AUTHOR QUERIES

AUTHOR PLEASE ANSWER ALL QUERIES

Q:1 AUTHOR: Snoring patients was changed throughout to patients who snore per style.
Q:2 AUTHOR: Please note that funding information was moved from the Acknowledgments to the Dis-
closure Statement per style.
Q:3 AUTHOR: Please provide supplier and location of supplier for Rooti Rx.
Q:4 AUTHOR: Please provide supplier and location of supplier for Compumedics Grael and ResMed
Embla N7000 and MPR.
Q:5 AUTHOR: The URL http://www.aasmnet.org/resources/pdf/Scoring-manual-update-April-2017.pdf
has been redirected to https://aasm.org/resources/pdf/scoring-manual-update-april-2017.pdf. Please
verify the URL.
Q:6 AUTHOR: Please spell out QRS.
Q:7 AUTHOR: One subhead should not be used. Please provide another subhead under Discussion or delete
subhead here.
 https://doi.org/10.5664/jcsm.8462

S C I E N T I F I C I N V E S T I G AT I O N S

Q:1 Screening of obstructive sleep apnea in patients who snore using a patch-type
device with electrocardiogram and 3-axis accelerometer
Ying-Shuo Hsu, MD1,2; Tien-Yu Chen, MD3,4; Dean Wu, MD5,6,7; Chia-Mo Lin, MD8,9,10; Jer-Nan Juang, PhD11;
Wen-Te Liu, MD5,11,12,13,14,15
1
Department of Otolaryngology, Shin Kong Wu Ho-Su Memorial Hospital, Taipei, Taiwan; 2School of Medicine, Fu Jen Catholic University, New Taipei City, Taiwan; 3Department of
Psychiatry, Tri-Service General Hospital, School of Medicine, National Defense Medical Center, Taipei, Taiwan; 4 Institute of Brain Science, National Yang-Ming University, Taipei,
Taiwan; 5Sleep Center, Shuang Ho Hospital, Taipei Medical University, New Taipei City, Taiwan; 6Department of Neurology, Shuang Ho Hospital, Taipei Medical University, New Taipei
City, Taiwan; 7Department of Neurology, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan; 8Division of Chest Medicine, Shin Kong Wu Ho-Su Memorial
Hospital, Taipei, Taiwan; 9 Department of Chemistry, Fu-Jen Catholic University, New Taipei City, Taiwan; 10Graduate Institute of Biomedical and Pharmaceutical Science, Fu Jen
Catholic University, New Taipei City, Taiwan; 11Department of Engineering Science, National Cheng Kung University, Tainan, Taiwan; 12Division of Pulmonary Medicine, Department of
Internal Medicine, Shuang Ho Hospital, Taipei Medical University, New Taipei City, Taiwan; 13Department of Internal Medicine, School of Medicine, College of Medicine, Taipei Medical
University, Taipei, Taiwan; 14School of Respiratory Therapy, College of Medicine, Taipei Medical University, Taipei, Taiwan; 15Sleep Science Center, Taipei Medical University
Hospital, Taipei Medical University, Taipei, Taiwan

Study Objectives: People with obstructive sleep apnea (OSA) remain undiagnosed because of the lack of easy and comfortable screening tools. Through this
study, we aimed to compare the diagnostic accuracy of chest wall motion and cyclic variation of heart rate (CVHR) in detecting OSA by using a single-lead
electrocardiogram (ECG) patch with a 3-axis accelerometer.
Methods: In total, 119 patients who snore simultaneously underwent polysomnography with a single-lead ECG patch. Signals of chest wall motion and CVHR
from the single-lead ECG patch were collected. The chest effort index (CEI) was calculated using the chest wall motion recorded by a 3-axis accelerometer in the
device. The ability of CEI and CVHR indices in diagnosing moderate-to-severe OSA (apnea hypopnea index ≥ 15) was compared using the area under the curve
(AUC) by using the DeLong test.
Results: CVHR detected moderate-to-severe OSA with 52.9% sensitivity and 94.1% specificity (AUC: 0.76, 95% confidence interval: 0.67–0.84, optimal cutoff:
21.2 events/h). By contrast, CEI identified moderate-to-severe OSA with 80% sensitivity and 79.4% specificity (AUC: 0.87, 95% confidence interval: 0.80–0.94,
optimal cutoff: 7.1 events/h). CEI significantly outperformed CVHR regarding the discrimination ability for moderate-to-severe OSA (ΔAUC: 0.11, 95% confidence
interval: 0.009–0.21, P = .032). For determining severe OSA, the performance of discrimination ability was greater (AUC = 0.90, 95% confidence interval:
0.85–0.95) when combining these two signals.
Conclusions: Both CEI and CVHR recorded from a patch-type device with ECG and a 3-axis accelerometer can be used to detect moderate-to-severe OSA.
Thus, incorporation of CEI is helpful in the detection of sleep apnea by using a single-lead ECG with a 3-axis accelerometer.
Keywords: apnea–hypopnea index, cyclic variation of heart rate, chest wall motion, electrocardiogram, sleep apnea, obstructive sleep apnea
sleep-disordered breathing
Citation: Hsu Y-S, Chen T-Y, Wu D, Lin C-M, Juang J-N, Liu W-T. Screening of obstructive sleep apnea in patients who snore using a patch-type device with
electrocardiogram and 3-axis accelerometer. J Clin Sleep Med. 2020;16(0):XXX–XXX.

BRIEF SUMMARY
Current Knowledge/Study Rationale: To determine the accuracy and tolerability of a single electrocardiogram lead to screen for sleep apnea, we collected
the data of 119 patients who snore who simultaneously underwent polysomnography and a single-lead electrocardiogram patch with 3-axis accelerometer.
Chest effort index from the chest wall motion and cyclic variation of heart rate were calculated and compared with the apnea-hypopnea index recorded
through polysomnography.
Study Impact: We found that chest effort index significantly outperformed the cyclic variation of heart rate on the discrimination ability in identifying
moderate-to-severe obstructive sleep apnea. Our study validated that a combination of chest effort index and cyclic variation of heart rate is helpful in
identifying obstructive sleep apnea in sleep tests conducted using a single-lead electrocardiogram with 3-axis accelerometer.

