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Evaluation of Candidate Measures for Home-Based Screening of Sleep Disordered Breathing in Taiwanese Bus Drivers

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      Background: Sleepiness-at-the-wheel has been identified as a major cause of highway accidents. The aim of our study is identifying the candidate measures for home-based screening of sleep disordered breathing in Taiwanese bus drivers, instead of polysomnography. Methods: Overnight polysomnography accompanied with simultaneous measurements of alternative screening devices (pulse oximetry, ApneaLink, and Actigraphy), heart rate variability, wake-up systolic blood pressure and questionnaires were completed by 151 eligible participants who were long-haul bus drivers with a duty period of more than 12 h a day and duty shifting. Results: 63.6% of professional bus drivers were diagnosed as having sleep disordered breathing and had a higher body mass index, neck circumference, systolic blood pressure, arousal index and desaturation index than those professional bus drivers without evidence of sleep disordered breathing. Simple home-based candidate measures: (1) Pulse oximetry, oxygen-desaturation indices by ≥3% and 4% (r = 0.87∼0.92); (2) Pulse oximetry, pulse-rising indices by ≥7% and 8% from a baseline (r = 0.61∼0.89); and (3) ApneaLink airflow detection, apnea-hypopnea indices (r = 0.70∼0.70), based on recording-time or Actigraphy-corrected total sleep time were all significantly correlated with, and had high agreement with, corresponding polysomnographic apnea-hypopnea indices [(1) 94.5%∼96.6%, (2) 93.8%∼97.2%, (3) 91.1%∼91.3%, respectively]. Conversely, no validities of SDB screening were found in the multi-variables apnea prediction questionnaire, Epworth Sleepiness Scale, night-sleep heart rate variability, wake-up systolic blood pressure and anthropometric variables. Conclusions: The indices of pulse oximetry and apnea flow detection are eligible criteria for home-based screening of sleep disordered breathing, specifically for professional drivers.

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      Most cited references 41

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      A new method for measuring daytime sleepiness: the Epworth sleepiness scale.

       W. Johns (1991)
      The development and use of a new scale, the Epworth sleepiness scale (ESS), is described. This is a simple, self-administered questionnaire which is shown to provide a measurement of the subject's general level of daytime sleepiness. One hundred and eighty adults answered the ESS, including 30 normal men and women as controls and 150 patients with a range of sleep disorders. They rated the chances that they would doze off or fall asleep when in eight different situations commonly encountered in daily life. Total ESS scores significantly distinguished normal subjects from patients in various diagnostic groups including obstructive sleep apnea syndrome, narcolepsy and idiopathic hypersomnia. ESS scores were significantly correlated with sleep latency measured during the multiple sleep latency test and during overnight polysomnography. In patients with obstructive sleep apnea syndrome ESS scores were significantly correlated with the respiratory disturbance index and the minimum SaO2 recorded overnight. ESS scores of patients who simply snored did not differ from controls.
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        The role of actigraphy in the study of sleep and circadian rhythms.

