This article has been accepted for publication in a future issue of this journal, but has not been
fully edited. Content may change prior to final publication. Citation information: DOI 10.1109/JBHI.2018.2842919, IEEE Journal of
Biomedical and Health Informatics
Automatic Detection of Obstructive Sleep Apnea
Using Wavelet Transform and Entropy based
Features from Single-Lead ECG Signal
Asghar Zarei, Babak Mohammadzadeh Asl*, Member, IEEE
Abstract—Obstructive Sleep Apnea (OSA) is a prevalent sleep
disorder, and highly affects the quality of human life. Currently,
gold standard for OSA detection is Polysomnogram. Since this
method is time consuming and cost inefficient, practical systems
focus on the usage of electrocardiogram (ECG) signals for OSA
detection. In this paper, a novel automatic OSA detection method
using a single-lead ECG signal has been proposed. A non-linear
feature extraction using Wavelet Transform (WT) coefficients
obtained by an ECG signal decomposition is employed. In
addition, different classification methods are investigated. ECG
signals are decomposed into 8 levels using a Symlet function as
a mother Wavelet function with third-order. Then, the entropy-
based features including fuzzy/approximate/sample/correct con-
ditional entropy as well as other non-linear features including
interquartile range, mean absolute deviation, variance, Poincare
plot and recurrence plot are extracted from WT coefficients.
The best features are chosen using the automatic sequential
forward feature selection algorithm. In order to assess the
introduced method, 95 single-lead ECG recordings are used.
SVM classifier having a RBF kernel leads to an accuracy
of 94.63% (Sens: 94.43%, Spec: 94.77%) and 95.71% (Sens:
95.83%, Spec: 95.66%) for minute-by-minute and subject-by-
subject classifications, respectively. The results show that apply-
ing entropy-based features for extracting hidden information of
the ECG signals outperforms other available automatic OSA
detection methods. The results indicate that a highly accurate
OSA detection is attained by just exploiting the single-lead ECG
signals. Furthermore, due to the low computational load in the
proposed method, it can easily be applied to the home monitoring
systems.
Index Terms—Obstructive Sleep Apnea, automatic detection,
Wavelet Transform, entropy based features, single-lead ECG
signal.
I. I NTRODUCTION
BSTRUCTIVE Sleep Apnea (OSA) is a prevalent sleep
O disorder (2% of women and 4% of men suffering from)
which can be characterized using repetitive respiratory ces-
sation during sleep [1], [2]. Clinically, there are three types
of Sleep Apnea (SA): OSA, Central SA and Mixed SA [3],
[4]. When there is a significant reduction in the volume of the
air entering into the lungs, it is called Hypopnea (HA) [5].
In OSA, a temporal obstruction happens at the upper airway,
especially throat, and causes throat collapse. During OSA, the
airway is obstructed while there are still respiratory efforts
against the obstruction [6]. OSA causes excessive daytime
drowsiness, neurocognitive deficits, fatigue, depression, and
*Corresponding author
The authors are with the Department of Biomedical Engineering, Tarbiat
Modares University, Tehran, Iran (e-mail: babakmasl@modares.ac.ir).
2168-2194 (c) 2018 IEEE. Personal use is permitted, but republication/redistribution requires IEEE permission. See http://www.ieee.org/publications_standards/publications/rights/index.html for more information.
1
heart stroke [7]–[9]. Also, undiagnosed and untreated OSA
may lead to a high blood pressure, brain stroke, myocardial
infarction, arrhythmias, and ischemia [10]–[12]. Even though
OSA is detectable, the most cases are still not recognized [13].
Polysomnogram (PSG) is the gold standard for OSA detection,
which is based on the comprehensive evaluation of the cardio-
respiratory system and sleep signals [14]. In this method, case
studies should be asleep for a couple of nights in the exclusive
sleep laboratory in order to record the 16 major signals such
as Electrocardiogram (ECG), Electroencephalogram (EEG),
respiratory effort, airflow, and oxygen saturation (SaO2) [15],
[16]. A PSG device needs at least 12 channels to record the
data using 22 wire connectors [17]. The large number of the
necessary wire connectors in a PSG device would interrupt the
sleep, which affects the OSA detection. Moreover, the PSG
test is typically performed in a hospital setting and it requires
the supervision of a clinical expert, factors that make PSG an
uncomfortable and costly procedure [18], [19].
When an OSA takes place, the oxygen saturation level falls
while the cardiovascular and the automatic neural systems try
to maintain this level [20]. Moreover, abnormal activities of
the heart or significant changes in heart rate may indicate an
OSA. Thus, among the developing trustworthy and low-cost
techniques only single-lead ECG is used which can improve
the early detection of OSA. So, the OSA detection would be
possible by the friendly-used at home setting. [3], [6], [7], [21].
In 2000, the organizers of Physionet database held a challenge
to detect the OSA using a single-lead ECG signal, in order
to show the importance of the issue [22]–[24]. Khandoker
et al. extracted 28 features from the heart rate variability
(HRV) and ECG derived respiratory (EDR) signals [2]. Bsoul
et al. proposed a real-time OSA detection system which has
111 features extracted from RR interval time series and EDR
signals in time and frequency domains. [17]. Varon et al. used
the extracted features from ECG, HRV and EDR signals [6].
Song et al. applied the extracted features from EDR signals
and RR interval time series to the combination of the Hidden
Markov Model (HMM) and Support Vector Machine (SVM)
[15]. In 2017, Hassan et al. employed the features extracted
from the ECG signals where, the signals were decomposed to
some sub-bands through a tunable-Q factor wavelet transform
(TQWT) and focused on the statistical features to detect OSA
[15].
There are two common issues in the previous researches
related to this field of study. Initially, there is a large number of
features used in the previous methods which results in a high
This article has been accepted for publication in a future issue of this journal, but has not been fully edited. Content may change prior to final publication. Citation information: DOI 10.1109/JBHI.2018.2842919, IEEE Journal of
Biomedical and Health Informatics
2

computational load. Secondly, most of these methods did not

present a quantitative measurement (Apnea-Hypopnea Index
(AHI)) for the level of the possible OSA. To address these
problems in this paper, we focus on four goals:
• Evaluation of applying two new non-linear entropy-based
features including fuzzy entropy and correct conditional
entropy for OSA detection and their additional advantages
in this field of study.
• Development of a feature selection algorithm for feature
dimension reduction and lowering complexity.
• Applying different classification methods on the same
collection of features in order to show the performance
of each classifier and finally selecting the best one.
• Providing minute-by-minute OSA detection and AHI
measurement for patients to prioritize them in the treat-
ment stage.
The rest of the paper is organized as follows. The database
and the proposed method for OSA detection are presented in
section II. The results of the proposed method are evaluated
in section III. In section IV, the discussion is presented and Fig. 1: Overview of proposed method for automatic detection of
finally, section V contains the conclusions. OSA using single-lead ECG signals.
II. M ATERIALS AND M ETHODS
The proposed method consists of two main steps. In the 2) St. Vincent’s University Hospital/University College
first step, noisy windows are identified by the weight calcula- Dublin Sleep Apnea Database (UCD database): This database
tion procedure and eliminated. At this stage, after the pre- is available online on the Physionet website. In this database,
processing, the wavelet transform is applied to the single- twenty-five subjects (21M, 4F) were selected (age: 50 ±
lead ECG signals. Then nonlinear features are extracted from 10 years, range 28-68 years; AHI: 24.1 ± 20.3, range 1.7-
the wavelet transform coefficients. The best set of features is 90.9). Onset time and duration of respiratory events were
selected by the sequential forward feature selection (SFFS) annotated by an experienced sleep technologist according to
algorithm and fed into different classifiers in order to dis- standard Rechtschaffen and Kales rules. All of the necessary
criminate the apnea events from the healthy. In the second information is found in [27].
stage, AHI is calculated by dividing the total number of apnea
events by the total number of minutes of actual sleep time,
then multiply by 60. Then, considering the calculated AHI,
B. Preprocessing
the subjects are marked as apnea or normal. Fig.1 shows the
block diagram of the proposed OSA detection method. Signal segmentation with two different time durations of
30s and 60s is the first stage. Selection of 60s is based on
A. Datasets the results presented at [28], in which it has proven that
1) Physionet Apnea-ECG database: The dataset used in this duration is the most efficient one. However, in order to
this study is available online1 . The ECG signals were sampled further approach the real-time system realizations, in another
at 100 H z , with 16 bi t s resolution and modified lead V2 investigation, the epoch duration is reduced to 30s . After
electrode configuration using an overnight PSG recording. The the segmentation stage, the noises (baseline wandering and
records have variable lengths of 7-10 hours. A specialist has power line interference) of the signals are suppressed using
attached the apnea labels (minute-by-minute) using the PSG a Chebyshev type II band-pass filter with the low and high
signals based on the standards introduced by the American cut-off frequencies of 0.5 H z and 48 H z , respectively.
Academy of Sleep Medicine [25]. A minute of the data
would be considered as an apnea if there is at least a single
apnea/hypopnea event in the minute [26]. The age of subjects C. Weight Calculation
is between 27-63 years, and their weights are in the range
of 35-135 K g . Also, the range of AHI is 0-93.5. There are After filtering, weight calculation procedure is performed
70 records available in the dataset which are divided into two for elimination of noisy segments. Based on the Fig.2, it can be
groups: train (called released-set) and test (called withheld- observe that some of the windows are completely noisy (B) or
set). The released-set includes 35 records with the index of the ECG signal are removed entirely (A). Varon et al. [29] have
a01-a20, b01-b05 and c01-c10, while the withheld-set includes introduced a simple method in order to automatic elimination
35 records having the index of x01-x35. of the noisy epochs. They have calculated a weight (W ) for
each segment based on the similarity of its Autocorrelation
1 https://physionet.org/cgi-bin/atm/ATM Function (ACF) with other segments ACF, considering the

