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\begin{document}

\title{Bispectral Index Values of Natural Sleep and its Use in Sleep Endoscopy}



\author[1]{Gokhan Yalciner}%
\author[2]{Mehmet Babademez}%
\author[3]{Hayati Kale}%
\author[2]{saliha atalay}%
\author[4]{kemal delioğlu}%
\author[1]{Ayça Dumanlı Özcan}%
\author[5]{togay müderris}%
\affil[1]{Ankara City Hospital}%
\affil[2]{Yildirim Beyazit Universitesi}%
\affil[3]{Medicana International Istanbul Hospital}%
\affil[4]{Basaksehir Cam and Sakura City Hospital}%
\affil[5]{Bakircay Universitesi}%


\vspace{-1em}



  
  \date{May 19, 2024}


\begingroup
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\selectlanguage{english}
\begin{abstract}
OBJECT\selectlanguage{polish}İ\selectlanguage{english}VE: To investigate the bispectral index values of normal sleep
stages PAT\selectlanguage{polish}İ\selectlanguage{english}ENTS and METHOD: Simultaneous polysomnography and bispectral
index recordings of 21 patients who underwent polysomnography for
diagnosis of obstructive sleep apnea were analyzed for determining the
BIS values of normal sleep stages. RESULTS: BIS values are found
sensitive in reflecting the various stages of natural sleep except for
REM and stage N2. REM and stage N2 BIS values were close to each other.
CONCLUSION: BIS is sensitive for the evaluation of the stages of natural
sleep and BIS values decreases as the sleep stages becomes deeper%
\end{abstract}%



\sloppy


\textbf{INTRODUCTION}

Bispectral Index (BIS) monitoring is an objective measurement tool for
sedation depth, which is derived from the electroencephalogram
(EEG)\textsuperscript{(1-2).} A BIS monitor automatically calculates and
displays the BIS index, a dimensionless number, whose value is comprised
between 0 (isoelectric EEG waves) and 100 (awake)\textsuperscript{(3)}.
In non-anesthetized patients, the BIS varies from 90 to 100. On the
other hand, total suppression of cortical electrical activity results in
a BIS of zero \textsuperscript{(2)} .A BIS between 40 and 60 is
associated with a low probability of intraoperative awakening and
awareness \textsuperscript{(2).}

Most studies evaluating the BIS system have been performed in anesthesia
and intensive care units in order to estimate the level of sedation and
anesthesia \textsuperscript{(3)}. Only a few small studies have
investigated the BIS index during natural
sleep\textsuperscript{(4-5-6)}, and their results are inconsistent.

Drug induced sleep endoscopy (DISE) using sedative agents infusion,
guided by a BIS monitor, has been used for decades to directly examine
the upper respiratory tract for detecting airway collapse
sites\textsuperscript{(7-8)}. According to Traxdorf
M\textsuperscript{*7*5}et all for DISE ,BIS leads to a precisely
controllable depth of sedation .The DISE-Target controlled infusion of
sedative agent -BIS analysis procedure is a step towards a required
reproducible protocol of sleep endoscopy capable of standardization.
According to Shlemer JW*\textsuperscript{8}* et all . between the
commonly used agents for DISE dexmedetomidine's mechanism of action
appear most likely to induce natural sleep pathways compared to propofol
and midazolam . Different sedation levels such as 50-60 (deep sedation)
or 65-75 (light sedation) are recommended for DISE by different
researchers\textsuperscript{(9-10)}, but it is not exactly known which
BIS level corresponds to which phase of normal sleep.

In this study, we aimed to investigate the BIS values of normal sleep
stages, by investigating BIS values during sleep in patients who
underwent polysomnography in the sleep laboratory.

\textbf{PATIENTS AND METHOD}

Twenty-one patients (15 men, 6 women) aged between 36 and 73 years (mean
59.2 years) who underwent polysomnography (PSG) for the diagnosis of
obstructive sleep apnea syndrome in the sleep laboratory of Atat\selectlanguage{ngerman}ürk
Training and Research Hospital, between October 2016 and March 2017 were
included in this prospective study. Patients with moderate or severe
apnea (apnea-hypopnea index \selectlanguage{english}[?] 15 ) and the patients who have comorbid
systemic illness (such as chronic obstructive pulmonary disease, heart
failure)that we think may affect sleep architecture were excluded from
study. Local ethical committee approval and written informed consents
from patients were obtained.

Simultaneous PSG and BIS recordings of all patients during whole night
were acquired.