INTRODUCTION excessive daytime sleepiness.5 Therefore, this disease consid-

Obstructive sleep apnea (OSA) occurs during sleep because of
recurrent upper airway obstruction. Several complications as-
sociated with OSA have been detected, such as hypertension,1
sudden cardiac death,2 cerebrovascular diseases,3 diabetes,4 and
erably impacts the health and quality of life of affected indi-
viduals. Benjafield et al6 estimated that globally, 936 million
adults 30–69 years of age (men and women) have mild-to-se-
vere OSA, and 425 million adults 30–69 years of age have
moderate-to-severe OSA. The prevalence is so high that there is

Journal of Clinical Sleep Medicine, Vol. nnn, No. nnn 1 nnn nnn, 2020
Y-S Hsu, T-Y Chen, D Wu, et al.
Figure 1—Rooti Rx, a wireless single-lead ECG monitoring patch.
(A) Appearance of the device. (B) CVHR pattern recorded by Rooti Rx. Cyclic lengthening/shortening in the heart rate during apnea/postapneic
hyperventilation is shown. The airflow and saturation data were derived from the PSG. The response of SpO2 and heart rate falls a little behind air flow in an
apnea event. This phenomenon means that desaturation and heart rate variability are likely an aftermath of sleep apnea. CVHR = cyclic variation of heart rate,
ECG = electrocardiogram, SpO2 = peripheral oxygen saturation.
a growing need for devices that are more accessible to people
to more efficiently and conveniently diagnose new patients
with sleep apnea; thus, a comprehensive assessment of novel
diagnostic devices for sleep apnea is warranted.
In-laboratory polysomnography (PSG) is the first-line di-
agnostic study for suspected OSA.7 However, this test is
expensive, time consuming, and uncomfortable. Therefore,
several alternatives to PSG were proposed, and home sleep
apnea testing is one of them.7 Oximetry is another less expensive
and easier alternative that is widely available.8,9 However,
attaching a device to the finger during sleep is uncomfortable
and may limit natural position change during sleep; moreover,
the device is removed on waking up, which limits its use in
multiday, continuous recordings.
Cyclic variation of heart rate (CVHR) was first introduced by
Guilleminault et al10 for screening of OSA. They found that at
the onset of sleep apnea, patients showed progressive brady-
cardia, followed by abrupt tachycardia on resumption of
breathing. As this screening tool has an advantage of comfort
recording in sleep, especially in modern-type single-lead
electrocardiogram (ECG) devices, it is potentially suitable for
multiday evaluation. Several studies have been conducted to
improve its algorithm and accuracy.11–16
Chest wall motion is affected in sleep apnea. During sleep
apnea, the muscle tone of the upper airway is reduced. However,
Journal of Clinical Sleep Medicine, Vol. nnn, No. nnn
Screening of sleep apnea
the diaphragm and intercostal muscle tone remain relatively
the same.17 The difference in muscle function results in upper
airway collapse and apnea.18 Staats et al19 suggested that respi-
ratory efforts against the occlusion cause distortion of the chest
wall and result in paradoxical motion of the rib cage, which can
adequately characterize apnea in most patients. The authors also
suggested that recognizing these paradoxical chest wall motions in
sleep apnea could help avoid the use of invasive sleep monitoring
techniques. We hypothesized that chest wall motion, as an indicator
of a sleep apnea episode, can also be simultaneously recorded during
recording using a single-lead ECG device.
Through this study, we aimed to evaluate the predictive
performance of chest wall motion and CVHR in detecting OSA
with wireless single-lead ECG monitoring patch with 3-axis ac-
celerometer in subjects who snore. We hypothesized that using an
overnight wireless single-lead ECG monitoring patch with a 3-axis
accelerometer is an accurate method to identify OSA, especially
when simultaneously considering CVHR and chest wall motion.
METHODS
Subjects and study protocol
In this prospective study, 119 patients who snore were included;
they were subjected to in-laboratory PSG examinations at the
2 nnn nnn, 2020
 Y-S Hsu, T-Y Chen, D Wu, et al. Screening of sleep apnea

Figure 2—The chest wall motion is translated from the signals of the 3-axis accelerometer.

(A) Placement of Rooti Rx monitoring patch and the axes of the 3-axis accelerometer. (B) Signals from PSG airflow and from 3-axis accelerometer of Rooti
Rx in X, Y, and Z axes (labeled as G-X, G-Y, and G-Z, respectively). The Y-axis signal has the largest fluctuation amplitude during apnea and normal
respiration. PSG = polysomnography.

sleep center. Among them, 97 were from Shin Kong hospital
(SKH), and 22 were from Shuang Ho Hospital (SHH). The study
was approved by the institutional review boards of both hos-
pitals (SKH: 20171003R, SHH: N201709023), and written
informed consent was provided by all participants. Adult pa-
tients aged between 18 and 70 years who complained of snoring
or those with suspected sleep-disordered breathing were in-
cluded. Patients with persistent atrial fibrillation, pacemaker
implantation, ventricular tachycardia, or those who were
Q:3 pregnant were excluded. At the sleep center, a wireless single-
F1 lead ECG monitoring patch (Rooti Rx; Figure 1A) was si-
multaneously used; it was placed between the midsternal line
and the left midclavicular line and around the third and fourth
intercostal space. This device also provides 3-axis acceler-
ometer signals, which could represent the motion of chest wall
during respiration. The signals collected by PSG and Rooti Rx
were synchronized, and the measurements derived from the two
tests were compared.
PSG
Q:4 The PSG recordings were obtained using Compumedics Grael
(SKH) or ResMed Embla N7000 and Embla MPR (SHH). The
sleep stages and respiratory events were scored using the
updated standard diagnostic criteria of the American Acad-
emy of Sleep Medicine (AASM)20 and AASM 2017 scoring
guidelines (https://aasm.org/resources/pdf/scoring-manual-
update-april-2017) by an experienced registered polysomno- Q:5
graphic technologist at the sleep center of SKH and SHH, and
these scorings were rechecked by at least 2 technologists to
ensure further accuracy of sleep apnea events and ECG staging.
Obstructive apnea was defined as a drop in the peak thermal
sensor excursion by more than 90% from the baseline for at least
10 seconds, caused by airway obstruction. If these events lacked
respiratory effort, they were defined as central apnea. Hypopnea
was defined as more than 30% reduction in airflow for at least
10 seconds with arousal or more than 3% oxygen desaturation.
Apnea-hypopnea index (AHI) was determined as the mean
number of apneas and hypopneas per hour of time in sleep for
each PSG recording. Patients were considered to have mod-
erate-to-severe OSA when their AHI was more than 15 events/h.
All the PSG recordings were performed during the night, and
split PSG studies were not included. The in-laboratory PSG data
were carefully reviewed by a second sleep technologist. If there
were differences in their assessments, these were carefully
evaluated by both sleep technologists until a final consensus
was met.

Journal of Clinical Sleep Medicine, Vol. nnn, No. nnn 3 nnn nnn, 2020
Y-S Hsu, T-Y Chen, D Wu, et al. Screening of sleep apnea

Figure 3—Illustration of the calculated peaks and troughs of the chest effort event.