2168-2194 (c) 2018 IEEE. Personal use is permitted, but republication/redistribution requires IEEE permission. See http://www.ieee.org/publications_standards/publications/rights/index.html for more information.
This article has been accepted for publication in a future issue of this journal, but has not been fully edited. Content may change prior to final publication. Citation information: DOI 10.1109/JBHI.2018.2842919, IEEE Journal of
Biomedical and Health Informatics
3

A (W=0.32)
1
ECG

-1
0 1000 2000 3000 4000 5000 6000

B (W=0.38)
5000
ECG

-5000
0 1000 2000 3000 4000 5000 6000

C C (W=0.99)
500
ECG

-500
0 1000 2000 3000 4000 5000 6000
Samples Fig. 3: ECG signal decomposition with 8 levels of a DWT using
Sym3 mother function.
Fig. 2: Different examples of one-minute segments in the Physionet
Apnea-ECG database and the corresponding calculated weights (W).
A and B are the noisy segments. C is a clean segment. of high-pass and low-pass filter pairs, named as quadrature
mirror filters [31]. In the first step of DWT, the ECG signal is
passed from low-pass and high-pass filters (h[n] and g [n],
cosine pair-wise similarity as the metric. Here, the similarity respectively), with a cut-off frequency of F s /4 (F s is the
values are calculated using (1): sampling frequency). The output of the low-pass and high-pass
0 filters are concerned with the approximate ( A i ) and detail (D i )
(X s − X s )(X t − X t )
d st = q q . (1) coefficients, respectively. We proceed the DWT in eight levels.
0 0
(X s − X s )(X s − X s ) (X t − X t )(X t − X t ) In each step, the frequency resolution is doubled compared to
the last level, using filtering, while the temporal resolution is
where, d st is the correlation distance, and X s and X t are
decreased as a result of the lower sampling frequency. The
the ACF of two different segments. X̄ s and X̄ t are the mean
selection of the optimum value for decomposition level in
value of the X s and X t , respectively. The result of (1) is a
DWT depends on the sampling frequency and the application.
vector containing the similarity of each segment. W of each
Fig.3 shows the 8 levels of a DWT. Where, the coefficients
segment is obtained with the normalized summation of all the
A1, D1, A2,D2, ..., A8 and D8 represent the frequency content
d st values. In this paper, all the segments with a calculated
of the original ECG signal within the bands of 0 → F s /4,
weight lower than 0.8 were considered as the noisy epochs
F s /4 → F s /2, 0 → F s /8, F s /8 → F s /4, ..., 0 → F s /1024 and
and removed.
F s /1024 → F s /512, respectively. for detailed explanations in
decomposition procedure the reader is referred to [30], [32].
D. Wavelet Transform
Wavelet Transform (WT), providing a better presentation E. Non-linear Entropy-Based Features Extraction
of the time-frequency domain of a signal with a different
size of windows, is designed to address the non-stationary 1) Approximate Entropy: In 1991, Pincus introduced the
problem of the signals [30]. Time windows with the large and approximate entropy (ApEn) to address the problem of the
low lengths provide the low and high frequency resolutions, short length of the data and noisy recording of physiological
respectively, which makes the WT a appropriate technique signals [33]. ApEn is a statistical method used for quanti-
for pattern recognition of an irregular data. The WT of a zation of irregularity of signals. The more ApEn, the more
continuous signal x(t ) is defined as follows: irregularity characteristics of signals, and vice versa [34]. In
OSA detection, for the first time, Haitham et al. used ApEn
Z+∞ to measure the irregularity of HRV signals, which is exhibited
1 t −b
CW T (a, b) = x(t ) p ψ( )d t , (2) in the following:
|a| a
−∞
• X (i ) vectors are constructed as follows:
where a and b are the scaling and the shifting parameters,
respectively. ψ is the scaled and shifted versions of a wavelet X (i ) = [u(i ), u(i + 1),..., u(i + m − 1)] ,1 ≤ i ≤ N − m + 1,
function. Coefficient calculation in each scale is a complicated (4)
process. To address this problem, Discrete WT (DWT) is where X (i ) and N are the time series and the number of
usually used: samples of the concerned signal, respectively.
• Distance between X (i ) and X ( j ) is calculated by:
Z+∞
1 t − 2j k £ ¤ £¯ ¯¤
DW T ( j , k) = p x(t )ψ( )d t . (3) d X (i ), X ( j ) = max ¯u(i + k − 1)−u( j + k − 1)¯ ,
|2 j |−∞ 2j k=1,2,...,m
(5)
In 1989, Mallet proposed an optimum method for DWT imple- where r is the threshold equal to r = 0.25 × st d , and st d
mentation. In this method, the signal is passed through a series is the standard deviation of input segment.

2168-2194 (c) 2018 IEEE. Personal use is permitted, but republication/redistribution requires IEEE permission. See http://www.ieee.org/publications_standards/publications/rights/index.html for more information.
This article has been accepted for publication in a future issue of this journal, but has not been fully edited. Content may change prior to final publication. Citation information: DOI 10.1109/JBHI.2018.2842919, IEEE Journal of
Biomedical and Health Informatics
4

• Define C im (r ) for each i , i = 1, 2, ...N − m : 4) Correct Conditional Entropy: To overcome the problem
£ ¤ of low available samples in Shannon Entropy (SE),Correct
number of d X (i ), X ( j ) ≤ r
C im (r ) = . (6) Conditional Entropy (CCE) has been proposed by Porta et
N −m +1 al. and is formulated as follows [37]:
1 N −m+1
Φm (r )=
X
ln(C im (r )). (7) CC E (L) = Ê (L|L − 1) + E c (L)
N − m + 1 i =1 (17)
Ê (L|L − 1) = Ê (L) − Ê (L − 1),
• m is increased to m +1, and all the last steps are repeated where Ê (L) and Ê (L −1) are the estimation of SE in the phase
now. space of L and L − 1 dimensions. E c (L) is the correction term
• Finally, the ApEn can be calculated as follows: which is:
ApEn(m, r, N )=Φm (r )−Φm+1 (r ). (8) E c (L) = per c(L) × Ê (1), (18)