All PSG recordings were performed with the Philips Respironics Alice 6
Equipment under supervision of experienced sleep technicians and all
recordings were manually scored by the same experienced and certified
medical doctor (GY). Sleep state scorings were performed according to
''AASM Manual for the Scoring of Sleep and Associated Events'', version
2.2.

BIS monitoring was performed with the BIS vista monitor (Covidien
Medtronic VISTA application revision 3.20, vista platform revision
2.03). BIS Quatro electrodes were used for recordings.

BIS and PSG recordings were started simultaneously by using the internal
clocks of the devices. By the reason of the fact that BIS device records
at 1 minute intervals and the epochs in PSG are 30 seconds, 1 BIS value
for 2 EEG epochs were obtained and used for analysis.

Only sleep stages lasting 2 minutes or more were included in the
analysis (stable sleep / awake state). BIS signals with a signal quality
index (SQI) \textless{}50 were not analyzed.

\textbf{STATISTICAL ANALYSIS}

The statistical analysis was carried out with SPSS v 23.0 for Windows
(SPSS, Chicago, IL) and statistical significance was determined at
p\textless{}0,05. One-way ANOVA test was used to evaluate BIS averages
of SQI groups and comparison of sleep stages according to BIS score
averages of SQI values over 70. Post hoc Tukey test was used to compare
variables that were found significant.

\textbf{RESULTS}

Polysomnographic sleep findings of patients were analyzed for the
distribution of sleep stages and other sleep related data\textbf{.}Sleep
stages were classified as W (wake), N1 (non-rem1), N2 (non-rem2), N3
(non-rem3) and R (rem). Total recording time, total sleep time, sleep
efficiency and the duration of each sleeping stage (W, N1, N2, N3,R)
were calculated from the PSG reports (Table 1).

The BIS analysis was performed according to different SQI values.
Initially SQI values were divided into three groups (Group 1: 50-70,
Group 2: 70-89, Group 3: \textgreater{}90) to calculate BIS averages for
each group. When the mean BIS values of these three SQI groups were
compared, no significant difference was found between Group 2 and Group
3 as a result of binary comparison of BIS values. There was
statistically significant difference between Group 1 and the other
groups (Table 2). So we included only the BIS values with an index of
SQI over 70 for comparison of BIS values of sleep stages (Table 3).

When the sleep stages were compared, no statistically significant
difference was found between the BIS score averages (for SQI values over
70) in stage 2 and REM stages. In all of the other comparisons, there
was significant difference in BIS values between the sleep stages (Table
4)

\textbf{DISCUSSION}

To our best knowledge, this study is one of the few researches that
attempt to define BIS values during normal sleep in the sleep laboratory
while performing PSG for obstructive sleep apnea syndrome (OSAS)
diagnosis. Although the patients included in this prospective study were
patients suspected to have OSAS; moderate and severe OSAS patients were
not included to study to provide a population closer to normal. By this
way, a study population with mildly distorted sleep architecture was
created.

Only the BIS and sleep stage values in the sleep period that were longer
than 2 minutes were taken into account (stable sleep stage) after the
end of second minute.

Although the BIS devices are not calibrated to identify the natural
sleep stages, there are few studies in the literature investigating the
BIS values during normal sleep with conflicting results. In 1999, Slergh
et al\textsuperscript{(6)} claimed that; changes in the depth of natural
sleep are reflected sensitively by changes in the BIS and BIS may be a
simple indicator of the depth of sleep. But their study group was
consisted of only 5 subjects. Benini et al\textsuperscript{(5)} also
concluded that BIS is sensitive in reflecting the changes on the EEG
trace that accompany various stages of natural sleep. To be more
specific, they found a progressive decrease in BIS values as the stages
of sleep becomes deeper, in their study performed with 15 children.
Contrarily, Neuwenhuijs D et al \textsuperscript{(11)} reported that the
processed EEG measurements (both BIS and spectral edge frequency) have a
limited ability to estimate classical sleep stages as a result of their
work with 10 patients.

It has been shown that, BIS can identify stage N3 with satisfactory
sensitivity and specificity, but it is unable to distinguish light sleep
stage (N1) from REM, sleep or wakefulness (W).
\textsuperscript{(3)}Signal quality index is used in different
scientific areas to explain some characteristics of determined
signals.Therefore the defined SQI is related with signal strength.The
SQI is ranged between 0 and 100\% (best signal quality). Mohammad et al
suggested that BIS signals should be read in relation to the current
signal quality index (SQI) and impedance. \textsuperscript{(3)} However
there is no validated threshold for the quality of the BIS signal and it
is not completely clear how the SQI is calculated and what should be an
ideal value.

