjects. Washington DC: Public Health Service, US Government Printing Office, 1963." "idioma" => "en" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "Rechtscaffen A" 1 => "Kales A." ] ] ] ] ] ] ] ] 3 => array:3 [ "identificador" => "bib4" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:3 [ "titulo" => "EEG arousals: scoring rules and examples. A preliminary report from the Sleep Disorders Association." "idioma" => "en" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "American Sleep Disorders Association." ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Sleep" "fecha" => "1992" "volumen" => "15" "paginaInicial" => "17" "paginaFinal" => "184" ] ] ] ] ] ] 4 => array:3 [ "identificador" => "bib5" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:3 [ "titulo" => "Statistical method for assessing agreement between two methods of clinical measurement." "idioma" => "en" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "Bland JM" 1 => "Altman DG." ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Lancet" "fecha" => "1986" "volumen" => "1" "paginaInicial" => "307" "paginaFinal" => "10" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/2563462" "web" => "Medline" ] ] ] ] ] ] ] ] 5 => array:3 [ "identificador" => "bib6" "etiqueta" => "6" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:3 [ "titulo" => "Visual and different automatic scoring profiles of respiratory variables in the diagnosis of sleep apnea-hypopnea syndrome." "idioma" => "en" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:7 [ 0 => "Carrasco O" 1 => "Monserrat JM" 2 => "Lloberes P" 3 => "Ascaso C" 4 => "Ballester E" 5 => "Fornes C" 6 => "et al." ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Eur Respir J" "fecha" => "1996" "volumen" => "9" "paginaInicial" => "125" "paginaFinal" => "30" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/8834345" "web" => "Medline" ] ] ] ] ] ] ] ] 6 => array:3 [ "identificador" => "bib7" "etiqueta" => "7" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:3 [ "titulo" => "An unattended device for sleep-related breathing disorders: validation study in suspected obstructive sleep apnea syndrome." "idioma" => "en" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "Zucconi M" 1 => "Ferini-Stambi L" 2 => "Castronovo V" 3 => "Oldani A" 4 => "Smirne S." ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Eur Respir J" "fecha" => "1996" "volumen" => "9" "paginaInicial" => "1251" "paginaFinal" => "6" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/8804946" "web" => "Medline" ] ] ] ] ] ] ] ] 7 => array:3 [ "identificador" => "bib8" "etiqueta" => "8" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:3 [ "titulo" => "Validating a 7-channel ambulatory polygraphy unit: operating instructions for the physician and patient." "idioma" => "en" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "Verse T" 1 => "Pirsing W" 2 => "Kroker B" 3 => "Junge-Hulsing B" 4 => "Zimmerman E." ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "HNO" "fecha" => "1999" "volumen" => "47" "paginaInicial" => "249" "paginaFinal" => "55" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/10407729" "web" => "Medline" ] ] ] ] ] ] ] ] 8 => array:3 [ "identificador" => "bib9" "etiqueta" => "9" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:3 [ "titulo" => "Validación de un polígrafo respiratorio de 3 canales (Edentec) para el diagnóstico del síndrome de apnea del sueño." "idioma" => "es" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "Jiménez Gómez A" 1 => "Golpe Gómez R" 2 => "Carpizo Alfayete R" 3 => "De la Roza Fernández C" 4 => "Fernández Rozas S" 5 => "García Pérez MM." ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Arch Bronconeumol" "fecha" => "2000" "volumen" => "36" "paginaInicial" => "7" "paginaFinal" => "12" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/10726178" "web" => "Medline" ] ] ] ] ] ] ] ] 9 => array:3 [ "identificador" => "bib10" "etiqueta" => "10" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:3 [ "titulo" => "Diagnostic accuracy of a portable recording device (MESAM IV) in suspected obstructive sleep apnea." "idioma" => "en" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "Esnaola S" 1 => "Durán J" 2 => "Infante-Rivard C" 3 => "Rubio R" 4 => "Fernández A." ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Eur Respir J" "fecha" => "1996" "volumen" => "9" "paginaInicial" => "2597" "paginaFinal" => "605" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/8980975" "web" => "Medline" ] ] ] ] ] ] ] ] 10 => array:3 [ "identificador" => "bib11" "etiqueta" => "11" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:3 [ "titulo" => "Hand-scoring of MESAM 4 recordings is more accurate than automatic analysis in screening for obstructive sleep apnea." "idioma" => "en" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "Koziej M" 1 => "Cieslicki JK" 2 => "Gorzelak K" 3 => "Sliwinski P" 4 => "Zielinski J." ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:7 [ "tituloSerie" => "Eur Respir J" "fecha" => "1994" "volumen" => "7" "paginaInicial" => "1771" "paginaFinal" => "5" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/7828683" "web" => "Medline" ] ] "itemHostRev" => array:3 [ "pii" => "S0140673603136409" "estado" => "S300" "issn" => "01406736" ] ] ] ] ] ] ] 11 => array:3 [ "identificador" => "bib12" "etiqueta" => "12" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:3 [ "titulo" => "Automatic Oxford-Medilog 9200 sleep stating scoring: comparison with visual analysis." "idioma" => "en" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "Sforza E" 1 => "Vandi S." ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "J Clin Neurophysiol" "fecha" => "1996" "volumen" => "13" "paginaInicial" => "227" "paginaFinal" => "33" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/8714343" "web" => "Medline" ] ] ] ] ] ] ] ] 12 => array:3 [ "identificador" => "bib13" "etiqueta" => "13" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:3 [ "titulo" => "Description of healthy and disturbed sleep by means of the spectral frequency index (SFX). A retrospective analysis." "idioma" => "en" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "Hammer N" 1 => "Todorova A" 2 => "Hofman HC" 3 => "Schober F" 4 => "Vonderheid-Guth B" 5 => "Dimpfel W." ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Eur J Med Ress" "fecha" => "2001" "volumen" => "6" "paginaInicial" => "333" "paginaFinal" => "44" ] ] ] ] ] ] 13 => array:3 [ "identificador" => "bib14" "etiqueta" => "14" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:3 [ "titulo" => "Automatic sleep spindle detection procedure: aspects of reliability and validity." "idioma" => "en" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "Schinicek P" 1 => "Zeitlhofer J" 2 => "Anderer P" 3 => "Saletu B." ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Clin Electroencephalogr" "fecha" => "1994" "volumen" => "25" "paginaInicial" => "26" "paginaFinal" => "9" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/8174288" "web" => "Medline" ] ] ] ] ] ] ] ] 14 => array:3 [ "identificador" => "bib15" "etiqueta" => "15" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:3 [ "titulo" => "Semi-automatic analysis of electroencephalogram in sleep apnea syndromes." "idioma" => "en" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "Philip-Joet FF" 1 => "Rey MF" 2 => "Dicroco AA" 3 => "Reynaud-Gaubert MJ" 4 => "Arnaud AG." ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Chest" "fecha" => "1993" "volumen" => "104" "paginaInicial" => "336" "paginaFinal" => "9" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/8339615" "web" => "Medline" ] ] ] ] ] ] ] ] 15 => array:3 [ "identificador" => "bib16" "etiqueta" => "16" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:3 [ "titulo" => "Changes in EEG power density during sleep laboratory adaptation." "idioma" => "en" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:7 [ 0 => "Toussaint M" 1 => "Luthringer R" 2 => "Schaltenbrand N" 3 => "Nicolas A" 4 => "Jacqmin A" 5 => "Carelli G" 6 => "et al." ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Sleep" "fecha" => "1997" "volumen" => "20" "paginaInicial" => "1201" "paginaFinal" => "7" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/9493933" "web" => "Medline" ] ] ] ] ] ] ] ] 16 => array:3 [ "identificador" => "bib17" "etiqueta" => "17" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:3 [ "titulo" => "Sleep stage scoring using the neural network model: comparison between visual and automatic analysis in normal subjects and patients." "idioma" => "en" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:7 [ 0 => "Scaltenbrand N" 1 => "Lengelle R" 2 => "Toussaint M" 3 => "Luthringer R" 4 => "Carelli G" 5 => "Jacqmin A" 6 => "et al." ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Sleep" "fecha" => "1996" "volumen" => "19" "paginaInicial" => "26" "paginaFinal" => "35" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/8650459" "web" => "Medline" ] ] ] ] ] ] ] ] 17 => array:3 [ "identificador" => "bib18" "etiqueta" => "18" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:3 [ "titulo" => "Two methods of scoring sleep with the Oxford Medilog 9000: comparison to conventional paper scoring." "idioma" => "en" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "Hoelscher TJ" 1 => "McCall WV" 2 => "Powell J" 3 => "Marsh GR" 4 => "Erwin CW." ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Sleep" "fecha" => "1989" "volumen" => "12" "paginaInicial" => "133" "paginaFinal" => "9" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/2711088" "web" => "Medline" ] ] ] ] ] ] ] ] 18 => array:3 [ "identificador" => "bib19" "etiqueta" => "19" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:3 [ "titulo" => "A method for the automatic detection of arousals during sleep." "idioma" => "en" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "De Carli F" 1 => "Nobili L" 2 => "Gelcich P" 3 => "Ferrillo F." ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Sleep" "fecha" => "1999" "volumen" => "22" "paginaInicial" => "561" "paginaFinal" => "72" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/10450591" "web" => "Medline" ] ] ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/15792129/0000003900000012/v0_201307090853/13055459/v0_201307090853/en/main.assets" "Apartado" => array:4 [ "identificador" => "14570" "tipo" => "SECCION" "es" => array:2 [ "titulo" => "Original papers" "idiomaDefecto" => true ] "idiomaDefecto" => "es" ] "PDF" => "https://static.elsevier.es/multimedia/15792129/0000003900000012/v0_201307090853/13055459/v0_201307090853/en/260v39n12a13055459pdf001.pdf?idApp=UINPBA00003Z&text.app=https://archbronconeumol.org/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/13055459?idApp=UINPBA00003Z" ]
Article information
ISSN: 15792129Original language: English
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| 2014 January | 35 | 9 | 44 |
| 2013 December | 34 | 8 | 42 |
| 2013 November | 44 | 7 | 51 |
| 2013 October | 43 | 10 | 53 |
| 2013 September | 52 | 12 | 64 |
| 2013 August | 48 | 14 | 62 |
| 2013 July | 58 | 17 | 75 |
| 2013 June | 50 | 11 | 61 |
| 2013 May | 47 | 10 | 57 |
| 2013 April | 38 | 8 | 46 |
| 2013 March | 13 | 3 | 16 |
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