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Poincaré Plot Width, Morning Urine Norepinephrine Levels, and Autonomic Imbalance in Children With Obstructive Sleep Apnea

  • Konstantinos Chaidas
    Affiliations
    Pediatric Pulmonology Unit and Sleep Disorders Laboratory, First Department of Pediatrics, University of Athens School of Medicine and Aghia Sophia Children's Hospital, Athens, Greece
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  • Marina Tsaoussoglou
    Affiliations
    Pediatric Pulmonology Unit and Sleep Disorders Laboratory, First Department of Pediatrics, University of Athens School of Medicine and Aghia Sophia Children's Hospital, Athens, Greece
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  • Emmanouel Theodorou
    Affiliations
    Pediatric Pulmonology Unit and Sleep Disorders Laboratory, First Department of Pediatrics, University of Athens School of Medicine and Aghia Sophia Children's Hospital, Athens, Greece
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  • Loukia Lianou
    Affiliations
    Pediatric Pulmonology Unit and Sleep Disorders Laboratory, First Department of Pediatrics, University of Athens School of Medicine and Aghia Sophia Children's Hospital, Athens, Greece
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  • George Chrousos
    Affiliations
    Pediatric Pulmonology Unit and Sleep Disorders Laboratory, First Department of Pediatrics, University of Athens School of Medicine and Aghia Sophia Children's Hospital, Athens, Greece
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  • Athanasios G. Kaditis
    Correspondence
    Communications should be addressed to: Dr. Kaditis; First University Department of Pediatrics; Aghia Sophia Children's Hospital; Thivon and Papadiamantopoulou St., Athens 115276, Greece.
    Affiliations
    Pediatric Pulmonology Unit and Sleep Disorders Laboratory, First Department of Pediatrics, University of Athens School of Medicine and Aghia Sophia Children's Hospital, Athens, Greece
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      Abstract

      Background

      Obstructive sleep apnea (OSA) in childhood is accompanied by sympathetic overflow unopposed by the parasympathetic tone. Complex methods like power spectral analysis of heart rate variability have been applied to study this imbalance. In this report, width of Poincaré scattergram of the R-R interval (parasympathetic tone) and morning urine norepinephrine concentration (sympathetic activity) were used to assess autonomic imbalance.

      Methods

      Poincaré plot was obtained from the electrocardiographic channel of nocturnal polysomnography and its width was measured, and norepinephrine-to-creatinine concentration ratio was calculated in morning urine specimen.

      Results

      Twenty children with obstructive sleep apnea and moderate-to-severe nocturnal hypoxemia (oxygen saturation of hemoglobin [SpO2] nadir <90%), 24 subjects with mild hypoxemia (SpO2 nadir ≥90%), and 11 control subjects were recruited. Children with obstructive sleep apnea and moderate-to-severe hypoxemia had significantly narrower Poincaré plot width (318.7 ± 139.3 ms) and higher ln-transformed urine norepinephrine-to-creatinine ratio (4.5 ± 0.6) than control subjects (484.2 ± 104.4 ms and 3.8 ± 0.4, respectively; P < 0.05). Ln-transformed urine norepinephrine levels were inversely related to Poincaré plot width (P = 0.02).

      Conclusions

      Subjects with obstructive sleep apnea and moderate-to-severe nocturnal hypoxemia have enhanced sympathetic activity and reduced parasympathetic drive. Poincaré plot width and urine norepinephrine levels are simple measures of autonomic imbalance in pediatric obstructive sleep apnea.

      Key words

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