To determine the chest effort event by this diagram, 3 criteria should be achieved (marked in bold). First, peak–trough differences should be greater than the
drop threshold. Second, the trough value should be lower than the block threshold. Third, the duration of each event (start point to end point) should be greater
than 10 seconds.

Table 1—Baseline characteristics of patients according to severity of obstructive sleep apnea.

Variables Total (n = 119) Moderate-to-Severe OSA (n = 85) None-to-Mild OSA (n = 34) P
Age (yr) 42.8 ± 11.6 43.6 ± 11.7 40.9 ± 11.2 .245
Male 96 (80.7) 72 (84.7) 24 (70.6) .069
Height (cm) 169.7 ± 7.5 170.5 ± 7.4 167.9 ± 7.4 .086
Weight (kg) 78.5 ± 16.0 81.8 ± 16.4 70.5 ± 11.4 <.001
BMI (kg/m2) 27.2 ± 4.7 28.0 ± 4.8 25.0 ± 3.6 .001
Neck length (cm) 38.7 ± 3.4 39.4 ± 3.5 37.0 ± 2.7 <.001
Mean heart rate (beats/min) 66.6 ± 10.0 68.1 ± 10.1 62.9 ± 9.0 .011
Mean SpO2 (%) 93.6 ± 4.2 92.4 ± 4.4 96.7 ± 1.0 <.001
Lowest SpO2 (%) 79.5 ± 13.3 76.8 ± 10.7 86.4 ± 16.4 <.001
Desaturation index (events/h) 25.9 ± 28.3 35.1 ± 28.7 2.7 ± 3.1 <.001
Snore index (events/h) 385 ± 238 427 ± 223 281 ± 244 .002
CVHR index (events/h) 22.9 ± 20.6 27.9 ± 21.9 10.4 ± 8.4 <.001
CEI (events/h) 13.5 ± 11.8 16.8 ± 12.3 5.4 ± 3.9 <.001
AHI (events/h) 35.6 ± 26.9 46.6 ± 24.1 7.9 ± 3.8 <.001
Total sleep time (h) 338.6 ± 55.5 342.0 ± 51.8 330.0 ± 63.9 .291
Sleep efficiency (%) 85.1 ± 11.3 85.8 ± 9.7 83.5 ± 14.7 .321
Apnea counts 94.3 ± 125.6 129.8 ± 132.9 5.4 ± 8.2 <.001
Hypopnea counts 112.3 ± 84.5 141.0 ± 83.2 40.7 ± 22.1 <.001

Values are presented as number (%) or mean ± SD. AHI = apnea-hypopnea index, BMI = body mass index, CEI = chest effort index, CVHR = cyclic variation
of heart rate, OSA = obstructive sleep apnea, SpO2 = peripheral oxygen saturation.

Journal of Clinical Sleep Medicine, Vol. nnn, No. nnn 4 nnn nnn, 2020
Y-S Hsu, T-Y Chen, D Wu, et al.
Figure 4—Relationship between (A) CVHR index, (B) CEI, and the severity of obstructive sleep apnea.
AHI = apnea–hypopnea index, CEI = chest effort index, CVHR = cyclic variation of heart rate.
CVHR
CVHR is a characteristic heart rate pattern that often presents
along with episodes of OSA. CVHR (Figure 1B) is an ECG
pattern characterized by progressive bradycardia at the onset of
sleep apnea, followed by abrupt tachycardia on resumption of
breathing. This pattern is identifiable through computer analysis
and can be used as a screening tool for sleep apnea.10 For single-
lead ECG, Hayano et al11,16 developed an algorithm called
autocorrelated wave detection with adaptive threshold for
automated detection of CVHR and demonstrated that this
pattern could be used to screen moderate-to-severe OSA.
Hence, the analysis of single-lead ECG during sleep could be
considered a screening tool.
In this study, single-lead ECGs were obtained using wireless
single-lead ECG monitoring patches (Rooti Rx; Figure 1A).
The ECG signals were then analyzed using RootiCare Sleep
Monitoring, a certified cloud-based computing software. Using
this, CVHR was detected through adaptive threshold and its
Journal of Clinical Sleep Medicine, Vol. nnn, No. nnn
Screening of sleep apnea
time-domain dip-detection algorithm.11 Valid CVHR events
were defined as at least 3 consecutive cycles of increase in heart
rate (>6 beats/min) that last for 10–120 seconds. The CVHR
index was then calculated as the mean number of CVHR events
per hour of sleep.
Chest effort
To measure the chest wall motion during respiratory cycles and
sleep apnea events, the recorded 3-axis accelerometer signals
were analyzed using the Rooti Rx monitoring patches, and chest
effort events were calculated (Figure 2). F2
The chest effort events were automatically detected through 3-axis
G-sensor signal recording (Figure 2B). As the most significant
chest wall motions were noted on the Y-axis and these signals
were less affected by position change, the Y-axis signals contributed
the most to the chest effort events in this study (Figure 2B).
The details of the calculation for chest effort events are shown
in Figure 3. The Y-axis signals were obtained at a sampling F3
5 nnn nnn, 2020
Y-S Hsu, T-Y Chen, D Wu, et al.
Table 2—Association between CVHR or CEI and risk of different types of OSA.
Log Value of CVHR
Model
OR (95% CI)
Mild, moderate, and severe OSA
Model 1 1.48 (0.94–2.33)
Model 2 1.53 (0.95–2.45)
Model 3 1.41 (0.85–2.34)
Moderate to severe OSA (primary outcome)
Model 1 2.00 (1.37–2.93)
Model 2 2.02 (1.38–2.94)
Model 3 1.80 (1.21–2.68)
Severe OSA
Model 1 5.06 (2.75–9.33)
Model 2 4.86 (2.64–8.93)
Model 3 4.14 (2.16–7.92)
Model 1 is without adjustment for any covariates. Model 2 is adjusted for age and sex. Model 3 is adjusted for age, sex, and body mass index. CEI = chest effort
index, CI = confidence interval, CVHR = cyclic variation of heart rate, OR = odds ratio, OSA = obstructive sleep apnea.
frequency of 31.25 Hz. We initially applied the Butterworth
bandpass filter with a pass band of 0.15–0.4 Hz and then per-
formed downsampling to 1 Hz by calculating the summation of
the signal in the moving window of 5 seconds. Then, the
downsampled moving sum signal was used to determine the
peaks and troughs. By searching forward and backward from the
trough point, the points at which there was 80% peak–trough
difference were also located at the start and the endpoint of
each event. Based on the median of moving sum signal ad-
justed for each case, the drop threshold value was determined
to detect sharp changes in chest wall motion, and the block
threshold value was determined to detect blocked chest wall
movement. Subsequently, chest effort events could be de-
tected using these three criteria: (1) peak–trough differences
should be greater than the drop threshold; (2) the trough value
should be lower than the block threshold; and (3) the duration of
each event (start point to endpoint) should be greater than
10 seconds.
Events that fulfilled these 3 criteria were considered chest
effort events. The chest effort index (CEI) was calculated as the
mean number of chest effort events per hour of sleep.
A further explanation of a drop threshold and block threshold
is described here. A drop threshold is used to check if a sharp
chest movement change occurs (peak-trough difference > drop
threshold), because a sharp chest movement change would be a
signal for the start of an obstruction event. A block threshold is a
fairly low chest movement level that is used to determine
whether the chest movement is blocked, and an even lower chest
movement is considered an obstruction event. Drop threshold
and block threshold were adjusted for each case based on the
median of the moving sum signal.
Statistical analysis
The baseline characteristics of the patients in the moderate-to-
severe and none-to-mild OSA groups were compared using the
independent-sample t test for age (continuous variable) or χ 2 test
Journal of Clinical Sleep Medicine, Vol. nnn, No. nnn 6 nnn nnn, 2020
Screening of sleep apnea
Log Value of CEI
P OR (95% CI) P
.091 3.82 (1.57–9.27) .003
.080 4.13 (1.59–10.74) .004
.184 3.89 (1.47–10.27) .006
<.001 9.78 (3.99–24.01) <.001
<.001 10.49 (4.09–26.89) <.001
.004 10.50 (3.81–28.92) <.001
<.001 11.50 (4.83–27.35) <.001
<.001 13.26 (5.20–33.77) <.001
<.001 12.72 (4.51–35.86) <.001
for the categorical variables. The relationships among CVHR,
CEI, and AHI index were studied using Spearman rank cor-
relation. The outcome of primary interest was moderate-to-
severe OSA (AHI ≥ 15 events/h, n = 85), whereas the outcomes
of secondary interest were mild, moderate, or severe OSA
(AHI ≥ 5 events/h, n = 110), as well as severe OSA (AHI ≥ 30
events/h, n = 58). The association between CVHR or CEI and
the risk of OSA was assessed using bivariate and multivariable
logistic regression analyses. Several known confounders of
OSA, including age, sex, and body mass index (BMI), were
adjusted in the multivariable analysis. The values of CVHR or
CEI were naturally log-transformed in logistic analyses because
of the lack of normality. The performance of CVHR or CEI to
detect OSA was evaluated through receiver operating charac-
teristic curve analysis. The optimal cutoffs were determined by
Youden index. The positive likelihood ratio (+LR), negative
likelihood ratio (−LR), positive predictive value (PPV), and
negative predictive value (NPV) were obtained according to the
prevalence of patients who snore, in which 40% had moderate-
to-severe OSA.21 The difference in AUCs between CEI and
CVHR was compared using the DeLong test. All tests were 2-
tailed, and P < .05 was considered statistically significant. No
adjustment of multiple testing (multiplicity) was made in this
study. Data were analyzed using SPSS 25 (IBM SPSS Inc.,
Chicago, IL).
The scale of AHI and CVHR/CEI is different even if their unit
is the same (i.e., the number of events per hour). In other words,
an AHI value of 1 is not equivalent to a CVHR/CEI value of 1;
likewise, a CVHR value of 1 is also not equivalent to a CEI value
of 1. Because not every apnea-hypopnea event results in heart
rate variability or a chest effort change, a suitable screening
threshold for CVHRI and CEI was required in this study. As
such, the Bland-Altman plot was not appropriate in this sce-
nario. Furthermore, neither ECG nor chest effort signals were
synchronized in this study, so we only compared the final
numbers for each patient.
 Y-S Hsu, T-Y Chen, D Wu, et al. Screening of sleep apnea

