Screening for Obstructive Sleep Apnea in Adults: Evidence Report and Systematic Review for the US Preventive Services Task Force

Craniofacial features of adult obese obstructive sleep apnoea patients in relation to the obesity onset - A pilot study

INTRODUCTION

Obesity and craniofacial structures are aetiologies of obstructive sleep apnoea (OSA). The effect of obesity onset on the craniofacial development and growth of obese OSA subjects has been suggested, but supporting data were lacking. This study aimed to assess the craniofacial features of adult obese OSA patients in relation to their obesity onset.

MATERIALS AND METHODS

A total of 62 adult OSA patients were included in the study, consisting of 12 early-onset (i.e. before puberty), 21 late-onset (i.e. after puberty) and 29 non-obese. All participants underwent a sleep study and cephalometric radiograph. Cephalometric analysis was conducted to measure the craniofacial features among the groups.

RESULTS

The early obesity onset group (n = 12) showed a more prognathic mandible, longer lower facial height, protrusive incisors, a more caudal position of the hyoid bone and a wider lower airway. The late-onset group (n = 21) had more proclined and protrusive upper incisors, a shallower overbite, a more inferiorly positioned hyoid bone and an obtuse craniocervical angle. The overall obese group showed a combination of the findings above, plus a shorter soft palate and shorter airway length. There was no significant difference between early and late obesity onset groups. However, the early group showed a tendency for a shallower or decreased mandibular plane angle and deeper overbite.

CONCLUSIONS

The current pilot study had many limitations but holds important information as a hypothesis generator. Craniofacial features of OSA patients with different obesity onset showed discrepancies and were distinguished from non-obese controls. Adult OSA patients with an early obesity onset showed a tendency for a more hypodivergent growth pattern than those with a late obesity onset.

Home Sleep Testing versus Traditional Polysomnography: Pros and Cons

Obstructive sleep apnea (OSA) is associated with long-term cardiovascular and respiratory comorbidities and increased burden on the health-care system. Early and accurate diagnosis is essential to reduce physical and financial implications of the disease. Polysomnography uses neurophysiologic channels as well as basic respiratory and sleep parameters to best estimate the presence and/or severity of OSA. Although home sleep testing may have the potential for more variable results, it is a viable alternative to increase access to diagnosis of OSA and facilitate initiation of positive airway pressure.

Assessment and management of continuous positive airway pressure therapy in patient with obstructive sleep apnea

Obstructive sleep apnea (OSA) causes excessive daytime sleepiness, impaired daytime functioning, and an increased risk of cardiovascular diseases. Continuous positive airway pressure (CPAP) is a highly effective therapy for moderate to severe OSA. Although CPAP adherence is commonly assessed using a 4-hthreshold, determining the optimal usage time based on clinical outcomes is crucial. While subjective sleepiness often improves with ≥4 h of CPAP usage, an extended duration (≥6 h) may be necessary to impact objective sleepiness. CPAP demonstrated a modest yet clinically meaningful dose-dependent effect on lowering blood pressure. For patients seeking antihypertensive benefits from CPAP therapy, the goal should extend beyond 4 h of use to maximize the therapeutic impact. Recognizing individual variations in sleep duration and responses to CPAP therapy is essential. The adoption of 'individualized goals for CPAP use,' outlining target times for specific outcomes, should also consider an individual's total sleep duration, including periods without CPAP. The impact of CPAP on clinical outcomes may vary, even with the same duration of CPAP use, depending on the period without CPAP use, particularly during the first or second half of sleep. Patients who remove or initiate CPAP midway or have a low CPAP usage frequency may require different forms of guidance. Tailoring patient education to address CPAP usage patterns may be necessary to enhanced satisfaction, self-efficacy, and adherence to therapy. Management of CPAP treatment should be personalized to meet individual needs and adapted based on specific response patterns for achieving treatment efficacy.

Association of obstructive sleep apnea symptoms with all-cause mortality and cause-specific mortality in adults with or without diabetes: A cohort study based on the NHANES

BACKGROUND

The association between obstructive sleep apnea syndrome (OSAS) and mortality has not been extensively researched among individuals with varying diabetic status. This study aimed to compare the relationship of OSAS with all-cause and cause-specific mortality in US individuals with or without diabetes based on data from the National Health and Nutrition Examination Survey (NHANES).

METHODS

The study included participants from the NHANES 2005-2008 and 2015-2018 cycles with follow-up information. OSAS data (OSAS.MAP10) was estimated from the questionnaire. Hazard ratios (HRs) and the 95% confidence interval (CI) of OSAS for mortality were calculated by Cox regression analysis in populations with different diabetes status. The relationships between OSAS and mortality risk were examined using survival curves and restricted cubic spline curves.

RESULTS

A total of 13 761 participants with 7.68 ± 0.042 follow-up years were included. In the nondiabetic group, OSAS.MAP10 was positively associated with all-cause, cardiovascular, and cancer mortality. In individuals with prediabetes, OSAS.MAP10 was positively related to all-cause mortality (HR 1.11 [95% CI: 1.03-1.20]) and cardiovascular mortality (HR 1.17 [95% CI: 1.03-1.33]). The relationship between OSAS.MAP10 and the risk of all-cause mortality and cancer mortality exhibited L-shaped curves in diabetes patients (both with nonlinear p values <.01). Further threshold effect analysis revealed that OSAS was positively related to death risk when OSAS.MAP10 exceeded the threshold scores.

CONCLUSION

The relationship between OSAS and mortality differed among participants with or without diabetes. Individualized clinical treatment plans should be developed in clinical practice to reduce the risk of death for patients with different metabolic conditions.

Assessment of oropharyngeal respiratory volume and sleep apnoea scores using peripheral arterial tonometry may improve diagnosis and treatment planning of combined dysgnathia therapy approaches

BACKGROUND

Increased daytime sleepiness is a frequently reported symptom in patients with pronounced dysgnathia.

OBJECTIVES

This study investigated possible correlations using home peripheral arterial tonometry (PAT) and oropharyngeal airway volume determination in patients with dysgnathia and daytime sleepiness.

METHODS

Twenty patients (13 male, median age 27.6 ± 6.8 years) with abnormal sleep history and 10 skeletal neutral configured controls (6 male, median age 29.5 ± 4.2 years) with normal sleep history were examined. Patients and controls were evaluated for apnoea-hypopnoea index (AHI), respiratory disturbance index (RDI), oxygen desaturation index (ODI), snoring volume (dB), total sleep time (TST) and REM-percentage (REM). Airway volumetry was measured via CBCT. Individual user experience for PAT was assessed using the User Experience Questionnaire (UEQ).

