On the rise and fall of the apnea−hypopnea index: A historical review and critical appraisal

Dirk A. Pevernagie; Barbara Gnidovec-Strazisar; Ludger Grote; Raphael Heinzer; Walter T. McNicholas; Thomas Penzel; Winfried Randerath; Sophia Schiza; Johan Verbraecken; Erna S. Arnardottir

doi:10.1111/jsr.13066

On the rise and fall of the apnea−hypopnea index: A historical review and critical appraisal

Dirk A. Pevernagie
, Barbara Gnidovec-Strazisar
, Ludger Grote
, Raphael Heinzer
, Walter T. McNicholas
, Thomas Penzel
, Winfried Randerath
, Sophia Schiza
, Johan Verbraecken
, Erna S. Arnardottir

Department of Engineering

Reykjavik University

Research output: Contribution to journal › Review article › peer-review

Abstract

The publication of “The Sleep Apnea Syndromes” by Guilleminault et al. in the 1970s hallmarked the discovery of a new disease entity involving serious health consequences. Obstructive sleep apnea was shown to be the most important disorder among the sleep apnea syndromes (SAS). In the course of time, it was found that the prevalence of obstructive sleep apnea reached the proportions of a global epidemic, with a major impact on public health, safety and the economy. Early on, a metric was introduced to gauge the seriousness of obstructive sleep apnea, based on the objective measurement of respiratory events during nocturnal sleep. The apnea index and later on the apnea−hypopnea index, being the total count of overnight respiratory events divided by the total sleep time in hours, were embraced as principle measures to establish the diagnosis of obstructive sleep apnea and to rate its severity. The current review summarises the historical evolution of the apnea−hypopnea index, which has been subject to many changes, and has been criticised for not capturing relevant clinical features of obstructive sleep apnea. In fact, the application of the apnea−hypopnea index as a continuous exposure variable is based on assumptions that it represents a disease state of obstructive sleep apnea and that evocative clinical manifestations are invariably caused by obstructive sleep apnea if the apnea−hypopnea index is above diagnostic threshold. A critical appraisal of the extensive literature shows that both assumptions are invalid. This conclusion prompts a reconsideration of the role of the apnea−hypopnea index as the prime diagnostic metric of clinically relevant obstructive sleep apnea.

Original language	English
Article number	e13066
Journal	Journal of Sleep Research
Volume	29
Issue number	4
DOIs	https://doi.org/10.1111/jsr.13066
Publication status	Published - Aug 2020

Bibliographical note

Funding Information: This work was in part funded by a grant from the European Sleep Research Society supporting the ESRS “Beyond AHI” task force, and by financial support from the Assembly of National Sleep Societies. Thomas Penzel is partially supported by the Russian Federation RF Government grant No. 075‐15‐2019‐1885. Funding Information: This work was in part funded by a grant from the European Sleep Research Society supporting the ESRS ?Beyond AHI? task force, and by financial support from the Assembly of National Sleep Societies. Thomas Penzel is partially supported by the Russian Federation RF Government grant No. 075-15-2019-1885. Meetings of the task force have been sponsored by grants from the European Sleep Research Society and the Assembly of National Sleep Societies. The authors thank Mrs Irene Gijselhart, librarian of the Kempenhaeghe Foundation, Heeze, The Netherlands, for retrieving rare vintage books and publications from different external libraries. Thankfulness is likewise extended to Ren?e Pevernagie, graphical illustrator, for the artwork in Figures?1 and 2. Funding Information: Meetings of the task force have been sponsored by grants from the European Sleep Research Society and the Assembly of National Sleep Societies. The authors thank Mrs Irene Gijselhart, librarian of the Kempenhaeghe Foundation, Heeze, The Netherlands, for retrieving rare vintage books and publications from different external libraries. Thankfulness is likewise extended to Renée Pevernagie, graphical illustrator, for the artwork in Figures 1 and 2 . Publisher Copyright: © 2020 European Sleep Research Society