2) Sample Entropy: Sample Entropy (SampEn) works al- where per c(L) is an amount of single points in the phase
most the same as the ApEn, and it is calculated as follows: space of L dimension. In addition, Ê (1) is the SE estimation
for L = 1.
C m+1
j
(r )
SampEn = − ln , (9)
Cm
j
(r ) F. Other non linear Features Extraction
where m is the embedding dimension which is considered to 1) Poincare Plot: Poincare Plot (PP) is a powerful method
be 2, and to show the graphical correlation of a signal with its shifted
© £ ¤ ª version. This method is based on nonlinear dynamics and
number of d X (i ), X ( j ) < r
Cm
j (r ) = ,∀i 6= j. (10) provides useful information related to short-time/long-time
N −m variations of a signal. The necessary equations for calculation
3) Fuzzy Entropy: Fuzzy Entropy (FE) is a new measure- of PP are as follows:
ment criterion which measures the irregularity of a signal [35]. 1 ¯ ¯
In FE, membership d 1,i = p ¯ X (i )−X (i + 1)¯, i = 1, 2,..., N − 1, (19)
³³ ´degree
n ´
is calculated by an exponential 2
function (exp −dimj /r ) [36]. For the first time, we have q
used FE to characterize the ECG signals for an automatic OSA SD1= v ar (d 1,i ), (20)
detection method. Considering the concept of FE, calculation
1 ¯¯ ¯
of FE is explained as follows: d 2,i = p ¯X (i )+X (i + 1)−2X ¯ , (21)
¯
m 2
• First, X i is calculated: q
X i m = {u(i ), u(i + 1), ..., u(i + m − 1)} −u 0 (i ), (11) SD2= v ar (d 2,i ), (22)

where {u(i ): 1 ≤ i ≤ N } is the time series of the concerned Rat i o SD1/SD2 = SD1/SD2, (23)
m−1
signal, and u 0 (i )= m1 where SD1 and SD2 are short-time and long-time standard
P
u(i + j ).
j =0 deviations, respectively, and X̄ is the mean of the signal.
• Distance dimj between X jm and X im is as follows:
2) Recurrence Plot: Recurrence plot (RP) is another crite-
i rion for irregularity measurement [13]. To obtain RP, firstly, it
d imj = d X i m , X jm =
£
¯ ¯ (12) is necessary to construct X (i ):
max ¯(u(i + k)−u 0 (i )) − (u( j + k)−u 0 ( j ))¯ .
k∈(0,m−1) X (i )= {u(i ), u(i + τ), ..., u(i + (m − 1)τ} , (24)
m
• D (similarity degree) for a given n and r can be written
ij where i = 1, ..., N − (m − 1)τ, m is embedding dimension, and
as follows: τ is embedding lag. Euclidean distance of two vectors is given
D imj (n, r ) =ϕ(d imj , n, r ) = exp − (d imj )n /r
¡ ¢
(13) by: v
uN −(m−1)τ
u
where ϕ(d imj , n, r ) is the fuzzy function. (u j (L) − u i (L))2 .
X
d (X ( j ), X (i )) = t (25)
• Finally, FE can be calculated using the difference of the L=1
natural logarithm of Φm (n, r ) and Φm+1 (n, r ): RP is a symmetric matrix which has a dimension of
m
F uzz yEn(m, n, r )= ln(Φ (n, r ))− ln(Φ m+1
(n, r )), (14) [N − (m − 1)τ] × [N − (m − 1)τ], and contains elements of one
and zeros where
where n
1 d (X ( j ),X (i ))≤r
! RP (i , j ) = 0 ot her wi se
(26)
1 NX
−m µ 1 NX
−m
m
Φ (n, r ) = D imj , (15) and r is the threshold, which is considered to be 0.2. In this
N −m i =1 N −m −1 j =1, j 6=i
! paper, we use Recurrence rate (REC) with τ = 1. REC can be
m+1 1 NX −m µ 1 NX
−m written as follows:
Φ (n, r ) = D im+1
j . N −(m−1)
N − m i =1 N − m − 1 j =1, j 6=i 1 X N −(m−1)
X
(16) REC = RP (i , j ). (27)
N − (m − 1) i =1 j =1

2168-2194 (c) 2018 IEEE. Personal use is permitted, but republication/redistribution requires IEEE permission. See http://www.ieee.org/publications_standards/publications/rights/index.html for more information.
This article has been accepted for publication in a future issue of this journal, but has not been fully edited. Content may change prior to final publication. Citation information: DOI 10.1109/JBHI.2018.2842919, IEEE Journal of
Biomedical and Health Informatics
5

TABLE I: List of the extracted features. TABLE II: The learning parameters of different classifiers. NHLN:
Number of Hidden Layer Neuron. NLC: Number of Learning Cycles.
Feature ID Description
ApEn Approximate Entropy classifiers Leaning Parameters
SampEn Sample Entropy KNN NumNeighbors: 10 - Distance: ’cityblock’
FE Fuzzy Entropy range-NHLN1 : {5, ..., 60} , range-NHLN2 : {5, ..., 50} ,
CCE Correct Conditional Entropy ANN
Num-Layers : 2 , training-func : Levenberg Marquardt
SD1
LDA Discrimiype: ’linear’ – Delta: 0.002 – Gamma : 0.0003
SD2 Poincare Plot Features
QDA ’DiscrimType’,’quadratic’ - Delta: 0 – Gamma : 1
SD1/SD2
RP Recurrence plot (Recurrence Rate) GentleBoost LearnRate: 0.4953 – niMLeafSize : 77 – NLC : 15
IQR Interquartile Range NB DidtribueionNamts: kernel - Width: 0.017253
MAD Mean Absolute Deviation LR Applying default parameters
Var Variance Kernel-Type = Linear, Polynomial and RBF
range-C = 2−1 , ..., 24 , range-δ2 = 2−3 , ..., 24 ,
© ª © ª
SE Shannon Entropy SVM
2
Poly-order = {2, 3, 4}, optimum-δ =1.9, optimum-C = 7
Kernel-Type = Linear, Polynomial and RBF
In addition, prevalent non-linear features including Interquar- LS-SVM range-C = 2−1 , ..., 24 , range-δ2 = 2−3 , ..., 24 ,
© ª © ª