RESULTS

Patients had significantly higher respiratory scores than controls. AHI increased 4.6-fold (p = .006), RDI 2.5-fold (p = .008) and ODI 6.4-fold (p < .001). Oropharyngeal volumes showed a 30% decrease (p = .003). dB, TST and REM showed no significant differences. AHI (r = -.51; p = .005), ODI (r = -.60; p < .001) and RDI (r = -.45; p = .016) correlated negatively with pharyngeal volume. Wits appraisal correlated negatively with oropharyngeal volume (r = -.47; p = .010) and positively with AHI (r = .41; p = .03) and ODI (r = .49; p = .007). dB and TST (r = -.49; p = .008) and REM and RDI (r = -.43; p = .02) correlated negatively. UEQ-KPI (2.17 ± 0.24) confirmed excellent usability of PAT.

CONCLUSION

Patients with mandibular retrognathia and abnormal sleep history showed significantly higher respiratory indices and smaller oropharyngeal volumes than neutrally configured controls. The dygnathia severity directly influenced the risk of obstructive sleep apnoea.

Novel clinical screening method to identify patients at risk of obstructive sleep apnea

OBJECTIVE

To investigate whether the distance between the two retromolar trigones (RMTs) with the distance between the two posterior plicas (PPs) affects obstructive sleep apnea syndrome (OSAS) and to determine a physical examination method that can be used in the selection of patients to be referred to polysomnography (PSG).

METHODS

The study included 86 OSAS patients and 29 healthy controls. RMTs and PPs were measured using a caliper-like device. The values obtained from these measurements were evaluated in both groups.

RESULTS

The PPs were narrower, and the RMTs-PPs, RMTs-PPs/RMTs, and RMTs/PPs values were greater in the OSAS group (p < .05) compared to the control group. The cut-off values were 0.612 for RMTs-PPs/RMTs and 2.589 for RMTs/PPs. The specificity of these values for OSAS was 97%, and sensitivity was 57% and 58%, respectively.

CONCLUSION

The presented method may play a role in preventing unnecessary PSG among patients with suspected OSAS.

Prevalence of Obstructive Sleep Apnea in the Young Adult Population: A Systematic Review

BACKGROUND

The prevalence of obstructive sleep apnea (OSA) is suggested to differ according to different age groups. While its prevalence has been extensively investigated among middle-aged and old individuals, very few studies have summarized its prevalence among young adults. The present study aimed to conduct a systematic review and meta-analysis of OSA prevalence among healthy adults aged 18-30 years in the general population.

METHODS

A search of Embase, Medline, and Web of Science databases for articles reporting the prevalence of OSA among young adults confirmed by objective diagnostic methods was completed by two reviewers. Studies identified and included in the review were summarized qualitatively. Additionally, a meta-analysis of prevalence rates was conducted using a random effects model.

RESULTS

11 articles out of 5898 met the inclusion criteria and were included in the meta-analysis. The diagnostic thresholds, scoring criteria, and the type of used device varied substantially among all the studies. We found that the pooled prevalence of OSA among young adults was 16% (CI 95%, 8-29%, I2 = 92%, τ2 = 1.47).

CONCLUSION

The prevalence of OSA among young adults was found to be ~16%. However, a few factors diverged prevalence between the studies, such as hypopnea definition, AHI threshold, and type of device. Most of the studies included examined healthy volunteers, suggesting that the disease burden may be underestimated. Findings from our review highlight the need to include OSA-related assessment and intervention in the overall health care of young adults. By early detection and offered treatment, further complications related to comorbidities may be omitted.

Sleeve Gastrectomy Surgery makes Obstructive Sleep Apnea Worse or Better?: a Multi-Center Observational Study in Patients with Obesity

BACKGROUND AND OBJECTIVE

Obstructive sleep apnea (OSA) is highly prevalent in the bariatric surgical population, with rates ranging from 50 to 70%. The impact of laparoscopic sleeve gastrectomy (LSG) on OSA and its associated risk factors remain relatively understudied. The aim of this study is to assess the effect of LSG on OSA and investigate predictors of new or worsening OSA postoperatively. Additionally, the study aims to provide evidence for the individualized selection of LSG procedures based on patient characteristics.

METHODS

This multi-center observational study enrolled 119 patients with obesity who underwent LSG and were subdivided into two groups based on their preoperative AHI: AHI < 15 and AHI ≥ 15. The patients were followed up and evaluated before and 30 days after LSG. The study utilized univariate and multivariate analyses to assess risk factors for postoperative AHI development.

RESULTS

Following LSG, there was a significant decrease in the mean AHI, leading to the resolution of OSA symptoms in 67.6% of patients with AHI ≥ 15. Neck circumference and the number of METS were also identified as independent risk factors for postoperative OSA. Furthermore, preoperative hypertension was found to be a significant predictor of new or worsened OSA after LSG.

CONCLUSION

LSG demonstrated effectiveness in improving OSA among patients with obesity. The study highlights the importance of preoperative hypertension evaluation and postoperative management in patients undergoing LSG. Further long-term, multicenter, and large-scale studies are recommended to validate and generalize these findings to diverse patient populations.

Recommended assessment and management of sleep disordered breathing in patients with atrial fibrillation, hypertension and heart failure: Taiwan Society of Cardiology/Taiwan Society of sleep Medicine/Taiwan Society of pulmonary and Critical Care Medicine joint consensus statement

Sleep disordered breathing (SDB) is highly prevalent and may be linked to cardiovascular disease in a bidirectional manner. The Taiwan Society of Cardiology, Taiwan Society of Sleep Medicine and Taiwan Society of Pulmonary and Critical Care Medicine established a task force of experts to evaluate the evidence regarding the assessment and management of SDB in patients with atrial fibrillation (AF), hypertension and heart failure with reduced ejection fraction (HFrEF). The GRADE process was used to assess the evidence associated with 15 formulated questions. The task force developed recommendations and determined strength (Strong, Weak) and direction (For, Against) based on the quality of evidence, balance of benefits and harms, patient values and preferences, and resource use. The resulting 11 recommendations are intended to guide clinicians in determining which the specific patient-care strategy should be utilized by clinicians based on the needs of individual patients.

Validation of the Apnealink Air for diagnosis of obstructive sleep apnoea (OSA) in pregnant women in early-mid gestation

PURPOSE

The detection of obstructive sleep apnoea (OSA) in pregnant women in early-mid gestation is logistically difficult. Accurate alternates to polysomnography (PSG) in early pregnancy are not well identified. We compared the agreement between Apnealink Air (AL) and existing screening questionnaires to PSG in pregnant women ≤ 24-week gestation.

