Comparison of Esophageal Pressure with Pulse Transit Time as a Measure of Respiratory Effort for Scoring Obstructive Nonapneic Respiratory Events

Obstructive nonapneic respiratory events (ONAREs) are much more difficult to detect and classify than apneas unless sensitive measures of respiratory effort and airflow are employed. The aim of this study was to compare two measures of respiratory effort, esophageal pressure monitoring (Pes) and pulse transit time (PTT), for scoring of ONAREs by visual analysis. Nine men (age 49 +/- 10 yr) with mild to moderate sleep apnea syndrome (AHI of 25.1 +/- 10. 8/h) were studied and 340 ONAREs (hypopneas and upper airway resistance episodes) were randomly selected for scoring by two experienced observers. Each observer blindly scored each ONARE twice (once with Pes and once with PTT) with a concurrent pneumotachography trace available for airflow quantification. This permitted the respiratory events scored with PTT to be compared with those scored with Pes, and in addition interobserver variability could be assessed for each signal. Even though standard criteria were used for scoring, there was significant interobserver variability for both Pes (29.7%) and PTT (37.1%). Taking those events for which there was agreement between the observers, PTT had a sensitivity of 79.9% and a positive predictive value of 91.2% (using Pes as the gold standard). In those ONAREs for which there was agreement between the two observers there was a larger percentage reduction in airflow compared to ONAREs that did not concur (51 versus 30.3%, p < 0.001), a larger increase in respiratory effort as assessed by PTT (slope of PTT: 23.1 versus 14. 3 arbitrary units, p < 0.01), and a higher incidence in autonomic microarousals detected with PTT (90 versus 45% of ONAREs, p < 0.006). Subtle respiratory events are more difficult to detect than apneas or frank hypopneas. When comparing PTT with esophageal pressure in detecting those events the sensitivity of PTT is good but limited when the reduction in airflow, the increase in respiratory effort, or the arousal reaction is the less clear. However, PTT appears to be a good noninvasive alternative to Pes in the detection of nonapneic obstructive respiratory events, and its ability to detect autonomic arousal gives this physiological signal added clinical usefulness.