In our study, we first investigated the BIS scores for SQI values of
50-70, 70-90 and over 90 and we found that there was no statistically
significant difference between average BIS values of 70-90 and over 90
SQI values, but there was significant difference between 50-70 and
50-70/over 90 SQI values. So we included only the BIS values with an
index of SQI over 70 to study.

According to our study, BIS values decrease progressively as the stages
of sleep becomes deeper. Mean BIS values were 87.70, 83.94, 74.41, 56.60
and 74.90 For W, N1, N2, N3 and R3 stages respectively (table 4).
Furthermore, BIS values were sensitive in reflecting the stages of
natural sleep except REM and N2; REM and stage N2 BIS values were
similar. One possible explanation of proximity of the index scores in N2
and REM stages may be the inability of the available BIS monitor to
distinguish the brain's electrical activiy in these two stages. Our
results are incompatible with some of the previous studies, which
reported BIS is not 100\% specific in predicting intraoperative
awakening and recall\textsuperscript{( 2)}. In their study, Duarte et al
also claimed that the model of BIS monitor could influence the
interpretation of the results. We found a statistically significant
relationship between BIS scores and sleep stages, which may due to use
of a higher model of BIS monitor.

All of the currently available monitors need different period of times
to calculate and update the index in response to changes in the depth of
anesthesia \textsuperscript{(2)}. The time to update BIS records can
range from 14 to 155 seconds. For this reason, to acquire more reliable
results, we evaluated only the data obtained after the second minute of
stable stages.

BIS monitoring may be a practical method to identify sleep
stages.Because in oder to recognize sleep stages,BIS is a numerical
method that everyone can evaluate in stead of EEG which can only be
assesed with a specific training. Which BIS values should be used for
sleep endoscopy is not exactly known yet. ~As a result of their research
Babar-Craig *\textsuperscript{12}* et all reported that : average BIS
values ranging from ~50 to 61 is appropriate for sleep nasendoscopy. Our
results suggest that, the 50-70 BIS values correspond to the deep stages
of sleep (N3), and it is well known fact that respiratory events are
less common in N3 phase of sleep \textsuperscript{(13)}. Thus, we
recommend that sleep endoscopy should be done at 70-80 BIS values, which
corresponds to N1 and N2 phases of sleep where respiratory events are
more frequently seen.

In conclusion, according to us BIS is a usefool tool for distinguishing
of normal sleep stages except the R2 REM stages and BIS values decreases
as the sleep stages become deeper.\selectlanguage{english}
\begin{longtable}[]{@{}llllll@{}}
\toprule
& N & Mean & Std. Deviation & Minimum & Maximum\tabularnewline
\midrule
\endhead
\vtop{\hbox{\strut \textless{}70}\hbox{\strut 70-89}\hbox{\strut \textgreater{}=90}\hbox{\strut Total}}
& 446 1504 1328 3278 & 82,84 73,83 73,22 74,81 & 13,973 16,702 16,599
16,622 & 27 27 38 27 & 98 94 98 98\tabularnewline
\bottomrule
\end{longtable}

Table 1: Distribution of BIS averages according to SQI\selectlanguage{english}
\begin{longtable}[]{@{}llll@{}}
\toprule
\begin{minipage}[b]{0.24\columnwidth}\raggedright\strut
\textbf{SQI group (A)}\strut
\end{minipage} & \begin{minipage}[b]{0.24\columnwidth}\raggedright\strut
\textbf{SQI group (B)}\strut
\end{minipage} & \begin{minipage}[b]{0.24\columnwidth}\raggedright\strut
Mean Difference (A-B)\strut
\end{minipage} & \begin{minipage}[b]{0.24\columnwidth}\raggedright\strut
\textbf{p}\strut
\end{minipage}\tabularnewline
\midrule
\endhead
\begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
\textless{}70\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
70-89\\
\textgreater{}=90\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
9,016\textsuperscript{*}\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
0,00\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
9,623\textsuperscript{*}\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
0,00\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
70-89\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
\textless{}70\\
\textgreater{}=90\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
-9,016\textsuperscript{*}\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
0,00\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
,607\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
0,58\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
\textgreater{}=90\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
\textless{}70\\
70-89\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
-9,623\textsuperscript{*}\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
0,00\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
-,607\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
0,58\strut
\end{minipage}\tabularnewline
\bottomrule
\end{longtable}