Other keywords

apnea−hypopnea index
bias
diagnosis
entanglement
severity rating
sleep apnea

Access to Document

10.1111/jsr.13066Licence: Unspecified

Cite this

@article{72836b9a11a64b9b860ee6c05266a648,

title = "On the rise and fall of the apnea−hypopnea index: A historical review and critical appraisal",

abstract = "The publication of {\textquotedblleft}The Sleep Apnea Syndromes{\textquotedblright} by Guilleminault et al. in the 1970s hallmarked the discovery of a new disease entity involving serious health consequences. Obstructive sleep apnea was shown to be the most important disorder among the sleep apnea syndromes (SAS). In the course of time, it was found that the prevalence of obstructive sleep apnea reached the proportions of a global epidemic, with a major impact on public health, safety and the economy. Early on, a metric was introduced to gauge the seriousness of obstructive sleep apnea, based on the objective measurement of respiratory events during nocturnal sleep. The apnea index and later on the apnea−hypopnea index, being the total count of overnight respiratory events divided by the total sleep time in hours, were embraced as principle measures to establish the diagnosis of obstructive sleep apnea and to rate its severity. The current review summarises the historical evolution of the apnea−hypopnea index, which has been subject to many changes, and has been criticised for not capturing relevant clinical features of obstructive sleep apnea. In fact, the application of the apnea−hypopnea index as a continuous exposure variable is based on assumptions that it represents a disease state of obstructive sleep apnea and that evocative clinical manifestations are invariably caused by obstructive sleep apnea if the apnea−hypopnea index is above diagnostic threshold. A critical appraisal of the extensive literature shows that both assumptions are invalid. This conclusion prompts a reconsideration of the role of the apnea−hypopnea index as the prime diagnostic metric of clinically relevant obstructive sleep apnea.",

keywords = "apnea−hypopnea index, bias, diagnosis, entanglement, severity rating, sleep apnea",

author = "Pevernagie, \{Dirk A.\} and Barbara Gnidovec-Strazisar and Ludger Grote and Raphael Heinzer and McNicholas, \{Walter T.\} and Thomas Penzel and Winfried Randerath and Sophia Schiza and Johan Verbraecken and Arnardottir, \{Erna S.\}",

note = "Funding Information: This work was in part funded by a grant from the European Sleep Research Society supporting the ESRS {\textquotedblleft}Beyond AHI{\textquotedblright} task force, and by financial support from the Assembly of National Sleep Societies. Thomas Penzel is partially supported by the Russian Federation RF Government grant No. 075‐15‐2019‐1885. Funding Information: This work was in part funded by a grant from the European Sleep Research Society supporting the ESRS ?Beyond AHI? task force, and by financial support from the Assembly of National Sleep Societies. Thomas Penzel is partially supported by the Russian Federation RF Government grant No. 075-15-2019-1885. Meetings of the task force have been sponsored by grants from the European Sleep Research Society and the Assembly of National Sleep Societies. The authors thank Mrs Irene Gijselhart, librarian of the Kempenhaeghe Foundation, Heeze, The Netherlands, for retrieving rare vintage books and publications from different external libraries. Thankfulness is likewise extended to Ren?e Pevernagie, graphical illustrator, for the artwork in Figures?1 and 2. Funding Information: Meetings of the task force have been sponsored by grants from the European Sleep Research Society and the Assembly of National Sleep Societies. The authors thank Mrs Irene Gijselhart, librarian of the Kempenhaeghe Foundation, Heeze, The Netherlands, for retrieving rare vintage books and publications from different external libraries. Thankfulness is likewise extended to Ren{\'e}e Pevernagie, graphical illustrator, for the artwork in Figures 1 and 2 . Publisher Copyright: {\textcopyright} 2020 European Sleep Research Society",

year = "2020",

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journal = "Journal of Sleep Research",

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AU - Pevernagie, Dirk A.

AU - Gnidovec-Strazisar, Barbara

AU - Grote, Ludger

AU - Heinzer, Raphael

AU - McNicholas, Walter T.

AU - Penzel, Thomas

AU - Randerath, Winfried

AU - Schiza, Sophia

AU - Verbraecken, Johan

AU - Arnardottir, Erna S.

