Relationships between Pulmonary Function Testing and Polysomnography in Adolescents with Severe Obesity

Relationships between Pulmonary Function Testing and Polysomnography in Adolescents with Severe Obesity | Authorea try { document.documentElement.classList.add('js'); } catch (e) { } var _gaq = _gaq || []; _gaq.push(['_setAccount', 'G-8VDV14Y67G']); _gaq.push(['_trackPageview']); (function() { var ga = document.createElement('script'); ga.type = 'text/javascript'; ga.async = true; ga.src = ('https:' == document.location.protocol ? 'https://ssl' : 'http://www') + '.google-analytics.com/ga.js'; var s = document.getElementsByTagName('script')[0]; s.parentNode.insertBefore(ga, s); })(); Skip to main content Preprints Collections Wiley Open Research IET Open Research Ecological Society of Japan All Collections About About Authorea FAQs Contact Us Quick Search anywhere Search for preprint articles, keywords, etc. Search Search ADVANCED SEARCH SCROLL This is a preprint and has not been peer reviewed. Data may be preliminary. 19 August 2025 V1 Latest version Share on Relationships between Pulmonary Function Testing and Polysomnography in Adolescents with Severe Obesity Authors : Abigail Strang 0000-0003-0300-7198 [email protected] , Benjamin Crain , Linhda Nguyen , Jobayer Hossain , Thomas Shaffer , and Aaron Chidekel Authors Info & Affiliations https://doi.org/10.22541/au.175557243.38753602/v1 Published Sleep and Breathing Version of record Peer review timeline 177 views 109 downloads Contents Abstract Polysomnography in Adolescents with Severe Obesity 3. Results Information & Authors Metrics & Citations View Options References Figures Tables Media Share Abstract Severe obesity (BMI ≥ 35 kg/m 2 or ≥ 120% of the 95% for age) is increasingly prevalent in adolescents and is associated with respiratory compromise including obstructive and restrictive lung disease and obstructive sleep apnea hypopnea syndrome (OSAHS). The prevalence of respiratory impairment and the relationships between lung volumes measured by pulmonary function tests (PFT) and polysomnography (PSG) in this group have not been well-studied. The objective of this study is to describe PFT and PSG results in a cohort of adolescents with severe obesity and identify relationships between PSG and PFT variables. Inclusion criteria for 215 patients: ages 12-17 years, diagnosis of severe obesity, completion of both PSG and PSG between 2014-2018. The following were collected from EMR: age, sex, BMI, BMI Z-score and percentage, and PFT and PSG results. Descriptive statistics were calculated; multiple regressions were performed to characterize associations between PFT and PSG variables, controlling for age, sex, and BMI. In this cohort of youth with severe obesity, there were high rates of OSAHS. While spirometry was generally normal, lung volume measurements by body plethysmography reveal low-normal residual volume and low expiratory reserve volume. In addition, there were multiple associations between PFT parameters (especially TLC) and PSG abnormalities. Full PFT and PSG should be considered for adolescents with severe obesity. Relationships between Pulmonary Function Testing and Polysomnography in Adolescents with Severe Obesity Abigail Strang, MD 1 ; Benjamin Crain 1 ; Linhda Nguyen, PA-C 2 ; Md Jobayer Hossain, PhD 3 ; Thomas H. Shaffer, PhD 3 ; Aaron Chidekel, MD 1 1. Division of Pediatric Pulmonology and Sleep Medicine, Nemours Children’s Hospital of Delaware 2. Division of Healthy Weight and Wellness; Nemours Children’s Hospital of Delaware 3. Center for Pediatric Lung Research; Nemours Children’s Hospital of Delaware The authors have no conflicts of interest to disclose. All authors contributed to the study conception, data collection, data analysis and writing and editing of this manuscript. Corresponding author: Abigail Strang, MD 1600 Rockland Road Wilmington, Delaware 19803 Phone: (302)-651-6400 Fax: (302)-651-6408 [email protected] Co-author email addresses: [email protected] , [email protected] , [email protected] , [email protected] , [email protected] Keywords: PFT, obesity, polysomnography Abstract Severe obesity (BMI \(\geq\) 35 kg/m 2 or ≥ 120% of the 95% for age) is increasingly prevalent in adolescents and is associated with respiratory compromise including obstructive and restrictive lung disease and obstructive sleep apnea hypopnea syndrome (OSAHS). The prevalence of respiratory impairment and the relationships between lung volumes measured by pulmonary function tests (PFT) and polysomnography (PSG) in this group have not been well-studied. The objective of this study is to describe PFT and PSG results in a cohort of adolescents with severe obesity and identify relationships between PSG and PFT variables. Inclusion criteria for 215 patients: ages 