Acoustic Reection for Nasal Airway Measurement in Patients with Obstructive

Sleep Apnea-Hypopnea Syndrome

Hsueh-Yu Li, MD1,2; Heather Engleman1; Chung-Yao Hsu, MD1,3; Bilgay Izci, MSc1; Marjorie Vennelle, RGN1; Melanie Cross, MD1; Neil J Douglas, MD1
Department of Sleep Medicine, Royal Inrmary, Edinburgh, UK; 2Department of Otolaryngology, Sleep Center, Chang Gung Memorial Hospital, Taipei, Taiwan; 3Department of Clinical Neuroscience, Kaohsiung Medical University, Kaohsiung, Taiwan
1

signicantly lower in the small MCSA group (P = .007), but apnea-hypopnea index and titration pressure were indistinguishable between the
2 groups. Furthermore, CPAP use correlated signicantly and positively
with MCSA (r = 0.34, P = .008), mean area (r = 0.27, P = .04), and volume
(r = 0.28, P = .03). Step-wise multiple regression models revealed that
MCSA was a predictor of the CPAP compliance (R2 = 0.16, P = .002),
and MCSA (P = .001) and age (P = .04) were predictive factors of CPAP
compliance (R2 = 0.22). Nasal dimensions were not related to subjective
nasal stufness.
Conclusions: CPAP use in patients with smaller nasal passages was
lower than in those with larger passages. Objective measurement of nasal dimension may be more reliable than subjective self-report of nasal
symptoms in identifying patients with OSAHS who might struggle with
CPAP therapy.
Keywords: Obstructive sleep apnea/hypopnea syndrome, acoustic reection, titration pressure, compliance
Citation: Li HY; Engleman H; Hsu CY et al. Acoustic reection for nasal
airway measurement in patients with obstructive sleep apnea-hypopnea
syndrome. SLEEP 2005;28(12): 1554-1559.

Study Objective: To measure nasal dimensions and explore relationships

between these and patients use of continuous positive airway pressure
(CPAP) in patients with obstructive sleep apnea-hypopnea syndrome
(OSAHS).
Design: Prospective single-blind study.
Setting: A tertiary-care, sleep disorders referral center.
Patients: Sixty OSAHS patients (52 men, mean age 51 years, body mass
index (BMI) 36.1 9.4 kg/m2).
Measurements: After in-vitro validation, acoustic reection was used to
measure the nasal minimal cross-sectional area (MCSA), mean area,
and volume in OSAHS patients receiving CPAP treatment. Variables from
sleep studies included the apnea-hypopnea index (AHI), titration pressure,
and CPAP use (hours per night) after 3 months. Median MCSA was used
to categorize subjects into small and large MCSA groups. Correlation and
regression analyses were conducted to investigate the relationship between results of polysomnography and nasal acoustic reection.
Results: At baseline the small and large MCSA groups were not different
(P > .05) in BMI, age, mask type, or previous nasal stufness, but there
were more women in the smaller MCSA group (P = .02). CPAP use was

symptoms have been reported in approximately 60% of CPAP

users and may adversely affect CPAP use.6,7 Nevertheless, the decision to prescribe CPAP for patient with OSAHS in sleep laboratories may often be made without formally assessing patients
nasal configuration and morphology, and nasal function generally
may be overlooked as a factor in patients intolerance of nasal
CPAP. Nasal surgery has been used as a component of the surgical
treatment of snoring and OSAHS, and nasal resistance has been
proven to play a role in contributing to obstructive sleep apnea.8,9
However, little information has been published concerning the
relationship between objective nasal dimensions and tolerance of
CPAP.10
Acoustic reflection is a noninvasive technique for determining the internal dimensions of the airway of varying cross-section
developed by Fredberg et al.11 This technique estimates the upper-airway cross-sectional area or volume from the behavior of an
incident sound wave and its subsequent reflection, and computed
this as a function of distance from the mouth. Although some
components have been modified to extend its clinical application
in the past 20 years, the principle remains valid.12 In this study,
acoustic reflection was used to measure the nasal cavity instead
of the upper airway via the oral route, as we have done in our
previous research. We therefore first assessed an in-vitro nasalairway model to assess the validity of nasal acoustic reflection
and identify the accuracy of the measurements obtained and then
investigated relationships between nasal airway caliber, clinical
outcomes, and tolerance of CPAP in patients with OSAHS.

