Sleep and Breathing

, Volume 22, Issue 4, pp 1179–1188 | Cite as

Addition of frontal EEG to adult home sleep apnea testing: does a more accurate determination of sleep time make a difference?

  • Matthew P. LightEmail author
  • Thalia N. Casimire
  • Catherine Chua
  • Viachaslau Koushyk
  • Omar E. Burschtin
  • Indu Ayappa
  • David M. Rapoport
Sleep Breathing Physiology and Disorders • Original Article



Home sleep apnea testing (HSAT) typically does not include electroencephalogram (EEG) monitoring for sleep assessment. In patients with insomnia and low sleep efficiency, overestimation of the sleep period can result from absence of EEG, which will reduce sleep disordered breathing (SDB) indices and may lead to a false-negative result.


To validate a single channel frontal EEG for scoring sleep versus wake against full EEG during polysomnography, and then to examine the utility of adding this single channel EEG to standard HSAT to prevent false-negative results.


Epoch-by-epoch validation for sleep scoring of single channel EEG versus full PSG was first performed in 21 subjects. This was followed by a separate retrospective analysis of 207 consecutive HSATs in adults performed in a university-affiliated sleep center using the Somte (Compumedics) HSAT with one frontal EEG as well as chin EMG, nasal airflow, oxyhemoglobin saturation, respiratory effort, pulse rate, and body position. Each study was scored twice, with (HSATEEG) and without the EEG signal visible (HSATPolygraphy), to calculate AHI4 and RDI and the effect on OSA diagnosis and severity. Analyses were repeated in 69 patients with poor sleep suggesting insomnia plus Epworth Sleepiness Scale < 7 as well as in 38 patients ultimately shown to have sleep efficiency < 70% on HSAT with EEG.

Measurements and main results

Single channel and full EEG during polysomnography agreed on sleep versus wake in 92–95% of all epochs. HSAT without EEG overestimated the sleep period by 20% (VST = 440 ± 76 min vs TST = 356 ± 82 min), had a false-negative rate of 8% by AHI4 criteria, and underestimated disease severity in 11% of all patients. Sub-group analysis of patients with subjective poor sleep suggesting insomnia did not change the results. Patients later shown to have low sleep efficiency had lower SDB indices and a 20.8% false negative rate of sleep apnea diagnosis.


Although overall false negative rates using HSATPolygraphy were moderate, suggesting utility for ruling out OSA, there was a specific subgroup in whom there were significant missed diagnoses. However, we were unable to identify this subgroup a priori.


Obstructive sleep apnea Home sleep apnea testing Electroencephalogram OSA diagnosis Portable monitoring 



Apnea-Hypopnea Index based on hypopneas with 4% oxygen desaturation


American Academy of Sleep Medicine




Epworth Sleepiness Scale


Home sleep apnea testing


Obstructive sleep apnea




Respiratory Disturbance Index based on hypopneas with either 4% desaturation or arousal/arousal surrogate


Sleep disordered breathing


Total sleep time


Valid signal time



This research was funded in part by grants from the NIH K24HL109156 (Principal Investigator: Ayappa, Indu), and the Foundation for Research in Sleep Disorders.

Compliance with ethical standards

Conflict of interest

All authors certify that they have no affiliations with or involvement in any organization or entity with any financial interest (such as honoraria; educational grants; participation in speakers’ bureaus; membership, employment, consultancies, stock ownership, or other equity interest; and expert testimony or patent-licensing arrangements), or non-financial interest (such as personal or professional relationships, affiliations, knowledge, or beliefs) in the subject matter or materials discussed in this manuscript.

Ethical approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

Informed consent

For this type of study formal consent is not required.

Supplementary material

11325_2018_1735_MOESM1_ESM.docx (12 kb)
Supplement Table 1 Results of sleep scoring by full in-laboratory polysomnography with Fz moved to the forehead (PSG) vs scoring from a limited montage consisting of forehead EEG and chin EMG only (two independent scorers LM1 and LM2). Lines 1–3 in the table show the agreement between Full PSG and limited montage sleep scoring. While standard sleep scoring requires only the EEG, HSAT studies are usually scored with all channels visible. Because of this we also investigated the impact of visualizing flow and oximetry while scoring sleep on the HSAT. These results are shown in lines 4–6. The data show that there was little influence of visualizing airflow and oximetry on the agreement with PSG. (Fz) scoring by scorer 1. LM2: Limited montage (Fz) scoring by scorer 2. PSG: Scoring from Full PSG (DOCX 12 kb)
11325_2018_1735_MOESM2_ESM.docx (15 kb)
Supplement Table 2 Cross-tabulations of sleep scoring showing (a) limited montage inter-scorer agreement, (b) limited montage (scorer 1) vs PSG, and (c) limited montage (scorer 2) vs PSG. (DOCX 15 kb)
11325_2018_1735_MOESM3_ESM.docx (14 kb)
Supplement Table 3 Summary of events, sleep times, and respiratory event indices with and without EEG available to the scorer for (a) subjects with complaints of difficulty falling or staying asleep and ESS < 7, and (b) subjects with TST ≤ 70% of VST (low sleep efficiency). Delta = HSATEEG − HSATPolygraphy. (DOCX 13 kb)
11325_2018_1735_MOESM4_ESM.docx (14 kb)
Supplement Table 4 Cross-tabulations of OSA severity defined by AHI4 scoring with and without EEG for (a) subjects with complaints of Poor Sleep and low Epworth Score, and (b) subjects with low sleep efficiency. (DOCX 14 kb)


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Copyright information

© Springer Nature Switzerland AG 2018

Authors and Affiliations

  • Matthew P. Light
    • 1
    • 2
    Email author
  • Thalia N. Casimire
    • 1
  • Catherine Chua
    • 1
    • 3
  • Viachaslau Koushyk
    • 1
  • Omar E. Burschtin
    • 1
    • 3
  • Indu Ayappa
    • 1
    • 3
  • David M. Rapoport
    • 1
    • 3
  1. 1.Division of Pulmonary, Critical Care, and Sleep MedicineNew York University School of MedicineNew YorkUSA
  2. 2.Division of Pulmonary, Critical Care & Sleep MedicineUniversity of California, San DiegoLa JollaUSA
  3. 3.Division of Pulmonary, Critical Care and Sleep MedicineIcahn School of Medicine at Mount SinaiNew YorkUSA

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