METHODS

Pregnant women (≤ 24-week gestation) underwent AL at home plus attended PSG in any order, completed within 7 days where practicable. AL was manually scored (AL(M)) and automatically scored (AL(A)). An apnoea-hypopnea index (AHI) ≥ 5 was considered diagnostic of OSA and an AHI ≥ 15 considered at least moderate OSA. Diagnostic analysis was undertaken (sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV)) by generating receiver operating characteristic (ROC) curves and an area under the curve (AUC) (95% CI). Bland-Altman plots were used to plot agreement. Screening questionnaires (Epworth sleepiness score (ESS), STOP-BANG, calculated pregnancy-specific screening tool) were compared to PSG.

RESULTS

A total of 49 participants successfully completed both tests at around 14-weeks gestation (IQR 12.9, 17.1). The time interval between AL and PSG was a median of 2 days (IQR 1, 5 (range 1-11)). A total of 14 (29%) participants had OSA. The median AHI of AL(A) (3.1(IQR 0.85,4.6)) and AL(M) (IQR2.4(0.65,4.8)) did not differ from PSG (1.7(IQR1.0,6.1)). AL(A) and AL(M) compared to PSG demonstrated diagnostic test accuracy (area under curve (ROC)) of 0.94(95% CI 0.87-1.0) and 0.92(95% CI 0.85-1.0) respectively. Apnealink Air outperformed screening questionnaires tested.

CONCLUSION

The findings suggest that Apnealink may provide a substitute to attended PSG identification of OSA in pregnant women in early-mid gestation using both manual and auto-scoring methods.

TDP43/HDAC6/Prdx1 signaling pathway participated in the cognitive impairment of obstructive sleep apnea via regulating inflammation and oxidative stress

Neuroinflammation and oxidative stress induced by intermittent hypoxia (IH) are associated with cognitive dysfunction in patients with obstructive sleep apnea (OSA). Recently, TAR DNA-binding protein 43 (TDP-43), histone deacetylase 6 (HDAC6), and peroxiredoxin 1 (Prdx1) have been reported to be involved in cognitive impairment in many degenerative diseases; however, the underlying mechanisms remain unclear. In the present study, subjects underwent polysomnography to diagnose OSA. Cognitive function was evaluated using the Montreal Cognitive Assessment (MoCA) and peripheral blood samples were collected. HMC3 cells were treated with lipopolysaccharide (LPS) to mimic in vitro neuroinflammation. Western blotting was used to assess protein expression and ELISA to assess inflammation and oxidative stress levels. Participants were divided into three groups: healthy control (n = 20); mild to moderate OSA (n = 20); and severe OSA (n = 20). The MoCA scores in mild-moderate OSA and severe OSA were lower than those in healthy controls. Continuous positive airway pressure therapy was found to be effective for cognitive impairment in subjects with severe OSA (24.70 ± 1.81). Expression of TDP-43 and HDAC6 was increased in subjects with OSA, whereas Prdx1 expression was decreased. Alterations in these proteins were partially reversed after 12 weeks of CPAP treatment. Protein expression of TDP-43 and HDAC6 was negatively correlated with MoCA scores in patients with OSA, while Prdx1 expression exhibited the opposite trend. In LPS-treated HMC3 cells, TDP-43 and HDAC6 were upregulated, whereas Prdx1 expression was reduced. TDP-43 influenced the expression of Prdx1 by regulating HDAC6, and inflammation and oxidative stress varied with the expression of TDP-43. When a specific inhibitor of HDAC6 was used, LPS-induced inflammation and oxidative stress were alleviated by an elevated level of Prdx1. In summary, findings of the present study suggest that TDP-43 influenced Prdx1 by regulating HDAC6 expression and promoting neuroinflammation and oxidative stress. This process may be involved in the cognitive impairment experienced by patients with OSA and may provide potential therapeutic targets.

Self-reported oral moistening disorders in obstructive sleep apnoea: A scoping review

BACKGROUND

Obstructive sleep apnoea (OSA) is a highly prevalent problem with significant consequences. Continuous positive airway pressure (CPAP) and oral mandibular advancement device (MAD) are considered the standard treatments for OSA. Patients may experience self-reported oral moistening disorders (OMDs) (i.e. xerostomia or drooling) at the beginning, throughout and after treatment. This affects oral health, quality of life and treatment effectiveness. The exact nature of the associations between OSA and self-reported OMD is still unknown. We aimed to provide an overview of the associations between self-reported OMD on the one hand and OSA and its treatment (namely CPAP and MAD) on the other hand. In addition, we sought to determine whether OMD affects treatment adherence.

MATERIALS AND METHODS

A literature search in PubMed was performed up to 27 September 2022. Two researchers independently assessed studies for eligibility.

RESULTS

In total, 48 studies were included. Thirteen papers investigated the association between OSA and self-reported OMD. They all suggested an association between OSA and xerostomia but not between OSA and drooling. The association between CPAP and OMD was addressed in 20 articles. The majority of studies have indicated xerostomia as a CPAP side effect; however, some have observed that xerostomia diminishes with CPAP therapy. In 15 papers, the association between MAD and OMD was investigated. In most publications, both xerostomia and drooling have been described as common side effects of MADs. These side effects are often mild and transient, and they improve as patients continue to use their appliance. Most studies found that these OMDs do not cause or are not a strong predictor of non-compliance.

CONCLUSION

Xerostomia is a common side effect of CPAP and MAD, as well as a significant symptom of OSA. It may be regarded as one of the indicators of sleep apnoea. Moreover, MAD therapy can be associated with OMD. However, it seems that OMD may be mitigated by being adherent to the therapy.

Association between alcohol use disorder and risk of obstructive sleep apnea

Obstructive sleep apnea (OSA) is a common sleep disorder characterised by recurrent upper airway collapse during sleep. Alcohol consumption has been linked to an increased risk of OSA due to its effects on the upper airway and body mass index (BMI). We aimed to investigate the correlation between alcohol use disorders and OSA. We used 11,859 participants data from Korean National Health and Nutrition Examination Surveys. The variable of interest was alcohol use disorder, measured using the Alcohol Use Disorders Identification Test, and the dependent variable was the risk of OSA, measured using the Snoring, Tiredness, Observed apnea, high blood Pressure, BMI, age, neck circumference, and male gender questionnaires. Multiple logistic regression was used to assess the association between alcohol use disorder and OSA risk after adjusted analysis. A significant association was found between alcohol use disorder and OSA (adjusted odds ratio [aOR] 2.14, 95% confidence interval [CI] 1.93-2.37). In the unemployed group, those with alcohol use disorder had the highest odds of being at risk of OSA compared with those who did not have this disorder (aOR 2.45, 95% CI 2.04-2.95). The OSA risk increased as the snoring frequency, amount of alcohol consumed, and frequency of binge drinking increased. This study suggests an association between alcohol use disorders and the risk of OSA. The frequency of alcohol consumption, quantity of alcohol consumed, and snoring frequency were associated with the risk of OSA. Therefore, ceasing alcohol consumption is recommended as an effective approach to enhancing sleep quality.