INTRODUCTION
OBSTRUCTIVE SLEEP APNEA-HYPOPNEA SYNDROME
(OSAHS) IS CHARACTERIZED BY EPISODES OF COMPLETE OR PARTIAL PHARYNGEAL OBSTRUCTION during
sleep and is combined with excessive daytime sleepiness or at
least 2 other major symptoms.1 Patients with OSAHS have a higher rate of automobile and work-related accidents and an increased
risk of cardiovascular disease and cardiopulmonary disorder.2,3
Nasal continuous positive airway pressure (CPAP) is the treatment of choice in OSAHS patients, acting by blowing pressurized
air through the nasal passages to prevent airway collapse. Several
researchers have suggested that nasal obstruction may exacerbate
OSAHS through increased nasal resistance, necessitating a higher
inspiratory pressure, pressure changes resulting from Bernoullis
effects, or mouth opening during sleep.4,5 Furthermore, nasal
Disclosure Statement
This was not an industry supported study. Dr. Douglas has received research
support from ResMed, Ltd; and has participated in the Medical Advisory
Board of ResMed, Ltd. Drs. Li, Engleman, Hsu, Izci, Vennelle, and Cross
have indicated no nancial conicts of interest.
Submitted for publication February 2005
Accepted for publication August 2005
Address correspondence to: Neil J Douglas, MD, Department of Sleep
Medicine, Royal Inrmary Edinburgh, 51 Little France Crescent, Edinburgh,
EH16 4SA, UK; Tel: 44 0 131 242 1836; Fax: 44 0 131 242 1776; E-mail:
n.j.douglas@ed.ac.uk
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Figure 1The nasal probe (upper) and airway model.

Figure 2The equipment and implementation of acoustic reflection.

Aims

sleep and breathing for every patient. The AHI was defined as the
total number of apnea and hypopnea episodes per hour of sleep,
with apneas defined as a 10-second breathing pause and hypopneas as a 10-second event during which there is continued breathing but the nasal pressure or thoracoabdominal movement is reduced by at least 50% from the previous baseline during sleep.1
The single technician who scored the sleep studies was blind to
acoustic-reflection measurement.
After polysomnography, patients with an AHI > 15 and symptoms of OSAHS were CPAP titrated and then issued a Sullivan
6 CPAP unit (ResMed, Sydney, Australia) set at the appropriate fixed pressure for 3 months, since this period correlates with
long-term CPAP use.15 Use of CPAP was expressed by the usage
time of CPAP per night, calculated by total CPAP machine run
time divided by number of nights available for use.16 A device
measuring the patients breathing on the CPAP machine was used
to accurately measure the use time of CPAP.16 Patients complaining of nasal stuffiness were treated with nasal decongestants and,
if that did not work, then given heated humidifiers.

The primary analysis was to assess the association between nasal area and compliance with CPAP. The secondary aim was to
determine the relationship between nasal area and CPAP titration
pressure.
MATERIALS AND METHODS
Nasal Model
A cylindrical Perspex tube (Figure 1), 10 cm in length, with
3 narrowing cross-sectional areas corresponding to nasal valve,
anterior part of middle turbinate, and middle portion of the middle turbinate, respectively,13 was used as a model to validate our
acoustic reflectometer in assessing nasal dimensions. This nasal
model is derived from our previous airway model with validation.14 Fifteen measurements were obtained on 3 occasions over a
5-day period.
Pilot Study
At the beginning of the clinical study, we performed measurements of nasal acoustic reflection in 10 patients at diagnosis and 3
months after CPAP therapy to assess any impact of CPAP therapy
on nasal dimensions.

Acoustic Reflection
The acoustic reflection technique used in this study was conducted in the laboratory, which have been implemented in our
previous research for assessment of upper airway caliber.17,18 A
commercialized nasal probe consisting of rigid polyvinyl chloride
tube 1.2 cm in internal diameter and 5 cm in length (RhinoSleep,
Lynge, Denmark) was used to connect the acoustic reflection instrument to the subjects nasal alae. Acoustic reflection measurements were performed in a quiet room to decrease the effect of
environmental noise on the signals, with a single physician performing all acoustic reflection measurement in this study. Subjects accommodated to the supine position for 3 minutes before
acoustic reflection was measured. During measurement, the nasal
probe was held parallel to the nasal ridge with a tight connection
to the nasal alae but a minimum of distortion of the nose. Five
recordings were taken automatically in quick succession at each
testing, and all traces recorded were stored, amplified, and analyzed by computer (Figure 2) and integrated into a 2-dimensional
graph with the X axis representing distance into the nasal cavity
and the Y-axis, the cross-sectional area relative to this distance.
The shaded portion of this sample demonstrates the range (50-