12-17 years, diagnosis of severe obesity, completion of both PSG and PSG between 2014-2018. The following were collected from EMR: age, sex, BMI, BMI Z-score and percentage, and PFT and PSG results. Descriptive statistics were calculated; multiple regressions were performed to characterize associations between PFT and PSG variables, controlling for age, sex, and BMI. In this cohort of youth with severe obesity, there were high rates of OSAHS. While spirometry was generally normal, lung volume measurements by body plethysmography reveal low-normal residual volume and low expiratory reserve volume. In addition, there were multiple associations between PFT parameters (especially TLC) and PSG abnormalities. Full PFT and PSG should be considered for adolescents with severe obesity. Introduction Severe obesity is increasingly prevalent in adolscents 1,2 and is an important risk factor for respiratory disease. The prevalence of adolescent obesity has increased over time with many well-known consequences including hypertension, metabolic syndrome, and obstructive sleep apnea hypopnea syndrome (OSAHS). 3,4,5 OSAHS is defined by instances of complete or partial airway collapse and an associated sleep disruption and/or reduction in oxygen saturation and is diagnosed using overnight polysomnography (PSG). Adolescents with obesity have increased risk of OSAHS, affecting up to 60% 5 of those with obesity compared to only about 1-4% of all children .6,7 Those with OSAHS may experience daytime sleepiness and are at increased risk for cardiometabolic disease, such as hypertension. 8,9,10 Although there is a well-established relationship between obesity and OSAHS in adolescents, less is known about those adolescents with severe obesity (BMI \(\geq\)35 kg/m 2 or ≥ 120% of the 95% for age), who are at higher risk for complications. In addition to OSAHS, adolescents with severe obesity are at risk for obstructive and restrictive lung disease, measured by pulmonary function testing (PFT). Younger children (3-7 years) with obesity exhibit impaired lung function in total and peripheral airway resistance measured by impulse oscillometry measurements. 11 Lung function in adolescents with obesity is complex due to the impact of obesity on airway and lung growth. 12 In one study, adolescents with obesity showed increased FVC and reduced FEV 1 /FVC. 13 Literature on the lung function of adolescents with obesity is overall limited. The purpose of this study is to describe PSG and PFT results from a cohort of adolescents with severe obesity. Additionally, we aim to examine the relationships between PFT and PSG variables, while controlling for BMI, sex and age. In this cohort of adolescents with severe obesity, we hypothesized there would be a high incidence of PFT and PSG abnormalities, and correlations would exist between PFT and PSG variables. 2. Methods This retrospective review study was approved by the Nemours Institutional Review Board (IRB # 934310). Clinical data of adolescents aged 12 – 17 years at the Nemours Children’s Hospital in Wilmington, Delaware who completed both PSG and PFT between 2014-2018 during the same 23-hour period were examined via review of electronic medical record (EMR). The requirement for informed consent was waived by the IRB as the study utilized existing data collected for non-research purposes and involved no more than minimal risk. Patients were included if they had BMI \(\geq\) 35 kg/m 2 or ≥ 120% of the 95% for age, were followed by the Healthy Weight and Wellness Program, a multidisciplinary clinic that treats children with obesity, and completed both a PFT in addition to an overnight PSG in the same 23-hour period. Adolescents were excluded if they had craniofacial, genetic, or hypothalamic abnormalities. Patients were also excluded if they were unable to complete all testing or had incomplete results available in the EMR. Only baseline PSG, without positive pressure or other respiratory support, were included in this study. PFT results were only included if patients met ATS criteria for interpretation of results. 