Considerations for Functional Nasal Surgery in the Obstructive Sleep Apnea Population

Obstructive sleep apnea (OSA) and nasal obstruction are common in the general population and frequently treated by otolaryngologists and facial plastic surgeons. Understanding the appropriate pre-, peri-, and postoperative management of OSA patients undergoing functional nasal surgery is important. OSA patients should be appropriately counseled in the preoperative period on their increased anesthetic risk. In OSA patients who are continuous positive airway pressure (CPAP) intolerant, the role of drug-induced sleep endoscopy should be discussed with the patient, and depending on the surgeon's practice may prompt referral to a sleep specialist. Should multilevel airway surgery be indicated, it can safely be performed in most OSA patients. Surgeons should communicate with the anesthesiologist regarding an airway plan given this patient population's higher propensity for having a difficult airway. Given their increased risk of postoperative respiratory depression, extended recovery time should be given to these patients and the use of opioids as well as sedatives should be minimized. During surgery, one can consider using local nerve blocks to reduce postoperative pain and analgesic use. After surgery, clinicians can consider opioid alternatives such as nonsteroidal anti-inflammatory agents. Neuropathic agents, such as gabapentin, require further research in their indications for managing postoperative pain. CPAP is typically held for a period of time after functional rhinoplasty. The decision on when to restart CPAP should be individualized to the patient based on their comorbidities, OSA severity, and surgical maneuvers performed. More research would provide further guidance in this patient population to shape more specific recommendations regarding their perioperative and intraoperative course.

Co-existence of OSA and respiratory diseases and the influence of gender

INTRODUCTION

Sleep-disordered breathing (SDB), especially obstructive sleep apnea (OSA), is commonly associated with respiratory diseases, such as COPD, asthma and interstitial lung disease.

AREAS COVERED

This narrative review aims to comprehensively synthesize the existing information on SDB in respiratory diseases, investigate the role of gender in this association, and highlight the importance of OSA management in improving sleep, quality of life, and disease prognosis in these specific patient populations.

EXPERT OPINION

Research indicates a synergistic link between OSA and chronic respiratory diseases, which leads to greater morbidity and mortality compared to each disorder alone. Given the lack of an optimal OSA screening tool for these patients, a comprehensive patient approach and overnight diagnostic sleep study are imperative. Despite the limited evidence available, it seems that gender has an impact on the prevalence, severity, and susceptibility of this coexistence. Recognizing the role of gender in the coexistence of OSA and other respiratory diseases can enhance everyday medical practice and enable clinicians to adopt a more personalized approach toward optimal screening and diagnosis of these patients.

Bariatric surgery and obstructive sleep apnea: a systematic review and meta-analysis

BACKGROUND

Several studies evaluated the effect of bariatric surgery on obstructive sleep apnea (OSA) but findings have been inconsistent. The aim of this study was to conduct an updated systematic review and meta-analysis to investigate the effect of bariatric surgery on OSA.

METHODS

The databases for PubMed, CENTRAL, and Scopus were searched up to the 1st of December, 2021. Studies were included if they were cohort or case-control in design, included patients with diagnosis of OSA, the patients underwent any bariatric surgery, and the study performed postoperative polysomnography.

RESULTS

The total number of the included patients was 2310 patients with OSA from 32 studies. Our analysis showed that bariatric surgery was associated with significant reduction in BMI (WMD =  - 11.9, 95%CI: - 13.4, - 10.4), apnea-hypopnea index (AHI) (WMD =  - 19.3, 95%CI: - 23.9, - 14.6), and respiratory disturbance index (RDI) (WMD =  - 33.9, 95%CI: - 42.1, - 25.7). The rate of OSA remission after the surgery was 65% (95%CI: 0.54, 0.76).

CONCLUSION

Our results suggest that bariatric surgeries are effective in reducing obesity among patients with OSA in addition to OSA severity measures. However, the low rate of OSA remission suggests that the main etiology of OSA is not only obesity but also includes other important variables such as the anatomy of the jaw.

Effects of continuous positive airway pressure on cardiac events and metabolic components in patients with moderate to severe obstructive sleep apnea and coronary artery disease: a meta-analysis

STUDY OBJECTIVES

This meta-analysis aimed to systematically assess the effects of continuous positive airway pressure (CPAP) in secondary prevention of major cardiovascular events (MACEs) in patients with moderate-to-severe obstructive sleep apnea and coronary artery disease.

METHODS

PubMed, Embase, the Cochrane Library, and ClinicalTrials.gov were searched for observational studies and randomized controlled trials that compared CPAP with usual care in patients with moderate-to-severe obstructive sleep apnea with coronary artery disease. The primary outcomes were MACEs, all-cause death, acute coronary syndrome, rehospitalization for heart failure, repeat revascularization, and arrhythmia.

RESULTS

A total of 11 studies (5 randomized controlled trials and 6 observational studies) with 5,410 patients reported outcomes of MACEs. Treatment with CPAP was associated with a modest risk reduction in MACEs (risk ratio [RR] 0.87, 95% confidence interval [CI] 0.78 to 0.98; P = .02). Similarly, CPAP significantly reduced the risk of all-cause and cardiovascular death by 23% (RR 0.77, 95% CI 0.60 to 0.99; P = .04; I2 = 0%). Subgroup analysis revealed that CPAP adherence time ≥ 4 hours/night had a greater benefit on MACEs by 42% (RR 0.58, 95% CI 0.42 to 0.79; P < .001; I2 = 0%) and repeat revascularization by 44% (RR 0.56, 95% CI 0.34 to 0.92; P = .02; I2 = 0%). Also, CPAP had a positive effect on systolic and diastolic blood pressure.

CONCLUSIONS

CPAP therapy might prevent subsequent MACEs and all-cause death among patients with moderate to severe obstructive sleep apnea and concomitant coronary artery disease. CPAP use exceeding 4 hours/night may add more benefits on MACEs, repeat revascularization, and blood pressure.

CLINICAL TRIAL REGISTRATION

Registry: PROSPERO database; Name: Effects of Continuous Positive Airway Pressure on Cardiovascular Events and Metabolic Components in Patients with Obstructive Sleep Apnea and Coronary Artery Disease; URL: https://www.crd.york.ac.uk/prospero/display_record.php?ID= CRD42020213546; Identifier: CRD42020213546.

CITATION

Yang D, Li L, Dong J, Yang W, Liu Z. Effects of continuous positive airway pressure on cardiac events and metabolic components in patients with moderate to severe obstructive sleep apnea and coronary artery disease: a meta-analysis. J Clin Sleep Med. 2023;19(12):2015-2025.

Improving the screening process for obstructive sleep apnea in the primary care setting

BACKGROUND

There is a high prevalence of obstructive sleep apnea (OSA) in the primary care setting that is underdiagnosed and underreported in 75-80% of the population. If untreated, OSA has implications for long-term cardiovascular, cerebrovascular, and metabolic health.