Clinical Patients
This study was performed prospectively at a sleep disorders
referral center. Patients had been diagnosed with OSAHS through
polysomnography. Those patients with an apnea-hypopnea index
(AHI) 15 and either an Epworth Sleepiness Scale score 10 or
sleepiness while driving were eligible and invited by letter to participate in this study. Patients aged less than 16 or greater than 80
years, those residing 100 miles or more away from the Edinburgh
Sleep Centre, or with serious coexisting lung, neurologic, cardiovascular, psychiatric, or sleep disorder were excluded. Study participants were drawn from the Sleep Clinic population with the
permission of the local ethics of medical research committees.
Sleep Study
Overnight polysomnography (Compumedics, Abbotsford, Australia) was performed using our usual techniques1 to document the
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Nasal Acoustic Reection in OSAHSLi et al

Figure 3The plot of acoustic reflection in a patient with obstructive sleep apnea-hypopnea syndrome. The X axis represents the distance leaving the source of the sound wave, and the Y axis represents
the area relative to distance. The arrow pinpoints the narrowest area
chosen as the minimal cross-sectional area (MCSA). The mean area
and volume were obtained with the use of an algorithm from 50 to
120 mm.

Figure 4The areas of the airway model, with the measured area as
the broken curve and the actual-area profile as the full curve.

RESULT
In-Vitro Airway Model
Figure 4 shows the actual and acoustic reflection-measured areas of the Perspex airway model. The MCSA was underestimated
by 3% (0.190 cm2 instead of 0.196 cm2), while the mean area was
underestimated by 15% (0.574 cm2 instead of 0.676 cm2) and volume was measured as 6.03 cm2 (a 15% underestimation).

120 mm) generally used to detect cross-sectional area in the nasal

cavity (Figure 3).19 From the traces, measurements were made of
minimal cross-sectional area (MCSA), mean nasal area, and nasal
volume, which were calculated automatically with coefficient of
variation of 5% to 10% from our previous measurements in airway models14 similar to those previously described for upper airway caliber.18,20 In this study, acoustic reflection parameters were
calculated by averaging the right and left nasal measurements to
minimize the effect of the nasal cycle. Measurement of acoustic
reflection was performed 3 months after CPAP therapy, when patients returned for recording of objective CPAP use.

Pilot Study of Changes in Acoustic Reflection With CPAP

The clinical characteristics of the pilot group (n = 10) were
first compared with the rest of the cohort (n=50) to examine the
possible selection bias and the results showed no significant differences in sex (P = .5), age (P = .07), BMI (P = .86), AHI (P =
.08), titration pressure (P = .73), and MCSA (P = .06). There were
no significant changes in acoustic reflection dimensions observed
after 3 months of CPAP therapy in MCSA (P = .72), mean area (P
= .23), or volume (P = .16).

Statistical Analysis
The Wilcoxon signed-ranks test was used to compare changes
in nasal dimensions after CPAP therapy in 10 patients who participated in the pilot study. Patients were divided into 2 groups based
on their measurements of MCSA for comparison using a median
split analysis. The small MCSA group had values less than 1.15
cm2 and the large group MCSA 1.15 cm2. Continuous, normally
distributed variables (age, titration pressure, and CPAP use) were
compared between these 2 groups with independent t tests. Variables that were not normally distributed (BMI and AHI) were
compared with the Mann-Whitney tests. Sex ratios and mask-type
ratios (nasal or full face) were compared 2 tests.
Spearman correlation coefficients were used to investigate
the associations between acoustic reflection parameters (MCSA,
mean area, and volume) and sleep parameters (AHI, titration pressure, and compliance). Using CPAP compliance as the dependent
variable and using sex, age, body mass index, MCSA, mean area,
volume, and AHI data as independent variables, multivariate regression models were applied to investigate the predictors of outcomes. Statistical analyses were performed using the SPSS 11.0
for Windows (SPSS Inc., Chicago, IL). Results are expressed as
mean SD. A P value of less than .05 was considered significant.
SLEEP, Vol. 28, No. 12, 2005

Main Study Patients

Sixty patients (52 men and 8 women) participated in the study,
ranging in age from 29 to 77 years, and in BMI from 25.9 kg/m2
to 78.3 kg/m2. Anthropometric data for patients in the 2 MCSA
groups are shown in Table 1. Comparisons between these 2
groups showed no significant difference (P > .05) in age, BMI,
previous existence of nasal stuffiness, and mask type. However,
sex ratios were significantly different (P = .02) with significantly
more women in the small MCSA group (Table 1).
Comparison of Sleep Parameters Between Small and Large MCSA
Groups
The MCSA of this study population varied from 0.7 to 1.1 cm2
in the small MCSA group and from 1.15 to 1.4 cm2 in the large
MCSA group. Comparisons of sleep-study variables between the
2 groups revealed a significant difference in CPAP use (P = .007)
(Table 1), with lower CPAP use in the smaller MCSA group.