14 Demographic information was collected on each patient including age and sex at birth. Anthropometric data was collected on each patient which included their height and weight on the date of testing. The Body Mass Index (BMI) was calculated using the weight (in kg) divided by the height (in meters) squared. BMI Z-scores and percentiles for age and sex were based on growth percentiles from CDC data of children 2 – 20 years old. 15 The study is reported in accordance with the STrengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines. PSG was performed in the American-Academy of Sleep Medicine-accredited sleep laboratory at Nemours Children’s Hospital, Delaware. PSG is the gold standard for the diagnosis of OSAHS. Electroencephalography, electrooculography, electromyography, and electrocardiography were continuously recorded throughout the PSG. Respiratory effort was measured via respiratory inductance plethysmography and oxygen saturation was measured via a finger probe on a pulse oximeter. A nasal pressure cannula and a thermistor measured airflow, and snoring was measured via a microphone. The patients were monitored by a polysomnographic technician during the entire duration of the study in a dark and comfortable environment with head of bed flat per laboratory protocol. After technician scoring in accordance with American Academy of Sleep Medicine guidelines for pediatric scoring, 16 the raw data were reviewed and interpreted by a board-certified pediatric sleep medicine physician. Routine quality assurance and inter-scorer reliability were conducted per laboratory policy to ensure consistency of PSG variables. PSG yielded the following data: total sleep time (TST), sleep efficiency % (total sleep time/total recording time), obstructive apnea index (OAI), hypopnea index (HI), total apnea hypopnea index (AHI), minimum oxygen level (SpO 2 nadir), baseline end-tidal carbon dioxide (EtCO 2 baseline), and peak EtCO 2 . The apnea-hypopnea index (AHI) was defined as the number of obstructive apneas and hypopneas per hour of sleep. OSAHS severity was categorized as follows: mild (AHI 5-15), moderate AHI (15-30) and severe (AHI >30). All patients completed Pulmonary Function Testing (PFT) including spirometry and lung volume measurements by plethysmography during the same 23-hour time as the PSG (either immediately before or after PSG testing). PFTs were performed based on American Thoracic Society standards with a trained pediatric respiratory therapist coaching the patient through the testing. 14 PFT data was obtained in the upright and seated position. PFT yielded the following data: forced vital capacity (FVC), forced expiratory volume in 1 second (FEV 1 ), FEV 1 /FVC, forced expiratory flow at 25% and 75% of the pulmonary volume (FEF 25-75 ), total lung capacity (TLC) residual volume (RV), expiratory reserve volume (ERV), diffusing capacity for carbon monoxide (DLCO). These values were represented as % predicted based on patient age, height, weight, sex and race using NHANES III. 17 Obstructive lung disease was defined as: FEV 1 /FVC < 85%, measured by spirometry. Restrictive lung disease was defined as TLC <80% based on body plethysmography. 2.5 Statistical Analysis Patient characteristics, including demographics, BMI data, and PSG and PFT variables, are summarized. Categorical variables are presented as frequencies and percentages, while quantitative variables are summarized using means and standard deviations (SD) or medians and interquartile ranges (IQR), as appropriate. Data are reported for the overall cohort. Several exploratory analyses including Pearson or Spearman rank correlation coefficient, as appropriate, were performed to examine the association between PSG and PFT. A multiple regression model was initially used to examine the association between a PSG variable with BMI z-score and PFT variable. The final model was further adjusted for age and sex. Assumptions underlying the statistical tests were evaluated, and appropriate adjustments, such as variable transformation or use of the non-parametric methods, were applied when necessary. All statistical tests were two-tailed, with a significance level set at 0.05. Analyses were conducted using R software, version 4.1.2 3. Results 264 children with severe obesity completed PSG and PFT testing; 49 participants were excluded due to missing data. 215 children and adolescents with severe obesity were included in the analysis with a mean BMI of 50.1 kg/m 2 (SD=7.2) and mean BMI z-score of 2.8 (SD=0.3). Mean age was 15.2 years (SD=1.7), Patients were: 66.5% female; 40% White; 46.5% Black. See Table 1. for additional demographic and anthropometric data. The majority (65.6%) of the patients met criteria for OSAHS (AHI ≥5 events/hour). Of those with OSAHS, the majority were mild to moderate in severity. The mean AHI was 16.1 (SD 21.1) events/hour with a mean SpO 2 nadir of 87.9 (SD 7.2)% and EtCO2 peak of 50.6 (SD 3.9) mmHg. See Table 2 for full details of PSG results. PFT data from simple spirometry showed overall normal measurements in most patients with mean FEV 1 % predicted at 96.8 (SD 14.7) % and mean FVC% predicted at 104.2 (SD 14.0) %. Additionally, the mean FEV 1 /FVC % predicted was normal at 92.5 (SD 8.3)%. A minority (15.3%) of study participants met criteria for obstructive lung disease. While spirometry was often normal, abnormalities noted in lung volumes measured by body plethysmography were more common. Mean total lung capacity was normal in this