tile range (IQR), Variance (var), Mean Absolute Deviation
(MAD) and SE are employed. All of the extracted features
are summarized in the TABLE I. After extracting all of the
features, the feature vectors are normalized using the z-score
method as follows:
X i − X̄
Zi =
S collection of data is experimented, since the implementation
th
where X i is the i feature vector, and X̄ and S are the mean
and standard deviation of X i , respectively.
G. Feature Selection
We extracted 12 features from the WT coefficients
( A 8 , D 1 , ..., D 8 ), all mentioned above. In total, 108 features
were extracted. The feature IDs and Descriptions are pre-
sented in TABLE I. To improve the performance of the used
classifiers and also to reduce the required processing time, a
subset of features leading to the most distinguished classes
was chosen through the SFFS algorithm. To this end, SFFS
algorithm with a misclassification rate criterion was used
where as the first step, all the features were individually
applied to the classifier to choose the best one. Then, the
best feature was combined with all the features to opt for
the best coupled one. The method is continued until the most
separation between the classes is attained. At the end, the
P-values of the selected collection of features are calculated
using the Kolmogorov-Smirnov method.
H. OSA Classification
The proposed method for apnea detection and calculation of
its severity, is a two-step method. In the first step, it is aimed
to classify all of the apnea and normal epochs. In this step,
the obtained segments by the released-set have been used for
feature selection, training and tuning the optimal parameters
of the different classifiers by the 10-fold cross validation
method. The selected features are extracted from the withheld-
set and UCD database. The withheld-set and UCD database
are used in independent tests for final performance evaluation
of different classifiers. In the next step, all of the released
and withheld sets (containing 70 recordings) are used for
Subject-by-Subject classification by the Leave-One-Record-
Out (LORO) cross validation method. Although the same
Poly-order={2, 3, 4}, optimum-δ2 =1.8, optimum-C=3.85
Kernel-Type = Linear, Polynomial and RBF
range-C = 2−1 , ..., 24 , range-δ2 = 2−3 , ..., 24 ,
© ª © ª
LIB-SVM
Poly-order={2, 3, 4}, optimum-δ2 =3.65, optimum-C=11.3
(28)
process of the classifiers is different, the results are distinct.
In addition, considering the type of data we are facing in
practice and also the problem, different classifiers would lead
to different performances. The used classifiers in this study
are as follows:
• Support Vector Machines(SVM) using RBF, Polynomial
and Linear Kernels
• Least-Square SVM using RBF, Polynomial and Linear
Kernels (LS-SVM)
• LIBSVM using RBF, Polynomial and Linear Kernels
(LIBSVM)
• Linear Discriminant Analysis (LDA)
• Quadratic Discriminant Analysis (QDA)
• Artificial Neural Network (ANN)
• K-Nearest Neighbor (KNN)
• Ensemble Model using Gentleboost Method (Gentle-
boost)
• Naive Bayes Model (NB)
• Logistic Regression (LR).
All of the aforementioned classifiers are evaluated in this study
to find the best one.
An important concept to consider is that the way that pa-
rameters are set has high influence on the performance of
the classifiers. The grid-search method was employed to set
the optimum parameters of SVM and the modified versions
(LS-SVM and LIBSVM). A neural network with two hidden
layers is developed. Statistics and Machine learning toolbox
in Matlab (2016b) was used to set the optimum parameters
of KNN, LDA and Ensemble. The learning range and the
optimum value of the parameters of different classifiers are
presented in TABLE II.
III. R ESULTS
In this work, one-minute and 30-second durations were
considered as two different epoch lengths. As mentioned in the

2168-2194 (c) 2018 IEEE. Personal use is permitted, but republication/redistribution requires IEEE permission. See http://www.ieee.org/publications_standards/publications/rights/index.html for more information.
This article has been accepted for publication in a future issue of this journal, but has not been fully edited. Content may change prior to final publication. Citation information: DOI 10.1109/JBHI.2018.2842919, IEEE Journal of
Biomedical and Health Informatics
Fig. 4: The boxplots of the selected features. Here, it is clear that ApEn, FE, IQR, RP and poincare plot features provide significant
differences between two classes (Apnea and Normal).
0.35
Classification Performance(%)
0.3
Classification Error
0.25
0.2
0.15
0.1
0.05
0 5 10 15 20
Number of Features
Fig. 5: SFFS Algorithm with its accuracy and classification error
in each iteration. (a) classification error for each subset of selected
features and (b) classification accuracy for each subset of selected
features.
weighting process, each segment should be weighted based on
the ACF. All the segments with the weights more than 0.8 are
considered as clean segments, while all of the segments with
the weights lower than 0.8 are considered as noisy segments
and removed from the collection of segments. According to
this approach, in the Physionet Apnea-ECG database, 1717
one-minute segments are removed which is less than 5% of
the total available segments.
A. Feature Selection
As shown in TABLE III, it is possible to use a low
number of features for classification, while the performance is
preserved. As noted before, SFFS is used for automatic feature
selection which, it opts for a collection of features with the
best performance in each step.
As demonstrated in Fig. 5, in the first step, the best feature
is selected, for which the classification error and accuracy
are lower than 0.35 and upper than 65%, respectively. At
each step, through the addition of the best feature to the
collection of the selected features, an increase in the accuracy
is observed while the error is declined expectedly. In this study,
2168-2194 (c) 2018 IEEE. Personal use is permitted, but republication/redistribution requires IEEE permission. See http://www.ieee.org/publications_standards/publications/rights/index.html for more information.
6
95 the stopping criterion is considered to be e i − e i −1 ≤ 1e − 6
where, e i is error of the i t h step. At the end, the error of
90
the classification is reduced to 0.0673 and the accuracy is
85
increased to 93.27%. The collection of the selected features
80 includes var(cd3), SE(cd1), IQR(cd1), IQR(cd3), IQR(cd5),
75 MAD(cd6), SD1(cd4), SD2(cd4), SD2(cd5), SD1/SD2(cd2),
70
SD1/SD2(cd6), FE(cd2), FE(cd3), CCE(cd1), ApEn(cd4),
SampEn(cd8), RP(cd2) and RP(cd1). Fig. 4 exhibits boxplots
65
0 5 10 15 20 of the selected features. It is clear that FE, ApEn, IQR,
Number of Features
RP and poincare plot features leads to significant differences
between the healthy and apnea cases. Also, statistically, all of
the features used in this paper have significant differences(p -
values<1e-6).
B. Epoch Classification Performance
After selection of the appropriate collection of the features,
some classifiers including SVM, LIBSVM, LS-SVM, ANN,
KNN, LR, LDA, QDA, NB and Genleboost are used for the
better evaluation of the proposed method. Metrics such as F-
measure (F), accuracy, specificity, sensitivity, and the Area
Under Curve (AUC) are used for the performance evaluation
of different classifiers. Moreover, important parameters such as
Cohen’s kappa coefficient (Kappa) and Matthews correlation
coefficient (MCC) are used in order to measure the agree-
ment between raters and the quality of binary classifications
respectively [38]. In the first experiment, all of the epochs
(without weighting application) are employed in epoch-based
classification. In this part, both the 60s and 30s segment
durations are considered and the corresponding results are
presented in TABLE III and TABLE IV, respectively. As
demonstrated in TABLE III, for Apnea-ECG database SVM
(RBF kernel) provided the best performance with an accuracy
of 92.98%, MCC of 0.85, F-measure of 0.91 and Kappa of 0.85
in the minute-by-minute classification. For UCD database, the
mentioned classifier outperformed the other classifiers with
an accuracy of 93.70%, MCC of 0.85, F-measure of 0.9
and Kappa of 0.85. According to the attained results, it is
This article has been accepted for publication in a future issue of this journal, but has not been fully edited. Content may change prior to final publication. Citation information: DOI 10.1109/JBHI.2018.2842919, IEEE Journal of
Biomedical and Health Informatics
7

TABLE III: Minute-by-Minute based Performance of different classifiers on selected features. Sensitivity (Sens), specificity (Spec), accuracy
(ACC), AUC, MCC, Kappa and F-measure (F) are calculated. All of the segments in both Apnea-ECG and UCD datasets have been used.
Physionet Apnea-ECG Database UCD Database
Classifier
MCC F Kappa Sens Spec Acc MCC F Kappa Sens Spec Acc
KNN 0.84 0.90 0.84 91.54 93.12 92.52 0.83 0.90 0.83 90.04 93.41 92.11
ANN 0.82 0.89 0.82 89.15 92.71 91.36 0.84 0.90 0.83 90.80 93.07 92.22
LDA 0.57 0.74 0.57 72.82 84.33 79.92 0.55 0.71 0.55 67.90 86.30 79.32
QDA 0.41 0.66 0.36 97.55 38.54 61.16 0.45 0.68 0.36 96.45 45.53 64.74
GentleBoost 0.77 0.86 0.77 87.10 90.63 89.27 0.82 0.89 0.82 89.19 93.17 91.65
NB 0.2 0.58 0.10 98.89 10 44.04 0.41 0.66 0.30 98.01 38.09 60.83
LR 0.45 0.66 0.45 68.16 77.20 73.7 0.43 0.65 0.41 71.64 71.27 71.33
Linear 0.63 0.78 0.63 78.26 85.38 82.65 0.60 0.75 0.60 67.50 87.88 80.03
SVM Polynomial 0.80 0.88 0.80 89.58 90.75 90.30 0.78 0.86 0.78 86.50 91.17 89.40
RBF 0.85 0.91 0.85 91.74 93.75 92.98 0.85 0.90 0.85 90.65 93.93 93.70
Linear 0.64 0.78 0.63 78.18 85.48 82.69 0.57 0.72 0.56 67.50 87.88 80.03
LS-SVM Polynomial 0.79 0.87 0.79 89.34 90.71 90.21 0.81 0.89 0.81 89.46 92.15 91.12
RBF 0.83 0.89 0.83 90.22 93.14 92.06 0.84 0.90 0.84 89.35 94.41 92.46
Linear 0.64 0.78 0.63 78.18 85.48 82.69 0.60 0.75 0.60 73.10 86.14 81.19
LIB-SVM Polynomial 0.70 0.82 0.70 83.09 87.16 85.61 0.69 0.81 0.69 81.63 87.20 85.07
RBF 0.81 0.88 0.81 89.74 91.77 90.88 0.80 0.88 0.80 86.88 92.88 90.61