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Table 1Anthropometric, Polysomnographic, and Reflectometric

Data Between Groups With Small and Large MCSA

Sex, no.
Men
Women
Age, y
BMI (kg/m2)
Mask type
Nasal
Full face
Previous nasal stuffiness
Yes
No
AHI, events/h
TP, cmH2O
Compliance, h/night
MCSA, cm2
Mean area, cm2
Volume, cm3

Small group
(n=30)

Large group
(n=30)

23
7
50.7 11
35.3 8.4

29
1
50.3 11.5
36.9 10.4

17
13

22
8

25
5
44.8 30.1
10.6 2
4.1 2.5
0.9 0.1
1.9 0.4
14.7 4.2

26
4
52.8 29.6
10.9 1.7
5.7 1.9
1.3 0.1
2.7 0.6
20.9 4.9

Table 2Spearman Correlation Between Reflectometric and Polysomnographic Data

P value

Compliance
0.34 (.008)
0.27 (.04)
0.28 (.03)

.02
.9
.44
.18

Data are presented as r (P value). AHI refers to the apnea-hypopnea

index, the number of apneas and hypopneas per hour of sleep; MCSA,
minimal cross-sectional area.

pilot and study groups showed no significant differences, there

are trends toward older age (P = .07), higher AHI (P = .08), and
bigger MCSA (P = .06). Further study to measure the nasal dimensions before and after CPAP therapy may clarify the potential
changes of nasal dimensions after use of CPAP.
It is not surprising to find that MCSA (in the anterior part of
the airway model, representing the nasal valve) was the most reliable variable with regard to actual area. The underestimation of
MCSA, mean area, and volume was 3%, 15%, 15%, respectively,
reflecting the fact that the accuracy of the acoustic reflection diminished with distance from source. Hence, we selected MCSA
to divide patients into 2 groups for comparison and further exploration. AHI was not significantly different in the 2 MCSA groups
(P = .2) and there was no relationship between AHI and MCSA
(r = 0.08, P = .57). These results may be explained by different
characteristics in the anatomy of the nose and pharynx. The nose
has a close-fitting rigid framework that prevents collapse during
sleep. By contrast, the pharynx, comprising a heavily muscular
structure and acting as a Starling resistor, is more vulnerable to
changes in airflow resistance and consequently to airway collapse. Thus nasal dimensions may not be a major contributor to
the development of OSAHS. This was reinforced by the fact that
although subjective clinical symptoms of nasal obstruction have
been considered to be a risk factor for sleep-disordered breathing,22 objective measurements of nasal size were not related to
severity of OSAHS in this study.
Titration pressure was intuitively presumed to be associated
with the size of the nasal cavity, since the nasal passages accounts
for approximately 50% of total airway resistance.23 Our study revealed that titration pressure was not different in the 2 MCSA
groups (P = .55). Additionally, there was no correlation between
titration pressure and MCSA (r = -0.01, P = .95). This may suggest that the location that was determining the titration pressure
during sleep was not at the nose.
There are many factors affecting compliance with CPAP therapy. The strongest and most consistent correlates of long-term
CPAP use are AHI, Epworth Sleepiness Scale score, presence of
snoring, and initial use in the first 3 months.15 However, the role
of nasal obstruction in contributing to CPAP compliance may be
overlooked, since those patients with severe nasal obstruction
might be intolerant of wearing CPAP at titration and might, therefore, be missed by some long-term follow-up series of CPAP users.
This could help explain the discrepancy between the high proportion of nasal symptoms (60%) occurring in new CPAP users and
the 4% prevalence as a major problem in long-term users.6 In this
study, CPAP use was lower in those with smaller nasal MCSA (P
= .007), a positive correlation between CPAP use and MCSA (r =
.34, P = .008) was observed, and MCSA explained 16% of CPAP

.72
.2
.55
.007

Data are presented as mean standard deviation unless otherwise

noted. BMI refers to body mass index; AHI, apnea-hypopnea index;
TP, titration pressure; MCSA, minimal cross-sectional area.