cohort at 101.5 (SD 16.5)%; however, mean expiratory reserve volume (ERV) and residual volume (RV) were decreased and at the lower end of normal at 70.2 (SD 25.7)% and 82.1 (SD 38.3)% respectively. A small minority of participants (3.7%) met criteria for restrictive physiology. DLCO was overall normal with mean of 93.6 (SD 17.6)%. See Table 3 for PFT results. Relationships Between BMI, PFT, and PSG In multiple regression analysis, when controlling for BMI, sex, and age, TLC was significantly associated with PSG variables. TLC was negatively associated with lnAHI (β = -0.011, p = 0.01), positively associated with SpO₂ nadir (β = 0.06, p = 0.03), and negatively associated with peak EtCO₂ (β = -0.04, p = 0.02). RV was negatively associated with lnAHI (β = -0.005, p = 0.01), but not significantly associated with SpO₂ nadir (p = 0.30) or peak EtCO₂ (p = 0.44). ERV showed a significant negative association with peak EtCO₂ (β = -0.03, p = 0.01), but was not significantly associated with lnAHI or SpO₂ nadir. DLCO was positively associated with lnAHI (β = 0.016, p < 0.001) and with peak EtCO₂ (β = 0.03, p = 0.03), but not with SpO₂ nadir (p = 0.64). See table 4 for full regression Analysis. not-yet-known not-yet-known not-yet-known unknown 4. Discussion There are several key and novel findings from our analysis of this cohort of adolescents with severe obesity who completed PSG and PFT testing. First, the rates of OSAHS were very high; the majority of (64.7%) of the study participants showed at least mild OSAHS. This percentage of study participants with OSAHS is much higher than the prevalence of OSAHS in normal-weight healthy children.6-7 The percentage of children with OSAHS with obesity is also higher than have previously been reported, even in children with obesity and including those seeking bariatric surgery, previously reported at 43-60% 5,18, 19. Therefore, clinicians should have a low threshold to order screening PSG for adolescents with severe obesity, even in the absence of overt clinical symptoms. Children with severe obesity are at risk for both obstructive and restrictive lung disease. Our study population overall showed normal spirometry findings and low rates of obstructive lung disease; however, there was a higher incidence of abnormal findings when lung volumes were measured by body plethysmography. There were important differences in lung volume measurements, specifically reduced ERV and low-normal RV, which may be the first signal of abnormal pulmonary physiology caused by obesity. This finding has been previously reported in obese adults, where a reduction in the expiratory reserve volume (ERV) is associated with an increase in BMI, and is the most common PFT abnormality in adults.20 Because residual volume normally does not change in obese subjects, but the mass-loading effect of obesity causes a reduction of FRC, the ERV declines. This finding in adolescents supports findings in adults that reduction in ERV is the first signal towards abnormal lung volumes associated with obesity. It is notable that lung function measurements were performed in the seated position and may be further reduced when supine. PSG parameters were obtained in the recumbent position. Prior studies demonstrated differences in pulmonary function results in children based on patient positioning with impairments in lung function when supine.21,22,23 Obese patients may be even more affected considering the mechanism for the effect of position of abdominal contents on the diaphragm.24, 25,26 In this study, PFT results were performed when seated and upright while PSG parameters were obtained while recumbent. Future studies using supine measurements of lung function testing in this population and comparison to PSG parameters will be important as there will likely be more significant associations. Overall, it is notable that, even in the upright and seated position, reduced ERV may be the first signal of abnormal lung function in this group. Our study shows that full PFTs with body plethysmography may be helpful in a clinical setting, rather than simple spirometry, which is more likely to be normal. This study has several strengths including a very large sample size with robust amount of data collected for severely obese patients, a population that is understudied in the literature. Additionally, each sleep study was performed within the same day as the PFT. Limitations include lack of available data on clinical symptoms of sleep-disordered breathing and respiratory symptoms (including asthma) as well as clinical descriptions of airway measurements, such as tonsil and neck size. Additionally, PFT reference values at the time of clinical testing for this cohort included race. While our PFT laboratory now uses race-neutral reference values based