LOCAL PROBLEM

At a primary care clinic in New Jersey, patients at high risk for OSA were not being routinely screened for the condition.

METHODS

This project intended to address the administration of the STOP-Bang Questionnaire among asymptomatic high-risk patient populations with hypertension and/or obesity. In addition to determining each participant's level of risk for OSA, and in turn, facilitating referrals and diagnostic testing per a provider's discretion.

INTERVENTIONS

The STOP-Bang Questionnaire, a validated screening tool for OSA, was implemented in a primary care practice to measure levels of risk for OSA among eligible participants.

RESULTS

A total of 32 out of the 100 patients assessed were identified as high risk for OSA. After screening, 36 participants were referred for confirmatory testing.

CONCLUSIONS

The STOP-Bang Questionnaire, a validated screening tool for OSA, is recommended for all asymptomatic high-risk patients, specifically for those with obesity and/or hypertension, at least annually. The use of a screening tool evaluates a level of risk, promotes detection of disease in the primary stages, delays disease progression, and improves treatment initiatives.

Giving weight to incretin-based pharmacotherapy for obesity-related sleep apnea: a revolution or a pipe dream?

Obesity is a chronic disease affecting over 670 million adults globally, with multiple complications including obstructive sleep apnea (OSA). Substantial weight loss in patients with obesity-related OSA can reduce or even eliminate OSA as well as reduce sleepiness and improve cardio-metabolic health. Evidence suggests that these improvements exceed those that occur with device-based OSA therapies like continuous positive airway pressure which continue to be the first-line of therapy. Resistance to weight management as a first-line strategy to combat OSA could arise from the complexities in delivering and maintaining adequate weight management, particularly in sleep clinic settings. Recently, incretin-based pharmacotherapies including glucagon-like peptide 1 (GLP-1) receptor agonists alone or combined with glucose-dependent insulinotropic polypeptide (GIP) receptor agonists have been developed to target glycemic control in type 2 diabetes. These medications also slow gastric emptying and reduce energy intake. In randomized, placebo-controlled trials of these medications in diabetic and non-diabetic populations with obesity, participants on active medication lost up to 20% of their body weight, with corresponding improvements in blood pressure, lipid levels, physical functioning, and fat mass loss. Their adverse effects are predominantly gastrointestinal-related, mild, and transient. There are trials currently underway within individuals with obesity-related OSA, with a focus on reduction in weight, OSA severity, and cardio-metabolic outcomes. These medications have the potential to substantially disrupt the management of OSA. Pending coming data, we will need to consider pharmacological weight loss as a first-line therapy and how that influences training and management guidelines.

Respiratory infection risk in positive airway pressure therapy users: a retrospective cohort study

STUDY OBJECTIVES

Concerns regarding the risk of positive airway pressure (PAP)-associated respiratory infection (RI) have shaped consumer views toward PAP device use and maintenance. However, data regarding temporal associations between PAP use and risk for RIs are limited. The purpose of the present study was to examine longitudinal associations between PAP use and risk of clinically significant RIs in a cohort of patients with obstructive sleep apnea.

METHODS

The frequency of clinically reported respiratory RIs pre- and post-PAP use were compared in a sample of 482 adult patients with obstructive sleep apnea who underwent PAP titration at a large academic sleep center between 2011 and 2014. RIs were identified by clinical record review beginning two years before and ending two years after the participants' PAP titration. Presence of longitudinal standard PAP data download reports identified PAP users from nonusers. PAP adherence was defined as at least 4 hours of use per day, five days per week for at least 70% of days. Poisson regression models, adjusted for age, sex, body mass index, and the number of pre-PAP use RIs were utilized to examine associations between PAP use and subsequent RIs.

RESULTS

Poisson regression models adjusted for age, sex, body mass index, and the number of pre-PAP use RIs did not show associations between PAP therapy use and rate of post-PAP use RIs (rate ratio = 1.27, 95% confidence interval: 0.86-1.86). A sensitivity analysis that included only PAP users with difference in PAP adherence showed similar results (rate ratio = 0.65, 95% confidence interval: 0.32-1.30).

CONCLUSIONS

Among adults with obstructive sleep apnea, we did not find evidence for association between PAP use/adherence and increased RI frequency. These data offer new information that could assuage patients with obstructive sleep apnea who are considering PAP deferral based on RI concerns.

CITATION

Gavidia R, Shieu MM, Dunietz GL, Braley TJ. Respiratory infection risk in positive airway pressure therapy users: a retrospective cohort study. J Clin Sleep Med. 2023;19(10):1769-1773.

Development of a Deep Learning-Based Epiglottis Obstruction Ratio Calculation System

Surgeons determine the treatment method for patients with epiglottis obstruction based on its severity, often by estimating the obstruction severity (using three obstruction degrees) from the examination of drug-induced sleep endoscopy images. However, the use of obstruction degrees is inadequate and fails to correspond to changes in respiratory airflow. Current artificial intelligence image technologies can effectively address this issue. To enhance the accuracy of epiglottis obstruction assessment and replace obstruction degrees with obstruction ratios, this study developed a computer vision system with a deep learning-based method for calculating epiglottis obstruction ratios. The system employs a convolutional neural network, the YOLOv4 model, for epiglottis cartilage localization, a color quantization method to transform pixels into regions, and a region puzzle algorithm to calculate the range of a patient's epiglottis airway. This information is then utilized to compute the obstruction ratio of the patient's epiglottis site. Additionally, this system integrates web-based and PC-based programming technologies to realize its functionalities. Through experimental validation, this system was found to autonomously calculate obstruction ratios with a precision of 0.1% (ranging from 0% to 100%). It presents epiglottis obstruction levels as continuous data, providing crucial diagnostic insight for surgeons to assess the severity of epiglottis obstruction in patients.

The Importance of Sleep for Successful Neurorehabilitation after Stroke

Sleep has important clinical implications for neurorehabilitation after stroke. We aimed to systematically explore sleep (including naps) as an essential factor in the neurorehabilitation of patients after stroke. After titles and abstracts were screened, 49 full texts were reviewed, and 7 were included in this review. Data were extracted and assessed for quality and risk of bias. We looked at any neurorehabilitation setting, and compared sleep with no sleep and explored these factors in stroke patients versus healthy individuals. Rehabilitation is critical for many activities that may need to be learned or re-learned following stroke and for returning to everyday life. In this context, sleep is essential in neurorehabilitation and physical therapy practice as it supports neuroplasticity, memory, and learning. The available data suggest that sleep should be considered in the treatment plan for successfully targeted physiotherapy to optimize cognitive and motor learning. Physical therapists should advise about sleep hygiene and therapies to improve sleep, both quality and quantity.