Correlations Between Acoustic Reflection and Polysomnography

Parameters
CPAP use correlated significantly with MCSA (r = 0.34, P =
.008) (Figure5), mean area (r = 0.27, P = .04), and volume (r =
0.28, P = .03). There was no other significant correlation between
acoustic-reflection parameters and AHI or titration pressure (Table 2).
Multivariate Regression
Step-wise multiple regression models revealed that MCSA was
a predictor of the CPAP compliance (R2 = 0.16, P = .002), and
MCSA (P = .001) and age (P = .04) were predictive factors of
CPAP compliance (R2 = 0.22).
DISCUSSION
In this study, acoustic reflection was used to investigate the
associations of nasal dimensions with patients use of CPAP therapy. We found that CPAP compliance was significantly different
between small and large MCSA groups, with lower CPAP use in
the smaller MCSA group. Compliance correlated significantly
and positively with MCSA. Multivariate regression revealed that
MCSA was an independent predictor explaining a significant proportion of CPAP compliance.
A previous study using tube models to validate the acoustic
pulse technique showed that airway size less than 0.8 to 1.0 cm2
resulted in inaccurate data downstream, possibly through viscous
losses.21 However, our in-vitro nasal airway model demonstrated
that MCSA (0.2 cm2) was the most accurate measure from acoustic reflection, with 3% error in measurement. This discrepancy
may be due to the fact that the earlier study used a heliox gas
mixture, which is more viscous than air. Further study is needed
to clarify these differences.
Although the comparisons of clinical characteristics between
SLEEP, Vol. 28, No. 12, 2005

AHI
Titration Pressure
0.08 (.57)
-0.01 (.95)
0.02 (.88)
-0.1 (.44)
0.02 (.87)
-0.12 (.38)

MCSA
Mean area
Volume

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Nasal Acoustic Reection in OSAHSLi et al

through the mouth and, subsequently, increased difficulties in using CPAP.24

The value of this study was limited by its accuracy in measuring nasal dimensions using acoustic reflection to explain the
complex respiratory physiology of obstructive sleep apnea and
tolerance of CPAP and was restricted by the lack of generalizability of our acoustic-reflection devices. Improvements in nasal
acoustic-reflection equipment to provide more accurate parameters of nasal area and volume for analysis could produce further
future studies.
CONCLUSION
Patients with smaller nasal passages had lower CPAP use than
those with larger passages. Objective measurement of nasal dimensions may be more reliable than subjective self-report of nasal stuffiness in identifying OSAHS patients who might struggle
with CPAP therapy.
Figure 5Compliance with continuous positive airway pressure
(CPAP) correlated significantly with the minimal cross-sectional area
(MCSA (r=0.34, P=.008).

ACKNOWLEDGEMENT
The authors are grateful to Dr. Li-Ang Lee, department of otolaryngology, Chang Gung Memorial Hospital, for sketching the
airway model figure. We also thank Dr Peter Wraith, Department
of Medical Physics, Royal Infirmary Edinburgh, for his technical
assistance in establishing the airway model.

compliance in multivariate regression. These results suggest that,

although standard CPAP can provide therapeutic levels of pressure to overcome upper airway resistance, the laminar airflow in
smaller nasal passages might increase velocity, magnify feelings
of breathing discomfort or effort, and subsequently decrease the
wish to use CPAP.
Our study also showed that women have smaller nasal dimensions than men, and there is no relationship between nasal size
and OSAHS or titration pressure. This raises the question of the
appropriateness of nasal surgery to treat OSAHS. Whether or not
women with OSAHS can get more benefits from nasal surgery
needs further investigation.
Another factor that may affect compliance with CPAP is the
type of mask used. We therefore compared compliance between
the nasal and full-face mask groups, and the results showed no
significant differences between these 2 groups (P = .18). This indistinguishable result in compliance between 2 mask types may
be due to the ordinary rule for OSAHS patients to switch to a full
face mask while uncomfortable with a nasal mask before starting
CPAP therapy.
Subjective nasal obstruction has been identified as a risk factor for sleep-disordered breathing in a population-based sample.22
The existence of nasal stuffiness might, intuitively, increase nasal discomfort during CPAP use and result in lower compliance.
However, a history of subjective nasal stuffiness was not different in the 2 MCSA groups (P = .72) and was not correlated with
CPAP compliance (r = -0.15, P = .25). This indicated thus that
the subjective symptom of nasal stuffiness is not equivalent to an
objective measurement of acoustic reflection, and the existence of
a complaint of nasal stuffiness may not necessarily lower the use
of CPAP. By contrast, compliance with CPAP was different in the
2 MCSA groups (.007) and correlated positively with all acousticreflection parameters. These findings suggest that objective nasal
acoustic reflection might be a more reliable tool than the subjective symptom of nasal stuffiness in identifying patients at risk of
low compliance with CPAP.
Another speculation for the link between nasal dimensions
and CPAP use is that severe narrowing of nasal passages during
sleep may produce mouth breathing, thus resulting in air leaking
SLEEP, Vol. 28, No. 12, 2005

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