TABLE IV: Evaluation the performance of different classifiers on selected features with epoch duration of 30 seconds. Sensitivity (Sens),
specificity (Spec), accuracy (ACC), AUC, MCC, Kappa and F-measure (F) are calculated.
Physionet Apnea-ECG Database UCD Database
Classifier
MCC F Kappa Sens% Spec% Acc% MCC F Kappa Sens% Spec% Acc%
KNN 0.80 0.87 0.79 87.30 92.18 90.31 0.82 0.86 0.82 84.54 95.87 92.76
ANN 0.80 0.87 0.80 86.89 92.48 90.34 0.79 0.85 0.79 83.51 95.02 91.96
LDA 0.51 0.69 0.51 64.93 84.87 77.16 0.50 0.60 0.50 52.82 92.10 81.15
QDA 0.54 0.73 0.50 89.98 64.72 74.39 0.24 0.50 0.13 96.67 23.96 43.86
GentleBoost 0.79 0.87 0.79 86.87 91.69 89.84 0.82 0.86 0.82 83.33 96.46 92.87
NB 0.42 0.67 0.38 87.19 55.46 67.61 0.25 0.50 0.15 92.38 31.27 47.99
LR 0.33 0.59 0.33 58.70 74.36 68.36 0.40 0.50 0.32 50.17 81.23 72.74
Linear 0.54 0.71 0.54 69.74 83.58 78.28 0.54 0.64 0.53 57.10 92.04 82.48
SVM Polynomial 0.74 0.84 0.74 85.80 88.47 87.45 0.74 0.81 0.74 78.40 94.37 90.00
RBF 0.82 0.89 0.82 89.17 92.66 91.33 0.77 0.83 0.77 78.97 95.88 91.46
Linear 0.52 0.70 0.52 66.67 84.52 77.67 0.45 0.57 0.47 51.72 93.61 80.67
LS-SVM Polynomial 0.80 0.88 0.80 87.91 92.32 90.58 0.78 0.84 0.78 84.50 93.99 91.37
RBF 0.83 0.89 0.83 89.37 93.33 91.81 0.77 0.83 0.77 80.83 95.09 91.33
Linear 0.54 0.71 0.54 69.85 83.56 78.31 0.54 0.65 0.53 57.10 92.07 82.52
LIB-SVM Polynomial 0.63 0.77 0.63 76.03 86.73 82.62 0.71 0.78 0.71 75.57 93.45 88.57
RBF 0.80 0.88 0.80 86.88 92.88 90.61 0.75 0.82 0.75 78.57 94.74 90.32

evident that NB classifier exhibits the worst performance. The
comparison of minute-by-minute based classification results
attained by the proposed method in this article, with state-of-
the-art is presented in TABLE VI.
In the following experiment, the same evaluations on the
same datasets were repeated with the exception of window
length, which was 30s in this part. The results are listed in
TABLE IV. As reported in TABLE IV, the LS-SVM (RBF
kernel) classifier provided the best results with an accuracy of
91.81%, F-measure of 0.89 and Kappa of 0.83 for Apnea-ECG
database where as the GentleBoost classifier achieved the best
performance with an accuracy of 92.87%, F-measure of 0.86
and Kappa of 0.82 for UCD database. The results of minute-
by-minute classification with weight calculation algorithm on
the Apnea-ECG database, are shown in TABLE V. Based
on the results, it is evident that, SVM with RBF kernel
outperforms other classifiers where an accuracy of 94.63%,
sensitivity of 94.43%, specificity of 94.77% and AUC of 0.98
are achieved by the minute-by-minute classification. Also, the
MCC of 0.89, F-measure of 0.93, and Kappa coefficient of
0.89 are attained for SVM with RBF kernel, which show a high
level of performance for this classifier. It should be noticed
that LIB-SVM, LSSVM with a kernel of RBF and KNN result
in an accuracy of 91.10%, 93.04%, and 92.47% respectively,
which is considered to be a satisfactory performance. The ROC
for the SVM based classifiers with the RBF kernel, holding
an outstanding performance compared to the other classifiers,
is demonstrated in Fig. 6. Based on this figure, it is obvious
that the ROC curves for all the SVM, LIBSVM and LSSVM
(with RBF kernel function) are almost the same, and all of
them admit the high performance of the proposed method of
OSA detection in minute-by-minute classification.
C. Subject-by-Subject Classification Performance
As noted in TABLE VII, a threshold of 5 apnea/hour is used
for AHI where subject-by-subject classification is used. The
cases having AHI higher than 5 are considered as cases with
apnea while others are considered as healthy subjects. Regard-

2168-2194 (c) 2018 IEEE. Personal use is permitted, but republication/redistribution requires IEEE permission. See http://www.ieee.org/publications_standards/publications/rights/index.html for more information.
This article has been accepted for publication in a future issue of this journal, but has not been fully edited. Content may change prior to final publication. Citation information: DOI 10.1109/JBHI.2018.2842919, IEEE Journal of
Biomedical and Health Informatics
8

TABLE V: Minute-by-Minute based performance of different classifiers on selected features. Sensitivity (Sens), specificity (Spec), accuracy
(Acc), AUC, MCC, Kappa and F-measure are calculated. Weight claculation algorithm was used (TNI: Total number of inatances, CCI:
Correctly classified instances).
Physionet Apnea-ECG Database
Classifier
TNI CCI Sens% Spec% Acc% AUC MCC F-score kappa
KNN 15919 14721 91.19 93.28 92.47 0.97 0.84 0.90 0.84
ANN 15919 14645 90.47 92.96 92.00 - 0.83 0.90 0.83
LDA 15919 13000 76.02 85.22 81.66 0.89 0.61 0.76 0.61
QDA 15919 13443 87.93 82.26 84.45 0.92 0.69 0.81 0.68
GentleBoost 15919 14639 89.67 93.40 91.96 0.97 0.83 0.90 0.83
NB 15919 12422 72.20 81.71 78.03 0.83 0.54 0.72 0.54
LR 15919 11823 66.72 79.02 74.27 0.89 0.46 0.67 0.46
Linear 15919 12826 78.15 84.80 81.68 0.88 0.59 0.75 0.59
SVM Polynomial d=2 15919 14024 86.14 89.29 88.07 0.94 0.75 0.85 0.75
RBF 15919 15064 94.43 94.77 94.63 0.98 0.89 0.93 0.89
Linear 15919 12872 74.33 85.48 80.86 0.88 0.58 0.75 0.58
LS-SVM Polynomial 15919 12827 89.34 90.71 90.21 0.96 0.79 0.87 0.79
RBF 15919 14859 92.00 95.19 93.04 0.98 0.86 0.91 0.86
Linear 15919 13116 78.98 84.54 82.40 0.89 0.63 0.78 0.63
LIB-SVM Polynomial d=2 15919 14231 84.20 92.81 89.48 0.95 0.78 0.86 0.78
RBF 15919 14501 91.00 91.16 91.10 0.97 0.81 0.89 0.81

TABLE VI: Comparison of minute-by-minute based classification

1 results between our method and previous works.
0.9
Physionet Apnea-ECG
Reference Classifier
0.8 Acc% Sens% Spec%
Hassan et al. [39] RUSboost 88.88 87.58 91.49
0.7
Gonzalez et al. [40] QDA 84.76 81.45 86.82
True positive rate