Hyperfructosemia in sleep disordered breathing: metabolome analysis of Nagahama study

Sleep disordered breathing (SDB), mainly obstructive sleep apnea (OSA), constitutes a major health problem due to the large number of patients. Intermittent hypoxia caused by SDB induces alterations in metabolic function. Nevertheless, metabolites characteristic for SDB are largely unknown. In this study, we performed gas chromatography-mass spectrometry-based targeted metabolome analysis using data from The Nagahama Study (n = 6373). SDB-related metabolites were defined based on their variable importance score in orthogonal partial least squares discriminant analysis and fold changes in normalized peak-intensity levels between moderate-severe SDB patients and participants without SDB. We identified 20 metabolites as SDB-related, and interestingly, these metabolites were frequently included in pathways related to fructose. Multivariate analysis revealed that moderate-severe SDB was a significant factor for increased plasma fructose levels (β = 0.210, P = 0.006, generalized linear model) even after the adjustment of confounding factors. We further investigated changes in plasma fructose levels after continuous positive airway pressure (CPAP) treatment using samples from patients with OSA (n = 60) diagnosed by polysomnography at Kyoto University Hospital, and found that patients with marked hypoxemia exhibited prominent hyperfructosemia and their plasma fructose levels lowered after CPAP treatment. These data suggest that hyperfructosemia is the abnormality characteristic to SDB, which can be reduced by CPAP treatment.

Obstructive sleep apnea hypopnea syndrome in ancient traditional Chinese medicine

In western medicine, obstructive sleep apnea hypopnea syndrome (OSAHS) is an increasingly serious public health hazard, which is exacerbated by the obesity epidemic and an aging population. Ancient medical literature of traditional Chinese medicine (TCM) also recorded OSAHS-like symptoms but described the disease from a completely distinct theoretical perspective. The earliest records of snoring in ancient China can be traced back 2500 years. In TCM, the pathogenesis of OSAHS can be attributed mainly to turbid phlegm and blood stasis. Various TCM prescriptions, herbal medicines, and external therapy have also been proposed for the prevention and therapy of OSAHS. Some of these strategies are still used in current clinical practice. This review highlights historical characterizations of OSAHS and the theory of TCM and also explores its therapy in TCM, which may shed light on future OSAHS research. This is the first systematic English review of the role of TCM in the treatment of OSAHS.

Association of obstructive sleep apnea with cardiometabolic diseases and cardiovascular mortality

BACKGROUND

Obstructive sleep apnea (OSA) is one of the leading respiratory disorders, increasing the risk of cardiometabolic diseases. In the study, we investigated the association between OSA and the risk of cardiometabolic diseases and all-cause and cardiovascular mortality in adults.

METHODS

Participants were enrolled in the National Health and Nutrition Examination Survey. The baseline covariates were compared between participants with and without OSA status. Multivariable logistic regression was performed to explore the association between OSA and cardiometabolic diseases, while Cox proportional regression was performed for all-cause and cardiovascular mortality.

RESULTS

OSA status was positively associated with higher risks of cardiometabolic diseases, including hypertension (odds ratio [OR] 1.28, 95% confidence interval [CI] 1.14-1.45; p < 0.001), diabetes (OR 1.46, 95% CI 1.22-1.76; p < 0.001), and cardiovascular diseases (OR 1.29, 95% CI 1.08-1.54; p = 0.006) after adjusting for numerous covariates. However, no associations of OSA with all-cause or cardiovascular mortality were observed.

CONCLUSION

OSA was associated with a higher risk of hypertension, diabetes, and cardiovascular diseases, but had no significant association with all-cause or cardiovascular mortality in adults.

Prevalence and Outcomes of Depression, Obstructive Sleep Apnea, and Concurrent Anxiety (DOCA) in Stroke Survivors: Insights From a Nationwide Study

BACKGROUND

Many individuals will also experience psychological side effects after a stroke episode, such as symptoms of depression, anxiety (generalized anxiety disorder (GAD)), and/or specific phobias, considerably decreasing their quality of life (QOL).

OBJECTIVE

This study aimed to evaluate the prevalence of depression, obstructive sleep apnea (OSA), and concurrent anxiety (DOCA) and their outcomes (morbidity, disability (All Patient Refined Diagnosis Related Group (APRDRG) - loss of function), and discharge disposition) among acute ischemic stroke (AIS) hospitalizations.

METHODS

A cross-sectional study used the National Inpatient Sample (NIS) from 2003-2017. Adults with hospitalizations with AIS were extracted, and DOCA was identified using ICD-9/10-CM codes. Weighted analysis using a chi-square test and mixed-effect multivariable survey logistic regression was used to assess the prevalence and role of DOCA in predicting outcomes.

RESULTS

Out of 5,690,773 AIS hospitalizations, 2.7%, 3.1%, and 4.4% had depression, OSA, and GAD, respectively. In AIS patients, females had a higher prevalence of depression (3.4% vs. 2.3%) and GAD (5.9% vs. 3.0%) and a quality of life lower prevalence of OSA (2.2% vs 4.4%) in comparison to males (p<0.0001). Caucasians had a higher prevalence of depression, OSA, and GAD in comparison to others (African Americans/Hispanics/Asians/Native Americans). Depressed patients had a higher prevalence of morbidity (9% vs. 8% vs 5% vs. 7%), disability (46% vs. 46% vs. 35% vs. 37%), transfer to non-home (69% vs. 58% vs. 61% vs. 63%) in comparison with OSA, GAD, and non-DOCA patients, respectively (p<0.0001). Depression was associated with a 40% higher chance of severe disability (aOR 1.40; 95% CI 1.38-41), morbidity (1.36; 1.33-1.38), and discharge to non-home (1.54; 1.52-1.56). OSA and GAD had higher odds of non-home discharge amongst post-AIS hospitalizations.

CONCLUSION

DOCA is associated with poor outcomes among post-AIS patients. Prompt recognition by screening and timely management of DOCA may mitigate the adverse outcomes.

International Consensus Statement on Obstructive Sleep Apnea

BACKGROUND

Evaluation and interpretation of the literature on obstructive sleep apnea (OSA) allows for consolidation and determination of the key factors important for clinical management of the adult OSA patient. Toward this goal, an international collaborative of multidisciplinary experts in sleep apnea evaluation and treatment have produced the International Consensus statement on Obstructive Sleep Apnea (ICS:OSA).

METHODS

Using previously defined methodology, focal topics in OSA were assigned as literature review (LR), evidence-based review (EBR), or evidence-based review with recommendations (EBR-R) formats. Each topic incorporated the available and relevant evidence which was summarized and graded on study quality. Each topic and section underwent iterative review and the ICS:OSA was created and reviewed by all authors for consensus.