Table 2: BIS averages of SQI groups Table 3: Distribution of BIS score
averages of SQI values over 70 according to sleep stages\selectlanguage{english}
\begin{longtable}[]{@{}llllll@{}}
\toprule
& N & Mean & Std. Deviation & Minimum & Maximum\tabularnewline
\midrule
\endhead
\vtop{\hbox{\strut W}\hbox{\strut 1}\hbox{\strut 2}\hbox{\strut 3}\hbox{\strut R}\hbox{\strut Total}}
&
\vtop{\hbox{\strut 480}\hbox{\strut 406}\hbox{\strut 902}\hbox{\strut 722}\hbox{\strut 322
2832}} &
\vtop{\hbox{\strut 87,70}\hbox{\strut 83,94}\hbox{\strut 74,41}\hbox{\strut 56,60}\hbox{\strut 74,90}\hbox{\strut 73,54}}
& 7,444 8,614 13,088 16,603 9,630 16,615 &
\vtop{\hbox{\strut 52}\hbox{\strut 47}\hbox{\strut 35}\hbox{\strut 27}\hbox{\strut 36}\hbox{\strut 27}}
&
\vtop{\hbox{\strut 98}\hbox{\strut 97}\hbox{\strut 96}\hbox{\strut 95}\hbox{\strut 95}\hbox{\strut 98}}\tabularnewline
\bottomrule
\end{longtable}

Table 4: Comparison of sleep stages according to BIS score averages of
SQI values over 70\selectlanguage{english}
\begin{longtable}[]{@{}llll@{}}
\toprule
\begin{minipage}[b]{0.24\columnwidth}\raggedright\strut
\textbf{Stage (A)}\strut
\end{minipage} & \begin{minipage}[b]{0.24\columnwidth}\raggedright\strut
\textbf{Stage (B)}\strut
\end{minipage} & \begin{minipage}[b]{0.24\columnwidth}\raggedright\strut
Mean Difference (A-B)\strut
\end{minipage} & \begin{minipage}[b]{0.24\columnwidth}\raggedright\strut
\textbf{p}\strut
\end{minipage}\tabularnewline
\midrule
\endhead
\begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
W\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
1\\
2\\
3\\
R\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
3,759\textsuperscript{*}\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
0,00\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
13,294\textsuperscript{*}\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
0,00\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
31,102\textsuperscript{*}\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
0,00\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
12,799\textsuperscript{*}\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
0,00\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
1\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
W\\
2\\
3\\
R\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
-3,759\textsuperscript{*}\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
0,00\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
9,535\textsuperscript{*}\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
0,00\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
27,343\textsuperscript{*}\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
0,00\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
9,040\textsuperscript{*}\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
0,00\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
2\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
W\\
1\\
3\\
R\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
-13,294\textsuperscript{*}\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
0,00\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
-9,535\textsuperscript{*}\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
0,00\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
17,807\textsuperscript{*}\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
0,00\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
-,495\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
0,97\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
3\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
W\\
1\\
2\\
R\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
-31,102\textsuperscript{*}\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
0,00\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
-27,343\textsuperscript{*}\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
0,00\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
-17,807\textsuperscript{*}\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
0,00\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
-18,302\textsuperscript{*}\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
0,00\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
R\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
W\\
1\\
2\\
3\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
3,759\textsuperscript{*}\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
0,00\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
13,294\textsuperscript{*}\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
0,00\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
31,102\textsuperscript{*}\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
0,97\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
12,799\textsuperscript{*}\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
0,00\strut
\end{minipage}\tabularnewline
\bottomrule
\end{longtable}

\textbf{Abbreviations}

Associate Professor G\selectlanguage{ngerman}ökhan Yalç\selectlanguage{polish}ı\selectlanguage{english}ner M.D: GY

Bispectral Index: BIS

Drug induced sleep endoscopy: DISE

Electroencephalogram: EEG

Obstructive sleep apnea syndrome: OSAS

Polysomnography: PSG

Signal quality index: SQI

\textbf{REFERENCES}

\begin{enumerate}
\tightlist
\item
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\item
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\item
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  Fernandez-Bolanos M, Quera-Salva MA, Fauroux B. Utility Of The
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\item
  Dahaba AA, Xue JX, Xu GX, Liu QH, Metzler H. Bilateral Bispectral
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\item
  Benini F, Trapanotto M, Sartori S, Capretta A, Gobber D, Boniver C,
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\item
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\item
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\item
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\item
  Stierer TL, Ishman SL. Bispectral Index In Evaluating Effects Of
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\item
  Lo YL, Ni YL, Wang TY, Lin TY, Li HY, White DP, Lin JR, Kuo HP.
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  15;11(9):1011-20
\item
  Nieuwenhuijs D, Coleman EL, Douglas NJ, Drummond GB, Dahan A.
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  Stages Of Physiologic Sleep. Anesth Analg. 2002;94:125-9
\end{enumerate}

\selectlanguage{english}
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\end{document}