        In summary, although actigraphy is not as accurate as PSG for determining some sleep measurements, studies are in general agreement that actigraphy, with its ability to record continuously for long time periods, is more reliable than sleep logs which rely on the patients' recall of how many times they woke up or how long they slept during the night and is more reliable than observations which only capture short time periods. Actigraphy can provide information obtainable in no other practical way. It can also have a role in the medical care of patients with sleep disorders. However, it should not be held to the same expectations as polysomnography. Actigraphy is one-dimensional, whereas polysomnography comprises at least 3 distinct types of data (EEG, EOG, EMG), which jointly determine whether a person is asleep or awake. It is therefore doubtful whether actigraphic data will ever be informationally equivalent to the PSG, although progress on hardware and data processing software is continuously being made. Although the 1995 practice parameters paper determined that actigraphy was not appropriate for the diagnosis of sleep disorders, more recent studies suggest that for some disorders, actigraphy may be more practical than PSG. While actigraphy is still not appropriate for the diagnosis of sleep disordered breathing or of periodic limb movements in sleep, it is highly appropriate for examining the sleep variability (i.e., night-to-night variability) in patients with insomnia. Actigraphy is also appropriate for the assessment of and stability of treatment effects of anything from hypnotic drugs to light treatment to CPAP, particularly if assessments are done before and after the start of treatment. A recent independent review of the actigraphy literature by Sadeh and Acebo reached many of these same conclusions. Some of the research studies failed to find relationships between sleep measures and health-related symptoms. The interpretation of these data is also not clear-cut. Is it that the actigraph is not reliable enough to the access the relationship between sleep changes and quality of life measures, or, is it that, in fact, there is no relationship between sleep in that population and quality of life measures? Other studies of sleep disordered breathing, where actigraphy was not used and was not an outcome measure also failed to find any relationship with quality of life. Is it then the actigraph that is not reliable or that the associations just do not exist? The one area where actigraphy can be used for clinical diagnosis is in the evaluation of circadian rhythm disorders. Actigraphy has been shown to be very good for identifying rhythms. Results of actigraphic recordings correlate well with measurements of melatonin and of core body temperature rhythms. Activity records also show sleep disturbance when sleep is attempted at an unfavorable phase of the circadian cycle. Actigraphy therefore would be particularly good for aiding in the diagnosis of delayed or advanced sleep phase syndrome, non-24-hour-sleep syndrome and in the evaluation of sleep disturbances in shift workers. It must be remembered, however, that overt rest-activity rhythms are susceptible to various masking effects, so they may not always show the underlying rhythm of the endogenous circadian pacemaker. In conclusion, the latest set of research articles suggest that in the clinical setting, actigraphy is reliable for evaluating sleep patterns in patients with insomnia, for studying the effect of treatments designed to improve sleep, in the diagnosis of circadian rhythm disorders (including shift work), and in evaluating sleep in individuals who are less likely to tolerate PSG, such as infants and demented elderly. While actigraphy has been used in research studies for many years, up to now, methodological issues had not been systematically addressed in clinical research and practice. Those issues have now been addressed and actigraphy may now be reaching the maturity needed for application in the clinical arena.
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          EEG arousals: scoring rules and examples: a preliminary report from the Sleep Disorders Atlas Task Force of the American Sleep Disorders Association.


            Author and article information

            [1] Department of Physical Medicine and Rehabilitation, Chung-Shan Medical University Hospital, Chung-Shan Medical University, Taichung 40201, Taiwan; E-Mail:
            [2] Center of Sleep Medicine, Chung-Shan Medical University Hospital, Chung-Shan Medical University, Taichung 40245, Taiwan; E-Mails: (R.-J.H.); (S.-W.C.); (A.-H.C.)
            [3] Institute of Medicine, Chung Shan Medical University, Taichung 40201, Taiwan
            [4] Department of Medical Image and Radiological Science, Chung-Shan Medical University, Taichung 40201, Taiwan
            [5] Department of Medical Informatics, Chung Shan Medical University, Taichung 40201, Taiwan; E-Mail:
            [6] PhD Program of Mechanical and Aeronautical Engineering, Feng Chia University; Taichung 40724, Taiwan; E-Mail:
            [7] Department of Photonics and Communication Engineering, Asia University, Taichung 41354, Taiwan; E-Mail:
            [8] Institute of Labor Policy and Occupational Safety and Health, Ministry of Labor Affairs, Executive Yuan, Taipei 22143, Taiwan
            [9] Department of Public Health, College of Public Health, China Medical University, Taichung 40402, Taiwan
            [10] School of Rehabilitation Medicine, Shanghai University of TCM, Shanghai 201203, China
            [11] Department of Physical Therapy, Graduate Institute of Rehabilitation Science, China Medical University, Taichung 40202, Taiwan
            [12] Department of Healthcare Administration, Asia University, Taichung 41354, Taiwan
            Author notes

            These authors contributed equally to this work.

            Author Contributions: Study concept and design: Hua Ting, Tung-Sheng Shih and Shin-Da Lee; data acquisition: Shen-Wen Chang, Ai-Hui Chung, and Ren-Jing Huang; analysis and interpretation of data: Ching-Hsiang Lai and Ching-Haur Chang; writing of the manuscript: Hua Ting and Shin-Da Lee; statistical analysis: Ren-Jing Huang and Teng-Yao Kuo; study supervision and funding: Hua Ting, Tung-Sheng Shih, and Shin-Da Lee

            [*]Authors to whom correspondence should be addressed; E-Mails: (T.-S.S.); (S.-D.L.); Tel.: +886-4-2205-3366 (ext. 7300) (S.-D.L.); Fax: +886-4-2206-5051 (S.-D.L.).
            Sensors (Basel)
            Sensors (Basel)
            Sensors (Basel, Switzerland)
            Molecular Diversity Preservation International (MDPI)
            May 2014
            05 May 2014
            : 14
            : 5
            : 8126-8149
            © 2014 by the authors; licensee MDPI, Basel, Switzerland.

            This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution license (

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