Table 3—Diagnostic properties of CVHR and CEI in detecting different severities of OSA.
Outcome/Statistics CVHR CEI CVHR + CEI
Mild, moderate or severe OSA
AUC (95% CI) 0.71 (0.56–0.85) 0.80 (0.64–0.96) 0.75 (0.61–0.89)
a
Cutoff >18.6 >6.6 CVHR>18.6 and CEI>6.6
Sensitivity, % (95% CI) 47.3 (37.7–57.0) 70.9 (61.5–79.2) 40.9 (31.6–50.7)
Specificity, % (95% CI) 100 (66.4–100) 88.9 (51.8–99.7) 100 (66.4–100)
+LR (95% CI)b NA 6.4 (1.0–40.7) NA
−LR (95% CI)b 0.5 (0.4–0.6) 0.3 (0.2–0.5) 0.6 (0.5–0.7)
PPV (95% CI)b NA 81 (40.0–96.4) NA
NPV (95% CI)b 74 (70.4–77.2) 82.1 (76.0–86.9) 71.7 (68.5–74.8)
Moderate to severe OSA (primary outcome)
AUC (95% CI) 0.76 (0.67–0.84) 0.87 (0.80–0.94) 0.82 (0.75–0.90)
Cutoffa >21.2 >7.1 CVHR > 21.2 and CEI > 7.1
Sensitivity, % (95% CI) 52.9 (41.8–63.9) 80.0 (69.9–87.9) 48.2 (37.3–59.3)
Specificity, % (95% CI) 94.1 (80.3–99.3) 79.4 (62.1–91.3) 97.1 (84.7–99.9)
+LR (95% CI)b 9 (2.3–35.0) 3.9 (2.0–7.6) 16.4 (2.3–114.5)
−LR (95% CI)b 0.5 (0.4–0.6) 0.3 (0.2–0.4) 0.5 (0.4–0.7)
PPV (95% CI)b 85.7 (60.6–95.9) 72.1 (57.0–83.5) 91.6 (61.0–98.7)
NPV (95% CI)b 75 (70.2–79.2) 85.6 (79.0–90.4) 73.8 (69.4–77.7)
Severe OSA
AUC (95% CI) 0.86 (0.79–0.93) 0.87 (0.81–0.94) 0.91 (0.85–0.96)
Cutoffa >21.9 >11 CVHR > 21.9 and CEI > 11
Sensitivity, % (95% CI) 70.7 (57.3–81.9) 72.4 (59.1–83.3) 58.6 (44.9–71.4)
Specificity, % (95% CI) 91.8 (81.9–97.3) 88.5 (77.8–95.3) 98.4 (91.2–100)
+LR (95% CI)b 8.6 (3.7–20.3) 6.3 (3.1–12.9) 35.8 (5.1–252.8)
−LR (95% CI)b 0.3 (0.2–0.5) 0.3 (0.2–0.5) 0.4 (0.3–0.6)
PPV (95% CI)b 85.2 (71.0–93.1) 80.8 (67.3–89.6) 96.0 (77.1–99.4)
NPV (95% CI)b 82.5 (75.8–87.6) 82.8 (75.9–88.1) 78.1 (72.4–82.9)
a
According to Youden index. bAccording to a prevalence of 40% of moderate-to-severe OSA in patients who snore. AUC = area under the curve, CEI = chest
effort index, CI = confidence interval, CVHR = cyclic variation of heart rate, +LR = positive likelihood ratio, −LR = negative likelihood ratio, NA = not applicable,
NPV = negative predicted value, OSA = obstructive sleep apnea, PPV = positive predicted value.