0.6 Hassan et al. [41] Bootstarp Aggregating 85.97 84.14 86.83

Hassan et al. [42] AdaBoost 87.33 81.99 90.72
0.5
chance line Sharma et al. [43] LS-SVM(RBF kernel) 83.8 79.5 88.4
LIBSVM
0.4
SVM
Song et al. [15] HMM+SVM 86.2 82.6 88.4
LSSVM Nguyen et al. [13] Decision Fusion 85.26 86.37 83.47
0.3
Sannino et al. [44] DEREx tool 85.76 65.82 66.03
0.2 Varon et al. [6] LS-SVM(RBF kernel) 84.74 84.96 84.71
0.1
Bsoul et al. [17] C-SVM(RBF kernel) 90.86 89.02 91.94
Mendez et al. [3] ANN 88 85 90
0 Chazal et al. [4] LD 90 86.4 92.3
0 0.2 0.4 0.6 0.8 1
False positive rate
Proposed Method SVM (RBF kerne) 92.98 91.74 93.75

Fig. 6: ROC curves of SVM, LIBSVM, LSSVM with RBF kernel TABLE VII: Class and Label for Subject Classification.
function on the test data. It is clear that all three SVM, LIBSVM,
Label Class AHI Score
and LSSVM models show high level performance; however, SVM 0 Normal Subject AHI ≤ 5
model (black line) presents hiegher AUC. 1 OSA Subject AHI > 5

ing the minute-by-minute labels in the Physionet database, the
real AHI is calculated through the following equation:
Number of (Apnea + Hyponea)
AH I Real =
Total sleep time (in minutes)
IV. D ISCUSSION
There are four main goals in this paper:
• Introducing of two new features for OSA detection (FE
and CCE) and showing their ability in distinguishing
× 60 (29)
apnea and healthy segments.
• Using an automatic feature selection to select the best

The numerator of the (29) is changed to the Number of collection of features in order to reduce the computational
Apnea due to the fact that in physionet database all the apnea burden and provide the best performance.
and hypopnea cases are considered as apnea segments. After • Comparison of the different classifiers to find the best

the minute-by-minute classification stage, AHI was calculated possible classifier.

using the best classifier obtained at the previous stage. The pro- • Providing an AHI index for patients to prioritize them in

posed method is evaluated by the 70 recordings (35 released-
set and 35 withheld-set), using the LORO technique. For
all the 70 recordings, AHI was calculated using (29). The
results show that the proposed method leads to an accuracy of
95.71%.
the treatment stage.
The boxplots presented in Fig. 4 show that ApEn, FE, IQR
and RP provide significant differences between the apnea
and normal classes. The selection of the classifier parameters
directly influences the outcome. The grid-search method is

2168-2194 (c) 2018 IEEE. Personal use is permitted, but republication/redistribution requires IEEE permission. See http://www.ieee.org/publications_standards/publications/rights/index.html for more information.
This article has been accepted for publication in a future issue of this journal, but has not been fully edited. Content may change prior to final publication. Citation information: DOI 10.1109/JBHI.2018.2842919, IEEE Journal of
Biomedical and Health Informatics
9

TABLE VIII: Comparison of subject-by-subject based classification results between our method and previous works on the Physionet
Apnea-ECG database.
Reference Year Classifier Acc Sens Spec Database
Jung et al. [7] 2017 RA 95.7% 87% 100% All subjects
Sharma et al. [43] 2016 LS-SVM (RBF kernel) 97.14% 95.8% 100% All subjects
Song et al. [15] 2015 HMM+SVM 97.1% 95.8% 100% All subjects
Chen et al. [45] 2015 SVM(RBF) 92.87% 97.41% 98.99% excluding 3 subjects
Morillo et al. [46] 2013 PNN 93.9% 92.4% 95.9% -
Alvarez et al. [47] 2010 QDA 89.7% 92.0% 85.4% -
Macros et al. [48] 2009 QDA, LDA, KNN, LR 87.6% 91.1% 82.6% -
Khandoker et al. [2] 2009 SVM 92.9% 92.4% 93.8% Using only 10 subjects
Mendez et al. [3] 2009 ANN 100% - - excluding 20 subjects
Proposed Method SVM with RBF kernel 95.71% 95.83% 95.66% All subjects

used to find the optimum parameters of the RBF kernels of
SVM, LIBSVM and LSSVM classifiers. The search ranges for
C and δ2 to attain an optimum cost values are reported in the
TABLE II. The optimum C for SVM, LIBSVM and LSSVM is
achieved to be 7, 11.3 and 3.85, respectively. The optimum δ2
for SVM, LIBSVM and LSSVM is obtained 1.9, 3.65 and 1.8,
respectively. The proper topology for ANN is gained 18:34:8:1
where two hidden layers holding 34 and 8 neurons. The results
presented in TABLE III show that the selection of the optimum
parameters results in a higher accuracy. As shown in TABLE
III, the SVM-based classifiers (with RBF kernel), ANN and
KNN provide better performances compared to other applied
classifiers in the epoch classification. The results show that
the proposed features in this study provide a high potential
to distinguish the healthy and the apnea cases. In addition,
an accuracy of 92.98% and 91.81% is achieved in minute-by-
minute and 30s -by-30s event detections, respectively, using
the developed approach in this article on the Physionet Apnea-
ECG database, which shows an improvement compared to the
previous studies in this field.
A. Feature Selection and Different Classification Methods
In this paper, SFFS was used for the selection of the best
features to provide a high performance in the classifiers. It
is proven that the features attained by the SFFS algorithm,
result in a more satisfactory performance for the classifier.
Not only, do the selected features retain the high performance,
but also they reduce the computational complexity. It should
be noted that when a low performance feature participates in
the feature vector, the performance of the classifier falls. The
smaller number of features results in a lower computational
load. Thus, the main goal of using SFFS is to choose the best
possible features for the classification.
Selection of a proper classifier to have the best possible
outcome is necessary. There is no general rule to choose the
best classifiers for different fields of study. In another respects,
there is no proof that a classifier with a high performance
in arrhythmia detection provides a high performance in OSA
detection. This is mainly due to the fact that for a specific
case study, there are some classifiers with higher performance
as compared to others. We had two goals by the evaluation of
different classifiers: (1) clarifying the condition in which they
provide a high performance and (2) indicating the best classi-
fier for the same input. There are a large number of studies in
OSA detection, which use different types of classifiers. In this
paper, we evaluated the performance of different classifiers
such as SVM, LS-SVM, LIBSVM, ANN, KNN, LDA, QDA,
LR, NB and Ensemble. The results gained by the mentioned
classifiers in minute-by-minute classification are reported in
TABLE III.
B. Comparison with Other Methods
It should be mentioned that the proposed method results in
an accuracy of 92.98% and 95.71% in the minute-by-minute
and subject-by-subject classifications, respectively. As can be
seen in TABLE VI, the proposed method outperforms other
minute-by-minute based techniques which have been imple-
mented on the Physionet Apnea-ECG database, providing an
accuracy of 92.98%. As can be seen in TABLE VIII, some of
the studies [3], [45] need a high quality dataset to show the
performance of their introduced methods. In addition, some of
them even remove a part of the dataset to prepare a condition
for their proposed methods to achieve better results. It should
be noted that the proposed method provides a high robustness
since all the recordings, including recordings with low quality,
are used. In addition, the most advantage of the proposed
method is that it does not depend on the extracted parameters
from the ECG signals for OSA detection (QRS complex, R
peak amplitude, EDR/HRV signals and etc.). The proposed
method in this study can be easily used at home monitoring
systems since it imposes a low computational complexity. An-
other advantage of the proposed method is the high achieved
accuracy in the minute-by-minute classifications. The results
of the subject-by-subject classification are presented in TABLE
VIII. Each ECG signal is divided into three groups: normal,
borderline, apnea. LORO method is used for AHI calculation.
Some of the reported results outperforms the proposed method
in this paper. Mendez et al. removed 20 patients with low
quality signals [3]. Also, Chen et al. removed 3 patients
with a low quality signals from the physionet database [45].
Considering the fact that all the data do not have a high quality
in practice, these algorithms may show low performances in
the practical conditions. In [15], there is a high complexity
imposed by the introduced algorithm, while the proposed
method in this paper imposes a low computational burden.
The results reported in [43] are highly dependent on the correct
estimation of the QRS complexes. In the cases where there is
no proper preprocessing for noise removal of the signals, the