RESULTS

The ICS:OSA addresses OSA syndrome definitions, pathophysiology, epidemiology, risk factors for disease, screening methods, diagnostic testing types, multiple treatment modalities, and effects of OSA treatment on multiple OSA-associated comorbidities. Specific focus on outcomes with positive airway pressure (PAP) and surgical treatments were evaluated.

CONCLUSION

This review of the literature consolidates the available knowledge and identifies the limitations of the current evidence on OSA. This effort aims to create a resource for OSA evidence-based practice and identify future research needs. Knowledge gaps and research opportunities include improving the metrics of OSA disease, determining the optimal OSA screening paradigms, developing strategies for PAP adherence and longitudinal care, enhancing selection of PAP alternatives and surgery, understanding health risk outcomes, and translating evidence into individualized approaches to therapy.

Association between obstructive sleep apnea symptoms and gout in US population, a cross-sectional study

The results of association between Obstructive Sleep Apnea (OSA) and gout are not consistent. Participants aged 20 years or older in the National Health and Nutrition Examination Survey (NHANES) 2007-2008 and 2015-2018 were included. Weighted univariable and multivariable logistic regressions were used to evaluate the association between OSA symptoms and gout. The subgroup and sensitivity analyses were also performed. Among the 15,947 participants in this study, the mean age was 47.8 years old, 48.87% of whom were male, 4891 had OSA symptoms, and 842 had gout. In multivariable logistic regression analyses, OSA symptoms were positively associated with gout in all models. The odds ratio (OR) was 1.315 and 95% confidence interval (CI) was 1.070-1.616 in fully adjusted model 4. In the subgroup analyses, we found a considerable interaction between OSA symptoms and gender with gout (P for interaction = 0.003). In the sensitivity analyses, the association between OSA symptoms and gout remained stable after adjustment for congestive heart failure and diuretics using. OSA symptoms were associated with an increased likelihood of gout. This association could especially be found in female participants.

Diagnosis of obstructive sleep apnea using a bio-radar contact-free system compared with an established HST device in older adults

GOAL AND AIMS

To compare a bio-radar contact-free monitoring device in diagnosing obstructive sleep apnea (OSA) in older people with an established home sleep apnea testing system (HST).

FOCUS METHOD/TECHNOLOGY

A bio-radar contact-free monitoring device (OrbSense+).

REFERENCE METHOD/TECHNOLOGY

An established HST, Alice NightOne.

SAMPLE

Fifty-three out of 63 recruited subjects were included in the final analysis. Seventy-two percent were male (age 72 ± 9 years; body mass index 31.05 ± 5.56 kg/m2).

DESIGN

An observational, prospective study.

CORE ANALYTICS

Intraclass correlation coefficient (ICC), Bland-Altman analysis, and receiver operating characteristic analysis.

ADDITIONAL ANALYTICS AND EXPLORATORY ANALYSES

None.

CORE OUTCOMES

Both 45 (84.91%) were diagnosed with OSA by Alice NightOne (average respiratory event index = 21.23 events/h) and by OrbSense+ (average respiratory event index = 25.98 events/h). Respiratory event index and oxygen desaturation index obtained by Alice NightOne and OrbSense+ were highly correlated, with ICC of 0.93 and 0.88, respectively. The Bland-Altman plot comparing the means showed good agreement between the 2 diagnostic techniques. With more than 5 respiratory events per hour as the standard for OSA diagnosis, OrbSense+ had a sensitivity of 100% and a specificity of 100% in diagnosis of OSA (P < .0001). With more than 15 respiratory events per hour as the standard for OSA diagnosis, OrbSense+ was found to have a sensitivity of 100% and a specificity of 86.96% in diagnosis of OSA (P < .0001).

IMPORTANT ADDITIONAL OUTCOMES

None.

CORE CONCLUSION

The bio-radar sleep monitoring device is a reasonably accurate home sleep apnea test for use in older patients.

Factors Associated with the Underestimation of Manual CPAP Titration Pressure

During the SARS-CoV-2 pandemic, the use of in-laboratory positive airway pressure (PAP) titration studies was not routinely suggested. PAP pressure prediction calculations are emerging as alternative methods for the treatment of these patients. The underestimation of PAP titration pressure usually leads to unsatisfactory results for PAP therapy. This study aimed to evaluate the factors associated with the underestimation of PAP titration pressure when using PAP pressure prediction equations. Estimated PAP pressure formulas based on body mass index (BMI) and apnea-hypopnea index (AHI) were chosen to validate the accuracy of equations in the successful prediction of titration pressure. Among 341 adult patients diagnosed with obstructive sleep apnea (OSA) by overnight polysomnography (PSG) and who received overnight PAP titration in order to select a successful pressure, the mean age of the total subjects was 55.4 years old and 78.9% of patients were male. The average BMI and AHI scores were 27.1 ± 4.8 and 37 ± 21.7, respectively. After multivariate stepwise regression analysis, the odds ratio of participants with a pretitration AHI was 1.017 (95% CI: 1.005-1.030). Only the severity of OSA was significantly different between the underestimated group and the adequately assessed group. In conclusion, a high AHI, but not BMI, is associated with an underestimated CPAP titration pressure in adult patients with OSA.

Comorbidity Profile and Predictors of Obstructive Sleep Apnea Severity and Mortality in Non-Obese Obstructive Sleep Apnea Patients

Backgrounds and Objectives: Obstructive sleep apnea (OSA) is associated with increased morbidity and mortality. OSA is an independent risk factor for many different conditions, especially cardiovascular diseases. The purpose of this study was to ascertain the comorbidity profile of non-obese patients with newly diagnosed OSA and evaluate the risk for cardiovascular disease and mortality. The present study also aimed to establish predictors for OSA severity. Materials and Methods: This study included 138 newly diagnosed patients who underwent polysomnographic analysis. The 10-year risk for cardiovascular disease was assessed using a newly validated prediction model: Systematic Coronary Risk Evaluation (SCORE-2). In addition, the Charlson Comorbidity Index (CCI) was assessed as a widely-used example of a mortality comorbidity index. Results: The study population included 138 patients: 86 males and 52 females. Patients were stratified, according to AHI (apnea/hypopnea index), into four groups: 33 patients had mild OSA (5 ≤ AHI < 15), 33 patients had moderate OSA (15 ≤ AHI < 30), 31 patients had severe OSA (AHI ≥ 30), and 41 individuals had AHI < 5, which were a part of the control group. SCORE-2 increased in line with OSA severity and was higher in OSA groups compared to the control group (H = 29.913; DF = 3; p < 0.001). Charlson Index was significantly higher in OSA patients compared to controls (p = 0.001), with a higher prevalence of total comorbidities in the OSA group of patients. Furthermore, CCI 10-year survival score was significantly lower in the OSA group, suggesting a shorter survival of those patients with a more severe form of OSA. We also examined the prediction model for OSA severity. Conclusions: Determining the comorbidity profile and estimation of the 10-year risk score of OSA patients could be used to classify these patients into various mortality risk categories and, according to that, provide them with adequate treatment.