moderate-to-severe OSA group than in the none-to-mild OSA

RESULTS
Characteristics of the study population
A total of 119 patients who met the inclusion criteria were
included in this study; of these, 97 patients were from SKH, and
T1 22 were from SHH. Table 1 presents the baseline characteristics
of the patients according to the severity of OSA. In this study
population, 85 patients were classified as having moderate-to-
severe OSA (AHI ≥ 15 events/h), and the other 34 were clas-
sified as having none-to-mild OSA (AHI < 15 events/h). No
significant difference in age, sex, and height was observed
between the 2 groups. However, patients in the moderate-to-
severe OSA group had a larger BMI and greater neck length.
Because the moderate-severe group was predominantly male
and the none-to-mild group was predominantly female, sex
could explain the differences observed between these 2 groups
in terms of weight, BMI, and neck length. The mean heart
rate, desaturation index, and snore index, as well as the CVHR,
CEI, and AHI index, were also significantly higher in the
group. Significantly lower mean saturation (92.4% in the
moderate-to-severe OSA group vs 96.7% in the none-to-mild
OSA group) and lowest saturation (76.8% in the moderate-to-
severe OSA group vs 86.4% in the none-to-mild OSA group)
were also noted in the moderate-to-severe OSA group. In ad-
dition, the moderate-to-severe OSA group had more apnea and
hypopnea events.
Association among CVHR, CEI, and severity of OSA
Figure 4 illustrates the relationships among CVHR, CEI, and F4
AHI index. The results demonstrated that both CVHR and CEI
were significantly positively correlated to AHI values (Spear-
man rank correlation coefficient = 0.65 and 0.77, respectively;
both P < .001). Table 2 shows the results of bivariate and T2
multivariable logistic regression analyses for the association
between CVHR or CEI and the risk of moderate-to-severe
OSA. After adjustment for age, sex, and BMI, both CVHR
and CEI were significantly associated with higher risks of

Journal of Clinical Sleep Medicine, Vol. nnn, No. nnn 7 nnn nnn, 2020
 Y-S Hsu, T-Y Chen, D Wu, et al.
Figure 5—Receiver operating characteristic curves of
CVHR and CEI in detecting moderate-to-severe obstructive
sleep apnea.
The difference of AUCs between CEI and CVHR was 0.11 (95% CI:
0.009–0.21), with P=.032. AUC = area under the curve, CEI = chest effort
index, CI = confidence interval, CVHR = cyclic variation of heart rate.
moderate-to-severe OSA (odds ratio [OR] = 1.80, 95% confi-
dence interval [CI]: 1.21–2.68 for CVHR; OR = 10.5, 95% CI:
3.81–28.92 for CEI). In addition, the CVHR was not associated
with higher risks of mild, moderate, and severe OSA, even
though the CEI was the following: OR = 3.89, 95% CI: 1.47–
10.27. Nonetheless, both CVHR and CEI were significantly
associated with higher risks of severe OSA (OR = 4.14, 95% CI:
2.16–7.92 for CVHR; OR = 12.72, 95% CI: 4.51–35.86
for CEI).
Detection performance of CVHR or CEI
The performance of CVHR in detecting moderate-to-severe
T3 OSA was satisfactory (Table 3), with an AUC of 0.76 (95% CI:
0.67–0.84). The optimal cutoff according to Youden index
was >21.2 events/h, with a PPV of 85.7% and an NPV of 75%.
By contrast, the performance of CEI in diagnosing moderate-to-
severe OSA was significantly better than CVHR (Table 3), with
an AUC of 0.87 (95% CI: 0.80–0.94). The optimal cutoff
was >7.1 events/h, with a PPV of 72.1% and an NPV of 85.6%.
F5 Figure 5 presents that the CEI significantly outperformed
CVHR with regard to discrimination ability of moderate-to-
severe OSA (ΔAUC = 0.11, 95% CI: 0.009–0.21, P = .032).
However, the combination of the CVHR and CEI did not out-
perform CEI alone in discriminating any type of OSA (mild,
moderate, or severe OSA) or moderate-to-severe OSA (Table 3).
Noticeably, the performance of discrimination ability of se-
vere OSA was excellent in terms of AUC (AUC = 0.90, 95% CI:
0.85–0.95) when combining these 2 signals. When using the
optimal cutoffs of both signals, the PPVs of moderate-to-severe
OSA (91.6%) and severe OSA (96%) were very high (Table 3).
Journal of Clinical Sleep Medicine, Vol. nnn, No. nnn
Screening of sleep apnea
Clinical use
Figure 6A presents the clinical use of Rooti Rx in the screening F6
of moderate-to-severe OSA. In our study, when CVHR was
more than 21.2 and CEI was more than 7.1 (42 patients in total),
the detection rate for moderate-to-severe OSA was 97.6% (41 of
42). When one of the indices (CVHR or CEI) was above the
cutoff value (38 patients in total), the detection rate for
moderate-to-severe OSA was 81.6% (31 of 38). When both
indices were under the cutoff value (39 patients in total), only
33.3% (13 of 39) of the patients had moderate-to-severe OSA.
Overall, when CVHR or CEI was found to be above the cutoff
value under the Rooti Rx examination (80 patients in total),
moderate-to-severe OSA was diagnosed in 90% (72 of 80) of
the patients.
Figure 6B illustrates the clinical use of Rooti Rx in the
screening of severe OSA. In our study, when CVHR was more
than 21.9 and CEI was more than 11 (35 patients in total), the
detection rate for severe OSA was 97.1% (34 of 35). When one
of the indices (CVHR or CEI) was above the cutoff value
(25 patients in total), the detection rate for severe OSA was 60%
(15 of 25). When both indices were under the cutoff value
(59 patients in total), only 15.2% (9 of 59) of the patients had
severe OSA. Overall, when CVHR or CEI was found to be
above the cutoff value in the Rooti Rx examination (60 patients
in total), 81.6% (49 of 60) of the patients were diagnosed with
severe OSA.
Figure 7 presents signal waveforms of the parallel trace of F7
cyclical heart rate variations and the chest effort signals dur-
ing apnea.
DISCUSSION
This study compared the diagnostic accuracy of detecting
chest wall motion and CVHR using a single-lead wireless ECG
patch with a 3-axis accelerometer for the screening of OSA.
Based on the survey on 119 patients who snore, a CVHR index
of >21.2 as the criterion to detect moderate-to-severe OSA
yielded only 52.9% sensitivity and 94.1% specificity. By
contrast, when CEI > 7.1 was used as the criterion, our chest
wall motion detection algorithm identified moderate-to-severe
OSA with 80% sensitivity and 79.4% specificity, which out-
performed the CVHR index. These observations indicate
that CVHR index and chest wall motion detection using a
single-lead wireless ECG patch with 3-axis accelerometer
during sleep could be used as a screening tool for moderate-to-
severe OSA.
In our study, the measurements of CVHR and CEI were
complementary to each other. When abnormal results were
revealed in this device (CEI > 7.1 or CVHR > 21.2), 90% of
patients who snore were found to have moderate-to-severe
OSA. Notably, when CVHR was less than the cutoff value,
55.5% (40 of 72) of patients had moderate-to-severe OSA. This
indicates that CEI evaluation may be necessary for screening
moderate-to-severe OSA in this wireless single-lead ECG patch
with 3-axis accelerometer.
This study has several strengths. 22 First, we conducted
a survey of all patients who snore with both the index
8 nnn nnn, 2020
Y-S Hsu, T-Y Chen, D Wu, et al. Screening of sleep apnea