N1 - Funding Information: This work was in part funded by a grant from the European Sleep Research Society supporting the ESRS “Beyond AHI” task force, and by financial support from the Assembly of National Sleep Societies. Thomas Penzel is partially supported by the Russian Federation RF Government grant No. 075‐15‐2019‐1885. Funding Information: This work was in part funded by a grant from the European Sleep Research Society supporting the ESRS ?Beyond AHI? task force, and by financial support from the Assembly of National Sleep Societies. Thomas Penzel is partially supported by the Russian Federation RF Government grant No. 075-15-2019-1885. Meetings of the task force have been sponsored by grants from the European Sleep Research Society and the Assembly of National Sleep Societies. The authors thank Mrs Irene Gijselhart, librarian of the Kempenhaeghe Foundation, Heeze, The Netherlands, for retrieving rare vintage books and publications from different external libraries. Thankfulness is likewise extended to Ren?e Pevernagie, graphical illustrator, for the artwork in Figures?1 and 2. Funding Information: Meetings of the task force have been sponsored by grants from the European Sleep Research Society and the Assembly of National Sleep Societies. The authors thank Mrs Irene Gijselhart, librarian of the Kempenhaeghe Foundation, Heeze, The Netherlands, for retrieving rare vintage books and publications from different external libraries. Thankfulness is likewise extended to Renée Pevernagie, graphical illustrator, for the artwork in Figures 1 and 2 . Publisher Copyright: © 2020 European Sleep Research Society

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N2 - The publication of “The Sleep Apnea Syndromes” by Guilleminault et al. in the 1970s hallmarked the discovery of a new disease entity involving serious health consequences. Obstructive sleep apnea was shown to be the most important disorder among the sleep apnea syndromes (SAS). In the course of time, it was found that the prevalence of obstructive sleep apnea reached the proportions of a global epidemic, with a major impact on public health, safety and the economy. Early on, a metric was introduced to gauge the seriousness of obstructive sleep apnea, based on the objective measurement of respiratory events during nocturnal sleep. The apnea index and later on the apnea−hypopnea index, being the total count of overnight respiratory events divided by the total sleep time in hours, were embraced as principle measures to establish the diagnosis of obstructive sleep apnea and to rate its severity. The current review summarises the historical evolution of the apnea−hypopnea index, which has been subject to many changes, and has been criticised for not capturing relevant clinical features of obstructive sleep apnea. In fact, the application of the apnea−hypopnea index as a continuous exposure variable is based on assumptions that it represents a disease state of obstructive sleep apnea and that evocative clinical manifestations are invariably caused by obstructive sleep apnea if the apnea−hypopnea index is above diagnostic threshold. A critical appraisal of the extensive literature shows that both assumptions are invalid. This conclusion prompts a reconsideration of the role of the apnea−hypopnea index as the prime diagnostic metric of clinically relevant obstructive sleep apnea.

AB - The publication of “The Sleep Apnea Syndromes” by Guilleminault et al. in the 1970s hallmarked the discovery of a new disease entity involving serious health consequences. Obstructive sleep apnea was shown to be the most important disorder among the sleep apnea syndromes (SAS). In the course of time, it was found that the prevalence of obstructive sleep apnea reached the proportions of a global epidemic, with a major impact on public health, safety and the economy. Early on, a metric was introduced to gauge the seriousness of obstructive sleep apnea, based on the objective measurement of respiratory events during nocturnal sleep. The apnea index and later on the apnea−hypopnea index, being the total count of overnight respiratory events divided by the total sleep time in hours, were embraced as principle measures to establish the diagnosis of obstructive sleep apnea and to rate its severity. The current review summarises the historical evolution of the apnea−hypopnea index, which has been subject to many changes, and has been criticised for not capturing relevant clinical features of obstructive sleep apnea. In fact, the application of the apnea−hypopnea index as a continuous exposure variable is based on assumptions that it represents a disease state of obstructive sleep apnea and that evocative clinical manifestations are invariably caused by obstructive sleep apnea if the apnea−hypopnea index is above diagnostic threshold. A critical appraisal of the extensive literature shows that both assumptions are invalid. This conclusion prompts a reconsideration of the role of the apnea−hypopnea index as the prime diagnostic metric of clinically relevant obstructive sleep apnea.

KW - apnea−hypopnea index

KW - bias

KW - diagnosis

KW - entanglement

KW - severity rating

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DO - 10.1111/jsr.13066

M3 - Review article

C2 - 32406974

SN - 0962-1105

VL - 29

JO - Journal of Sleep Research

JF - Journal of Sleep Research

IS - 4

M1 - e13066

ER -

On the rise and fall of the apnea−hypopnea index: A historical review and critical appraisal

Abstract

Bibliographical note

Other keywords

Access to Document

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Cite this