2168-2194 (c) 2018 IEEE. Personal use is permitted, but republication/redistribution requires IEEE permission. See http://www.ieee.org/publications_standards/publications/rights/index.html for more information.
This article has been accepted for publication in a future issue of this journal, but has not been fully edited. Content may change prior to final publication. Citation information: DOI 10.1109/JBHI.2018.2842919, IEEE Journal of
Biomedical and Health Informatics
accuracy of QRS estimation is reduced and as a result, the
performance of the algorithm is reduced.
V. C ONCLUSION
In this paper, a novel algorithm for automatic OSA de-
tection using a single-lead ECG signal was proposed. Two
new features were proposed for OSA detection, in which
the hidden information of ECG signals were utilized. These
features measured the complexity of the signals in the apnea
and healthy segments. A classification was done by SVM
with the RBF kernel, after optimizing the parameters of SVM
using the grid-search method. The performance of the classifier
was evaluated in terms of accuracy, sensitivity, specificity,
AUC, MCC, F-measure and Kappa coefficient. Two different
lengths of 30s and 60s were investigated and the 60s epoch
duration leads to superior results in both employed datasets.
The proposed method resulted in an accuracy of 92.98% in
minute-by-minute classification on the Apnea-ECG database,
outperforming other compared methods. Therefore, using only
the ECG sensors guarantees achieving an accuracy up to 94%
in the discrimination of the apnea and healthy cases. We
provided AHI metric for each patient to make the prioritization
possible in the treatment stage. As the further work in this
field, it is proposed to investigate on the OSA detection
through SPO2 signals. In addition, the fusion of the classifiers
would be a proper method to improve the accuracy of the
classification.
R EFERENCES
[1] T. Young, M. Palta, J. Dempsey, J. Skatrud, S. Weber, and S. Badr, “The
occurrence of sleep-disordered breathing among middle-aged adults,”
New England Journal of Medicine, vol. 328, no. 17, pp. 1230–1235,
1993.
[2] A. H. Khandoker, M. Palaniswami, and C. K. Karmakar, “Support vector
machines for automated recognition of obstructive sleep apnea syndrome
from ECG recordings,” IEEE Transactions on Information Technology
in Biomedicine, vol. 13, no. 1, pp. 37–48, 2009.
[3] M. O. Mendez, A. M. Bianchi, M. Matteucci, S. Cerutti, and T. Penzel,
“Sleep apnea screening by autoregressive models from a single ECG
lead,” IEEE Transactions on Biomedical Engineering, vol. 56, no. 12,
pp. 2838–2850, 2009.
[4] P. De Chazal, C. Heneghan, E. Sheridan, R. Reilly, P. Nolan, and
M. O’Malley, “Automated processing of the single-lead electrocardio-
gram for the detection of obstructive sleep apnoea,” IEEE Transactions
on Biomedical Engineering, vol. 50, no. 6, pp. 686–696, 2003.
[5] A. H. Khandoker, J. Gubbi, and M. Palaniswami, “Automated scoring of
obstructive sleep apnea and hypopnea events using short-term electro-
cardiogram recordings,” IEEE Transactions on Information Technology
in Biomedicine, vol. 13, no. 6, pp. 1057–1067, 2009.
[6] C. Varon, A. Caicedo, D. Testelmans, B. Buyse, and S. Van Huffel, “A
novel algorithm for the automatic detection of sleep apnea from single-
lead ECG,” IEEE Transactions on Biomedical Engineering, vol. 62,
no. 9, pp. 2269–2278, 2015.
[7] S. H. Hwang, Y. J. Lee, D.-U. Jeong, K. S. Park et al., “Apnea–hypopnea
index prediction using electrocardiogram acquired during the sleep-onset
period,” IEEE Transactions on Biomedical Engineering, vol. 64, no. 2,
pp. 295–301, 2017.
[8] J. B. Dixon, L. M. Schachter, and P. E. OâĂŹBrien, “Predicting sleep
apnea and excessive day sleepiness in the severely obese: indicators for
polysomnography,” CHEST Journal, vol. 123, no. 4, pp. 1134–1141,
2003.
[9] N. M. Ghahjaverestan, S. Masoudi, M. B. Shamsollahi, A. Beuchee,
P. Pladys, D. Ge, and A. I. Hernández, “Coupled hidden markov
model-based method for apnea bradycardia detection,” IEEE journal of
biomedical and health informatics, vol. 20, no. 2, pp. 527–538, 2016.
2168-2194 (c) 2018 IEEE. Personal use is permitted, but republication/redistribution requires IEEE permission. See http://www.ieee.org/publications_standards/publications/rights/index.html for more information.
10
[10] W. W. Flemons, J. E. Remmers, and A. M. Gillis, “Sleep apnea
and cardiac arrhythmias: is there a relationship?” American Review of
Respiratory Disease, vol. 148, no. 3, pp. 618–621, 1993.
[11] C. Guilleminault, S. J. Connolly, and R. A. Winkle, “Cardiac arrhythmia
and conduction disturbances during sleep in 400 patients with sleep
apnea syndrome,” The American Journal of Cardiology, vol. 52, no. 5,
pp. 490–494, 1983.
[12] Y.-Y. Lin, H.-t. Wu, C.-A. Hsu, P.-C. Huang, Y.-H. Huang, and Y.-L.
Lo, “Sleep apnea detection based on thoracic and abdominal movement
signals of wearable piezo-electric bands,” IEEE journal of biomedical
and health informatics, 2017.
[13] H. D. Nguyen, B. A. Wilkins, Q. Cheng, and B. A. Benjamin, “An
online sleep apnea detection method based on recurrence quantification
analysis,” IEEE Journal of Biomedical and Health Informatics, vol. 18,
no. 4, pp. 1285–1293, 2014.
[14] M. Ciołek, M. Niedźwiecki, S. Sieklicki, J. Drozdowski, and J. Siebert,
“Automated detection of sleep apnea and hypopnea events based on
robust airflow envelope tracking in the presence of breathing artifacts,”
IEEE journal of biomedical and health informatics, vol. 19, no. 2, pp.
418–429, 2015.
[15] C. Song, K. Liu, X. Zhang, L. Chen, and X. Xian, “An obstructive sleep
apnea detection approach using a discriminative hidden markov model
from ECG signals,” IEEE Transactions on Biomedical Engineering,
vol. 63, no. 7, pp. 1532–1542, 2016.
[16] K. E. Bloch, “Polysomnography: a systematic review,” Technology and
Health Care, vol. 5, no. 4, pp. 285–305, 1997.
[17] M. Bsoul, H. Minn, and L. Tamil, “Apnea medassist: real-time sleep ap-
nea monitor using single-lead ECG,” IEEE Transactions on Information
Technology in Biomedicine, vol. 15, no. 3, pp. 416–427, 2011.
[18] S. Gutta, Q. Cheng, H. Nguyen, and B. Benjamin, “Cardiorespiratory
model-based data-driven approach for sleep apnea detection,” IEEE
journal of biomedical and health informatics, 2017.
[19] C. Varon and S. Van Huffel, Complexity and Nonlinearities in
Cardiorespiratory Signals in Sleep and Sleep Apnea, R. Barbieri,
E. P. Scilingo, and G. Valenza, Eds. Cham: Springer International
Publishing, 2017. [Online]. Available: ht t ps : //d oi .or g /10.1007/978−
3 − 319 − 58709 − 7 − 19.
[20] B. L. Koley and D. Dey, “On-line detection of apnea/hypopnea events
using SpO2 signal: A rule-based approach employing binary classifier
models,” IEEE journal of biomedical and health informatics, vol. 18,
no. 1, pp. 231–239, 2014.
[21] A. Smruthy and M. Suchetha, “Real-time classification of healthy and
apnea subjects using ECG signals with variational mode decomposition,”
IEEE Sensors Journal, vol. 17, no. 10, pp. 3092–3099, 2017.
[22] M. Drinnan, J. Allen, P. Langley, and A. Murray, “Detection of sleep
apnoea from frequency analysis of heart rate variability,” in Computers
in Cardiology 2000. IEEE, 2000, pp. 259–262.
[23] M. Schrader, C. Zywietz, V. Von Einem, B. Widiger, and G. Joseph,
“Detection of sleep apnea in single channel ECGs from the physionet
data base,” in Computers in Cardiology 2000. IEEE, 2000, pp. 263–
266.
[24] P. Stein and P. Domitovich, “Detecting OSAHS from patterns seen on
heart-rate tachograms,” in Computers in Cardiology 2000. IEEE, 2000,
pp. 271–274.
[25] W. Flemons, D. Buysse, S. Redline, A. Oack, K. Strohl, J. Wheatley,
T. Young, N. Douglas, P. Levy, W. McNicolas et al., “Sleep-related
breathing disorders in adults: recommendations for syndrome definition
and measurement techniques in clinical research,” Sleep, vol. 22, no. 5,
pp. 667–689, 1999.
[26] T. Penzel, G. B. Moody, R. G. Mark, A. L. Goldberger, and J. H. Peter,
“The Apnea-ECG database,” in Computers in Cardiology 2000. IEEE,
2000, pp. 255–258.
[27] C. Heneghan, “St. vincent’s university hospital/university col-
lege dublin sleep apnea databaase.” (2008). [Online]. Available:
http://www.physionet.org/pn3/ ucddb/.
[28] P. de Chazal, T. Penzel, and C. Heneghan, “Automated detection of
obstructive sleep apnoea at different time scales using the electrocardio-
gram,” Physiological Measurement, vol. 25, no. 4, p. 967, 2004.
[29] C. Varon, D. Testelmans, B. Buyse, J. A. Suykens, and S. Van Huffel,
“Robust artefact detection in long-term ECG recordings based on auto-
correlation function similarity and percentile analysis,” in Engineering
in Medicine and Biology Society (EMBC), 2012 Annual International
Conference of the IEEE. IEEE, 2012, pp. 3151–3154.
[30] D. Cvetkovic, E. D. Übeyli, and I. Cosic, “Wavelet transform feature
extraction from human PPG, ECG, and EEG signal responses to elf pemf
exposures: A pilot study,” Digital Signal Processing, vol. 18, no. 5, pp.
861–874, 2008.
This article has been accepted for publication in a future issue of this journal, but has not been fully edited. Content may change prior to final publication. Citation information: DOI 10.1109/JBHI.2018.2842919, IEEE Journal of
Biomedical and Health Informatics
11