Figure 6—Clinical use for diagnosis of (A) moderate-to-severe OSA and (B) severe OSA.

CEI = chest effort index, CVHR = cyclic variation of heart rate, OSA = obstructive sleep apnea.

test (CEI and CVHR index) and the reference standard
(AHI by a standard overnight attended PSG). Second, be-
cause the CEI, CVHR index, and AHI were simultaneously
recorded, no time lag or treatment effect was observed
between the index test and the reference standard. Third, the
in-laboratory PSG data were carefully reviewed by a second
sleep technologist, which improved the accuracy of the
reference standard.
Several previous studies have demonstrated a high performance
of CVHR index in screening OSA both in the PhysioNet sleep

Journal of Clinical Sleep Medicine, Vol. nnn, No. nnn 9 nnn nnn, 2020
 Y-S Hsu, T-Y Chen, D Wu, et al.
Figure 7—Signal waveforms during apnea.
Note the response of SpO2 and heart rate falls a little behind air flow and chest effort in an apnea event. CEI = chest effort index, CVHR = cyclic variation
of heart rate, SpO2 = peripheral oxygen saturation.
apnea-ECG database (https://www.physionet.org/physiobank/
database/apnea-ecg/)11–14,23 and in clinical settings.15,16,24–26
Hayano et al16 reported 92% sensitivity and 96% specificity
of automated ECG detection algorithms in identifying mod-
erate-to-severe OSA among 165 adult male workers. Although
the algorithms were the same as those used in this study, their
performance was much higher than that observed in our study.
This difference may be attributed to the difference in the scoring
systems used in the 2 studies. The scoring system for AHI
has changed extensively, especially in hypopneas.20,27 Many
studies have shown a higher AHI if updated 2012 AASM re-
spiratory event criteria were used.28,29 Hayano et al used AASM
2007 scoring guidelines, and updated AASM 2017 scoring
guidelines were used in our study. This difference may have had
a substantial impact on our result regarding sensitivity to CVHR.
Although the difference in sensitivity and specificity between
CVHR and CEI for different respiratory event criteria should be
investigated further, it is beyond the scope of this study.
Magnusdottir et al26 used cardiopulmonary coupling to im-
prove CVHR performance and reported 89% sensitivity and
79% specificity in identifying moderate-to-severe OSA by
cardiopulmonary coupling–CVHR algorithms among 47 pa-
tients. There are some differences between their study and ours.
First, cardiopulmonary coupling–CVHR was calculated using
heart rate variability and ECG-derived respiration. ECG-
Q:6 derived respiration referred to amplitude variations in the QRS
complex because of shifts in the cardiac electrical axis during
respiration and changes in thoracic impedance. It was not the
direct measurement of chest wall motion, as used in this study.
Journal of Clinical Sleep Medicine, Vol. nnn, No. nnn
Screening of sleep apnea
Second, their sample size was also smaller than ours. Third, their
study cohort may not be fully representative of the general
population with sleep apnea, because their cohort comprised
71.4% women and only 28.6% men. In our cohort, there were
only 19.3% women and 80.7% men, which was closer to the
general epidemiology of individuals with sleep-disordered
breathing.30,31 Moreover, the BMI of the patients in their
study was higher than the BMI of patients in our study (average
BMI for both sexes was 33.9 kg/m2 in their study compared with
27.2 kg/m2 in our group). The BMI of patients in our cohort was
closer to that of the general population with sleep-disordered
breathing.32 These differences in study design and patient de-
mographic data may account for the different results of the 2
studies. Notably, Magnusdottir et al also found that the sen-
sitivity of cardiopulmonary coupling–CVHR dropped from
100% to 89% when they changed scoring guidelines from 2007
and 2017, which proved that different scoring systems strongly
affect the accuracy and screening ability of a single-lead ECG
test. In our study, detection of chest wall motion may have been
better than CVHR for identifying moderate-to-severe OSA with
updated AASM respiratory event criteria.
As this single-lead wireless ECG patch is very comfortable
and could be easily hidden under clothes during the daytime,
it is suitable for multiday examination. Analysis of mul-
tiday data could lead to higher sensitivity and enable a more
accurate diagnosis. Sleep hygiene and circadian rhythm
analysis could also be reviewed in this manner, and more
information other than sleep apnea numbers could be provided
to the patients.
10 nnn nnn, 2020
 Y-S Hsu, T-Y Chen, D Wu, et al. Screening of sleep apnea

In primary care settings, screening and assessment for OSA
is a priority. Primary care providers need accurate screening
tools to predict the presence of OSA.33 Although the STOP-
Bang and Berlin questionnaires have the highest sensitivity
(97.7% for STOP-Bang and 95.5% for Berlin questionnaires),
not only is their specificity very low (3.7% for STOP-Bang and
7.4% for Berlin questionnaires) but so is their NPV (20% for
STOP-Bang and 20% for Berlin questionnaires).34 Moreover,
the STOP-Bang and Berlin questionnaires do not perform very
well when excluding low-risk OSA.33 Our patch-type device
with an ECG and a 3-axis accelerometer could serve as a
supplemental screening tool to exclude low-risk OSA with
higher specificity and NPV in the diagnosis of moderate-severe
OSA (specificity for CVHR and CEI is 94.1% and 79.4%, re-
spectively, and NPV for CVHR and CEI is 74% and 82.1%,
respectively). When using the optimal cutoffs of both signals,
the specificity and NPV for moderate-severe OSA were
also very satisfactory (specificity of 97.1% and NPV of
73.8%; Table 3).
still suggested for symptomatic patients who do not meet the
cutoffs of this screening tool.
CONCLUSIONS
Our study validated the effectiveness of screening for OSA
using a patch-type device with ECG and 3-axis accelerometer.
We also proposed a new method for the quantification of chest
wall motion, namely chest effort index, to identify moderate-to-
severe OSA, which outperformed CVHR index in our study.
A CVHR index ≥21.2 or CEI ≥ 7.1 after screening suggests
moderate-to-severe OSA, and such patients should be re-
ferred for further studies. Furthermore, compared with ques-
tionnaires, the device has higher specificity and NPV; therefore,
it could serve as a supplemental screening tool to exclude
low-risk OSA.