on ATS recommendations,27we were unable to recalculate race-neutral reference values for this analysis. We acknowledge that the use of race in these reference values may compromise accuracy by attributing differences to race, rather than other relevant biologic mechanisms. Conclusions Lung volume measurements provide important clinical data about impaired respiratory function in adolescents with severe obesity; in this cohort, reduced ERV is noted as the first sign of impaired lung function, which has not been previously reported in pediatrics. In addition, high rates of OSAHS were also noted, with rates even higher than described in some literature, highlighting the importance of screening for sleep-disordered breathing in this population. Therefore, screening PSG and PFT should be considered when assessing respiratory health in adolescents with severe obesity. Table 1. Patient Characteristics (N=215) Age , years (mean, SD) 15.2 (1.7) BMI, kg/m2 (mean, SD) 50.1 (7.2) BMI z-score (mean, SD) 2.8 (0.3) Race (N, %) White Black Other 86 (40) 100 (46.5) 29 (13.5) Table 2. Polysomnogram Results (N = 215) Mild OSAHS (N, %) (65) 30.2% Moderate OSAHS (N, %) (46) 21.4% Severe OSAHS (N, %) (30) 14.0% AHI (events/hour), mean, SD 16.3 (21.1) SpO2 nadir (%), mean, SD 87.9 (7.2) EtCO2 peak (mmHg), mean, SD 50.6 (3.9) Table 3. Pulmonary Function Testing Results % Change post-bronchodilator in FEV 1 (mean, SD) 5.6 (9.5) FVC, % Predicted (mean, SD) 104.2 (14.0) FEV1/FVC, % Predicted (mean, SD) 92.5 (8.3) TLC, % Predicted (mean, SD) 101.5 (16.5) ERV, % Predicted (mean, SD) 70.2 (25.7) RV, % Predicted (mean, SD) 82.1 (39.3) DLCO, % Predicted (mean, SD) 93.6 (17.2) Participants with obstructive lung disease (N, %) 33 (15.3) Participants with restrictive lung disease (N, %) 8 (3.7) Table 4. Multiple Regression Analysis: not-yet-known not-yet-known not-yet-known unknown PSG Variables as function of BMI Z-score, Age, Sex and Lung Volume Measurements TLC -0.011 (p=0.01) 0.06 (p= 0.03) -0.04 (p=0.02) RV -0.005 (p=0.01) 0.01 (p=0.30) -0.005 (p=0.44) ERV -0.004 (p= 0.2) 0.02 (p= 0.23) -0.03 (p= 0.01) DLCO 0.016 (p<0.001) -0.01 (p=0.64) 0.03 (p =0.03) Npote: lnAHI is the log transformed AHI not-yet-known not-yet-known not-yet-known unknown References: Skinner AC, Ravanbakht SN, Skelton JA, Perrin EM, Armstrong SC. Prevalence of Obesity and Severe Obesity in US Children, 1999-2016. Pediatrics. 2018 Mar;141(3):e20173459. doi: 10.1542/peds.2017-3459. Erratum in: Pediatrics. 2018 Sep;142(3):e20181916. doi: 10.1542/peds.2018-1916. PMID: 29483202; PMCID: PMC6109602. Zhang X, Liu J, Ni Y, Yi C, Fang Y, Ning Q, Shen B, Zhang K, Liu Y, Yang L, Li K, Liu Y, Huang R, Li Z. Global Prevalence of Overweight and Obesity in Children and Adolescents: A Systematic Review and Meta-Analysis. 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Observational study of the effect of obesity on lung volumes. Thorax. 2014 Aug;69(8):752-9. doi: 10.1136/thoraxjnl-2014-205148. Epub 2014 Apr 15. PMID: 24736287 Bhakta NR, Bime C, Kaminsky DA, McCormack MC, Thakur N, Stanojevic S, Baugh AD, Braun L, Lovinsky-Desir S, Adamson R, Witonsky J, Wise RA, Levy SD, Brown R, Forno E, Cohen RT, Johnson M, Balmes J, Mageto Y, Lee CT, Masekela R, Weiner DJ, Irvin CG, Swenson ER, Rosenfeld M, Schwartzstein RM, Agrawal A, Neptune E, Wisnivesky JP, Ortega VE, Burney P. Race and Ethnicity in Pulmonary Function Test Interpretation: An Official American Thoracic Society Statement. Am J Respir Crit Care Med. 2023 Apr 15;207(8):978-995. doi: 10.1164/rccm.202302-0310ST. PMID: 36973004; PMCID: PMC10112445. Information & Authors Information Version history V1 Version 1 19 August 2025 Peer review timeline Published Sleep and Breathing Version of Record 25 Mar 2026 Published Copyright This work is licensed under a Non Exclusive No Reuse License. Keywords obesity pft polysomnography Authors Affiliations Abigail Strang 0000-0003-0300-7198 [email protected] Nemours Children's Hospital Delaware View all articles by this author Benjamin Crain Nemours Children's Hospital Delaware View all articles by this author Linhda Nguyen Nemours Children's Hospital Delaware View all articles by this author Jobayer Hossain Nemours Children's Hospital Delaware View all articles by this author Thomas Shaffer Nemours Children's Hospital Delaware View all articles by this author Aaron Chidekel Nemours Children's Hospital Delaware View all articles by this author Metrics & Citations Metrics Article Usage 177 views 109 downloads .FvxKWukQNSOunydq8rnd { width: 100px; } Citations Download citation Abigail Strang, Benjamin Crain, Linhda Nguyen, et al. Relationships between Pulmonary Function Testing and Polysomnography in Adolescents with Severe Obesity. Authorea . 19 August 2025. 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