[31] S. G. Mallat, “A theory for multiresolution signal decomposition: the

wavelet representation,” IEEE Transactions on Pattern Analysis and
Machine Intelligence, vol. 11, no. 7, pp. 674–693, 1989.
[32] H. Ocak, “Automatic detection of epileptic seizures in eeg using dis-
crete wavelet transform and approximate entropy,” Expert Systems with
Applications, vol. 36, no. 2, pp. 2027–2036, 2009.
[33] S. M. Pincus, “Approximate entropy as a measure of system complexity.”
Proceedings of the National Academy of Sciences, vol. 88, no. 6, pp.
2297–2301, 1991.
[34] H. M. Al-Angari and A. V. Sahakian, “Use of sample entropy approach
to study heart rate variability in obstructive sleep apnea syndrome,” IEEE
Transactions on Biomedical Engineering, vol. 54, no. 10, pp. 1900–
1904, 2007.
[35] Z. Cao, Y. Liu, C. Liu, J. Yang, C. Luo, B. Wang, H. Wang, Y. Wang, and
M. Yu, “Analysis of heart rate variability between rest and exercise states
in hypoxic environment using fuzzy measure entropy,” in Information
Technology in Medicine and Education (ITME), 2016 8th International
Conference on. IEEE, 2016, pp. 83–89.
[36] W. Chen, Z. Wang, H. Xie, and W. Yu, “Characterization of surface
EMG signal based on fuzzy entropy,” IEEE Transactions on Neural
Systems and Rehabilitation Engineering, vol. 15, no. 2, pp. 266–272,
2007.
[37] A. Porta, G. Baselli, D. Liberati, N. Montano, C. Cogliati, T. Gnecchi-
Ruscone, A. Malliani, and S. Cerutti, “Measuring regularity by means
of a corrected conditional entropy in sympathetic outflow,” Biological
Cybernetics, vol. 78, no. 1, pp. 71–78, 1998.
[38] Ş. Yücelbaş, C. Yücelbaş, G. Tezel, S. Özşen, S. Küççüktürk, and
Ş. Yosunkaya, “Pre-determination of osa degree using morphological
features of the ecg signal,” Expert Systems with Applications, vol. 81,
pp. 79–87, 2017.
[39] A. R. Hassan and M. A. Haque, “An expert system for automated
identification of obstructive sleep apnea from single-lead ECG using
random under sampling boosting,” Neurocomputing, vol. 235, pp. 122–
130, 2017.
[40] S. Martín-González, J. L. Navarro-Mesa, G. Juliá-Serdá, J. F. Kraemer,
N. Wessel, and A. G. Ravelo-García, “Heart rate variability feature
selection in the presence of sleep apnea: An expert system for the
characterization and detection of the disorder,” Computers in Biology
and Medicine, 2017.
[41] A. R. Hassan and M. A. Haque, “Computer-aided obstructive sleep
apnea screening from single-lead electrocardiogram using statistical
and spectral features and bootstrap aggregating,” Biocybernetics and
Biomedical Engineering, vol. 36, no. 1, pp. 256–266, 2016.
[42] A. R. Hassan, “Computer-aided obstructive sleep apnea detection using
normal inverse gaussian parameters and adaptive boosting,” Biomedical
Signal Processing and Control, vol. 29, pp. 22–30, 2016.
[43] H. Sharma and K. Sharma, “An algorithm for sleep apnea detection from
single-lead ECG using hermite basis functions,” Computers in Biology
and Medicine, vol. 77, pp. 116–124, 2016.
[44] G. Sannino, I. De Falco, and G. De Pietro, “An automatic rules extraction
approach to support OSA events detection in an mhealth system,” IEEE
Journal of Biomedical and Health Informatics, vol. 18, no. 5, pp. 1518–
1524, 2014.
[45] L. Chen, X. Zhang, and C. Song, “An automatic screening approach
for obstructive sleep apnea diagnosis based on single-lead electrocar-
diogram,” IEEE Transactions on Automation Science and Engineering,
vol. 12, no. 1, pp. 106–115, 2015.
[46] D. S. Morillo and N. Gross, “Probabilistic neural network approach
for the detection of SAHS from overnight pulse oximetry,” Medical &
Biological Engineering & Computing, vol. 51, no. 3, pp. 305–315, 2013.
[47] D. Alvarez, R. Hornero, J. V. Marcos, and F. del Campo, “Multivariate
analysis of blood oxygen saturation recordings in obstructive sleep apnea
diagnosis,” IEEE Transactions on Biomedical Engineering, vol. 57,
no. 12, pp. 2816–2824, 2010.
[48] J. V. Marcos, R. Hornero, D. Álvarez, F. del Campo, and C. Zamarrón,
“Assessment of four statistical pattern recognition techniques to assist in
obstructive sleep apnoea diagnosis from nocturnal oximetry,” Medical
Engineering & Physics, vol. 31, no. 8, pp. 971–978, 2009.

2168-2194 (c) 2018 IEEE. Personal use is permitted, but republication/redistribution requires IEEE permission. See http://www.ieee.org/publications_standards/publications/rights/index.html for more information.