Q:7 Limitations ABBREVIATIONS

This study has several limitations. First, patients with atrial
AASM, American Academy of Sleep Medicine
fibrillation, pacemaker implantation, ventricular tachycardia, or
AHI, apnea–hypopnea index
those who were pregnant were excluded because we could not
AUC, area under the curve
determine CVHR in these patients. Pregnant women were
BMI, body mass index
excluded because arrhythmias in pregnancy are common,
CEI, chest effort index
and analysis of CVHR is often difficult under excessive
CI, confidence interval
arrhythmias.35 Furthermore, CEI is difficult to interpret in
CVHR, cyclic variation of heart rate
women who are pregnant, particularly in the second and third
ECG, electrocardiogram
trimesters, given the effect of the gravid uterus on chest wall
+LR, positive likelihood ratio
motion. Further studies for these subgroups should be per-
−LR, negative likelihood ratio
formed to evaluate the use of chest wall motion in detecting
NPV, negative predicted value
OSA. Second, the influence of medical treatment for our pa-
OSA, obstructive sleep apnea
tients should be evaluated, although they were mostly healthy
PLM, periodic leg movement
other than the snoring habit. Third, several studies reported that
PPV, positive predicted value
automated ECG detection algorithms tend to overestimate AHI
PSG, polysomnography
in patients with central apnea and those with periodic leg
SHH, Shuang Ho Hospital
movements (PLMs).11–14,36 PLMs may overlap CVHR and
SKH, Shin Kong Wu Ho-Su Memorial Hospital
affect its accuracy. During PLM episodes, autonomic activa-
SpO2, peripheral oxygen saturation
tions and heart rate changes could occur, resulting in CVHR.37,38
PLM-related changes in CVHR are reported to have a briefer
duration and shorter cycle length than those of CVHR changes
related with OSA. In our study, the proportion of abnormal REFERENCES
PLM (PLM > 5) was 34.5% (41 of 119 patients). This may be
1. Kapur VK, Weaver EM. Filling in the pieces of the sleep apnea-hypertension
one of the reasons for the higher performance of CEI than that
puzzle. JAMA. 2012;307(20):2197–2198.
of CVHR in our study. The impact of PLM on the accuracy of
2. Gami AS, Olson EJ, Shen WK, et al. Obstructive sleep apnea and the risk of
CVHR and CEI warrants further investigation. Moreover, be- sudden cardiac death: a longitudinal study of 10,701 adults. J Am Coll Cardiol.
cause most patients (85 of 119) actually had moderate or severe 2013;62(7):610–616.
sleep apnea, the results of this study may well be artificially 3. Durgan DJ, Bryan RM. Cerebrovascular consequences of obstructive sleep
biased toward high performance. For instance, the lack of a more apnea. J Am Heart Assoc. 2012;1(4):e000091.
substantial control group with either healthy subjects or addi- 4. Reichmuth KJ, Austin D, Skatrud JB, Young T. Association of sleep apnea and
tional patients without sleep-disordered breathing prevents an type II diabetes: a population-based study. Am J Respir Crit Care Med.
2005;172(12):1590–1595.
effective assessment of the proposed method in real clinical
5. Engleman HM, Douglas NJ. Sleep. 4: Sleepiness, cognitive function, and quality
settings. On a further note, paradoxical motions of the rib cage
of life in obstructive sleep apnoea/hypopnoea syndrome. Thorax.
and abdomen generally require 2 sensors, and only using chest 2004;59(7):618–622.
motion may not be sufficient to differentiate an obstructed 6. Benjafield AV, Ayas NT, Eastwood PR, et al. Estimation of the global prevalence
breath. Because this patch-type device is only a screening tool, and burden of obstructive sleep apnoea: a literature-based analysis. Lancet Respir.
false-negative results are still possible. Therefore, full PSG is Med. 2019;7(8):687–698.

Journal of Clinical Sleep Medicine, Vol. nnn, No. nnn 11 nnn nnn, 2020
Y-S Hsu, T-Y Chen, D Wu, et al.
7. Kapur VK, Auckley DH, Chowdhuri S, et al. Clinical practice guideline for
diagnostic testing for adult obstructive sleep apnea: an American Academy of
Sleep Medicine clinical practice guideline. J Clin Sleep Med. 2017;13(3):479–504.
8. del Campo F, Crespo A, Cerezo-Hernández A, Gutiérrez-Tobal GC, Hornero R,
Álvarez D. Oximetry use in obstructive sleep apnea. Expert Rev Respir Med.
2018;12(8):665–681.
9. Lin SH, Branson C, Leung J, Park L, Doshi N, Auerbach SH. Oximetry as an
accurate tool for identifying moderate to severe sleep apnea in patients with acute
stroke. J Clin Sleep Med. 2018;14(12):2065–2073.
10. Guilleminault C, Connolly S, Winkle R, Melvin K, Tilkian A. Cyclical variation of
the heart rate in sleep apnoea syndrome. Mechanisms, and usefulness of 24 h
electrocardiography as a screening technique. Lancet. 1984;1(8369):126–131.
11. Hayano J, Watanabe E, Saito Y, et al. Screening for obstructive sleep apnea by
cyclic variation of heart rate. Circ Arrhythm Electrophysiol. 2011;4(1):64–72.
12. Penzel T, McNames J, Murray A, de Chazal P, Moody G, Raymond B.
Systematic comparison of different algorithms for apnoea detection based on
electrocardiogram recordings. Med Biol Eng Comput. 2002;40(4):402–407.
13. Khandoker AH, Palaniswami M, Karmakar CK. Support vector machines for
automated recognition of obstructive sleep apnea syndrome from ECG recordings.
IEEE Trans Inf Technol Biomed. 2009;13(1):37–48.
14. Mendez MO, Corthout J, Van Huffel S, et al. Automatic screening of obstructive
sleep apnea from the ECG based on empirical mode decomposition and wavelet
analysis. Physiol Meas. 2010;31(3):273–289.
15. Roche F, Celle S, Pichot V, Barthélémy J-C, Sforza E. Analysis of the interbeat
interval increment to detect obstructive sleep apnoea/hypopnoea. Eur Respir J.
2007;29(6):1206–1211.
16. Hayano J, Tsukahara T, Watanabe E, et al. Accuracy of ECG-based screening
for sleep-disordered breathing: a survey of all male workers in a transport company.
Sleep Breath. 2013;17(1):243–251.
17. Guilleminault C, Hill MW, Simmons FB, Dement WC. Obstructive sleep apnea:
electromyographic and fiberoptic studies. Exp Neurol. 1978;62(1):48–67.
18. Remmers JE, deGroot WJ, Sauerland EK, Anch AM. Pathogenesis of upper
airway occlusion during sleep. J Appl Physiol. 1978;44(6):931–938.
19. Staats BA, Bonekat HW, Harris CD, Offord KP. Chest wall motion in sleep
apnea. Am Rev Respir Dis. 1984;130(1):59–63.
20. Berry RB, Budhiraja R, Gottlieb DJ, et al. Rules for scoring respiratory events in
sleep: update of the 2007 AASM Manual for the Scoring of Sleep and Associated
Events. Deliberations of the Sleep Apnea Definitions Task Force of the American
Academy of Sleep Medicine. J Clin Sleep Med. 2012;8(5):597–619.
21. Jung Y, Junna MR, Mandrekar JN, Morgenthaler TI. The National Healthy Sleep
Awareness Project Sleep Health Surveillance Questionnaire as an obstructive
sleep apnea surveillance tool. J Clin Sleep Med. 2017;13(09):1067–1074.
22. Bossuyt PM, Reitsma JB, Bruns DE, et al. Towards complete and accurate
reporting of studies of diagnostic accuracy: the STARD initiative. BMJ.
2003;326(7379):41–44.
23. Hilmisson H, Lange N, Duntley SP. Sleep apnea detection: accuracy of using
automated ECG analysis compared to manually scored polysomnography (apnea
hypopnea index). Sleep Breath. 2019;23(1):125–133.
24. Poupard L, Court-Fortune I, Pichot V, Chouchou F, Barthélémy J-C, Roche F.
Use of high-frequency peak in spectral analysis of heart rate increment to improve
screening of obstructive sleep apnoea. Sleep Breath. 2011;15(4):837–843.
25. Zamarrón C, Hornero R, del Campo F, Abásolo D, Alvarez D. Heart rate
regularity analysis obtained from pulse oximetric recordings in the diagnosis of
obstructive sleep apnea. Sleep Breath. 2006;10(2):83–89.
26. Magnusdottir S, Hilmisson H. Ambulatory screening tool for sleep apnea:
analyzing a single-lead electrocardiogram signal (ECG). Sleep Breath.
2018;22(2):421–429.
Journal of Clinical Sleep Medicine, Vol. nnn, No. nnn
Screening of sleep apnea
27. Iber C. The AASM Manual for the Scoring of Sleep and Associated Events:
Rules, Terminology and Technical Specifications, Vol. 1. Westchester, IL: American
Academy of Sleep Medicine; 2007.
28. BaHammam AS, Obeidat A, Barataman K, Bahammam SA, Olaish AH,
Sharif MM. A comparison between the AASM 2012 and 2007 definitions for
detecting hypopnea. Sleep Breath. 2014;18(4):767–773.
29. Duce B, Milosavljevic J, Hukins C. The 2012 AASM Respiratory Event criteria
increase the incidence of hypopneas in an adult sleep center population. J Clin
Sleep Med. 2015;11(12):1425–1431.
30. Hsu YS, Hsu WC, Ko JY, Yeh TH, Lee CH, Kang KT. Readmission after adult
uvulopalatopharyngoplasty: a population-based inpatient cohort study in Taiwan.
Otolaryngol Head Neck Surg. 2019;160(3):559–566.
31. Hsu YS, Hsu WC, Ko JY, Yeh TH, Lee CH, Kang KT. Incidence of multilevel
surgical procedures and readmissions in uvulopalatopharyngoplasty in Taiwan.
JAMA Otolaryngol Head Neck Surg. 2019;145(9):803.
32. Liu WT, Wu HT, Juang JN, et al. Prediction of the severity of obstructive sleep
apnea by anthropometric features via support vector machine. PLoS One.
2017;12(5):e0176991.
33. Miller JN, Berger AM. Screening and assessment for obstructive sleep apnea in
primary care. Sleep Med Rev. 2016;29:41–51.
34. El-Sayed IH. Comparison of four sleep questionnaires for screening obstructive
sleep apnea. Egypt J Chest Dis Tuberc. 2012;61(4):433–441.
35. Adamson DL, Nelson-Piercy C. Managing palpitations and arrhythmias during
pregnancy. Heart. 2007;93(12):1630–1636.
36. Varon C, Caicedo A, Testelmans D, Buyse B, Van Huffel S. A novel algorithm for
the automatic detection of sleep apnea from single-lead ECG. IEEE Trans Biomed
Eng. 2015;62(9):2269–2278.
37. Sforza E, Pichot V, Barthelemy JC, Haba-Rubio J, Roche F. Cardiovascular
variability during periodic leg movements: a spectral analysis approach. Clin
Neurophysiol. 2005;116(5):1096–1104.
38. Guggisberg AG, Hess CW, Mathis J. The significance of the sympathetic
nervous system in the pathophysiology of periodic leg movements in sleep.
Sleep. 2007;30(6):755–766.
ACKNOWLEDGMENTS
The authors thank the anonymous reviewers and editors for their comments.
SUBMISSION & CORRESPONDENCE INFORMATION
Submitted for publication October 16, 2019
Submitted in final revised form March 25, 2020
Accepted for publication March 25, 2020
Address correspondence to: Wen-Te Liu, MD, 250 Wuxing St., Taipei 11031, Taiwan;
Tel: 886 2 2736 1661; Fax: 886 2 2739 1143; Email: b7801077@tmu.edu.tw
DISCLOSURE STATEMENT
All authors have read and approved the manuscript. Work for this study was performed
at the Shin Kong Wu Ho-Su Memorial Hospital and Shuang Ho Hospital. This study
was funded by grants from Shin Kong Wu-Ho-Su Memorial Hospital (2018SKHADR017)
and Shuang Ho Hospital (106TMU-SHH-17). The funders had no role in the study Q:2
design, data collection and analysis, decision to publish, or preparation of the
manuscript. The authors report no conflicts of interest.
12 nnn nnn, 2020