Cannabis and sleep disorders: not ready for prime time? A qualitative scoping review

STUDY OBJECTIVES

To perform a qualitative scoping literature review for studies involving the effects of cannabis on sleep and sleep disorders.

METHODS

Two electronic databases, MEDLINE and EMBASE, searched for comprehensive published abstracted studies that involved human participants. Inclusion criteria were article of any type, published in English, a target population of cannabis users, and reported data on cannabis effect on sleep and sleep disorders. The Joanna Briggs Institute's (JBI) approach was elected as the methodology framework guidance in the scoping review process.

RESULTS

A total of 40 unique publications were found. The majority (82.5%) were from the Americas with 60% published in the last decade. Of the 40 studies, only 25% were randomized control trials, and the sleep outcome measurements were similar and comparable in only 20%. Cannabis users studied were reported either 73% frequent users or 27% sporadic users. The utilization of cannabis showed improved sleep (21%), worse sleep (48%), mixed results (14%), or no impact at all (17%) in the studies published in the last 5 decades.

CONCLUSIONS

Our findings summarize the lack of robust evidence to support the use of cannabis for sleep disorders. The varied cannabis user-related characteristics may account for the inconsistent results identified. Further studies assessing cannabis and sleep are needed to discern what works in what context, how it works, and for whom.

CITATION

Amaral C, Carvalho C, Scaranelo A, Chapman K, Chatkin J, Ferreira I. Cannabis and sleep disorders: not ready for prime time? A qualitative scoping review. J Clin Sleep Med. 2023;19(5):975-990.

Sleep characteristics and inflammatory markers in women with post-traumatic stress disorder

INTRODUCTION

Sexual violence is one of the most severe traumatic events. It is associated with a higher risk for post-traumatic stress disorder (PTSD) development. Sleep disturbances such as insomnia are frequently reported by PTSD patients and play a key role in the development and course of the disorder. Sleep disturbances are associated with higher levels of pro-inflammatory cytokines emphasizing the importance of sleep studies in individuals with PTSD.

OBJECTIVES

To investigate the association between subjective and objective sleep measurements and PTSD symptoms with inflammatory markers in women with PTSD following sexual assault.

METHODS

In this longitudinal study fifty-seven women with PTSD were evaluated for sleep measurements and inflammatory markers. Participants completed the Clinician-Administered PTSD Scale, the Beck Depression Inventory, the Pittsburgh Sleep Quality Index (PSQI), and the Insomnia Severity Index. In addition, patients underwent full in-lab polysomnography and serum levels of interleukin (IL)-1β, IL-6, tumor necrosis factor (TNF)-α, and C-reactive protein (CRP) measurement. All assessments were performed at baseline and after one year. Patients received pharmacological and/or psychological interventions between baseline and one-year follow-up.

RESULTS

Despite improving PTSD symptoms severity and sleep quality (expressed in PSQI), we found an increase in the inflammatory markers IL-1β, TNF-α, IL-6 and CRP after one year of follow-up. These findings suggest that neurobiological processes may advance independently of PTSD symptoms. We found a significant increase in the levels of IL-1β and TNF-α associated with decreased slow-wave sleep (p = 0.019 and p = 0.018 respectively), IL-6 associated with arousal index (p = 0.024), and CRP associated with insomnia severity (p = 0.012), and sleep duration longer than 6 h per night (p < 0.001).

CONCLUSIONS

Sleep impairments in PTSD may be associated with a gradual and persistent alteration in the immune system, resulting in a progressive inflammatory process. Our results suggest that sleep mechanisms are involved in this incident inflammatory process in young women with PTSD.

Validation of the Revised Illness Perception Questionnaire of Obstructive Sleep Apnea among Elderly Chinese in the General Population

PURPOSE

The prevalence of under-diagnosis among individuals with obstructive sleep apnea (OSA) is alarming, and may be associated with perceptions regarding OSA. To facilitate future studies on OSA, this study validated the revised version of the Illness Perception Questionnaire (IPQ-R) for OSA in a general population.

METHODS

A random anonymous population-based telephone survey interviewed 580 adults aged ≥ 50 years in Hong Kong, who self-reported not having been told by doctors as having OSA, from February 5 to March 19, 2021.

RESULTS

The confirmatory factor analysis identified a modified 7-factor model (i.e., timeline chronic, consequence, personal control, treatment control, illness coherence, timeline cyclical, and emotional representation) that showed satisfactory model fit index and internal consistency. Nine items were removed from the original version because of low factor loadings. No floor and ceiling effects were observed. Convergent validity was supported by the positive associations between the consequence subscale with perceived negative outcomes of OSA and between the illness coherence subscale and perceived understanding of OSA symptoms. The participants tended to endorse the items of timeline chronic, treatment control, and illness coherence but not with those of emotional representations. The mean scores of the IPQ-R subscales differed by age and education level.

CONCLUSION

The modified IPQ-R of OSA showed acceptable psychometric properties. It is applicable to assessing illness perceptions of OSA in the Chinese general population aged ≥ 50 years not having received OSA diagnosis. The validated tool would support future studies and health practices related to OSA.

Out of the Laboratory and into the Home: Home Testing for Sleep Apnea and Other Sleep Disorders

SUMMARY

Home sleep testing has emerged over the past decade and become an intriguing option for patients and providers because it can be conducted in the home environment. However, appropriate application of this technology is key to ensure accurate and validated results to provide appropriate patient care. In this review, we will cover the current guidelines for the use of home sleep apnea tests, the types of testing available, and future directions of home testing.

Beyond Counting Sheep: Exploring the Link between Polycystic Ovary Syndrome and Sleep Health

Polycystic ovary syndrome (PCOS) is a common hormonal condition with reproductive, metabolic, and psychological sequelae that affects 8 to 13% of reproductive-aged women and 3 to 11% of adolescent girls. Sleep is often compromised in women with PCOS due to increased rates of sleep problems, with the most established problem being obstructive sleep apnea (OSA). OSA is highly prevalent in reproductive-aged adult women with PCOS, but not so in adolescence. The international evidence-based PCOS guideline to improve health outcomes in women with PCOS indicated routine screening to identify and alleviate symptoms of OSA. The guidelines, however, did not weigh other multidimensional constructs of sleep health such as sleep disturbances (e.g., sleep quality and quantity), beyond OSA. This is perhaps due to the lack of research and existing mixed findings in the area of PCOS and sleep health. This narrative review summarizes the current knowledge about OSA and expands further to include the limited knowledge about other sleep problems in PCOS among reproductive-aged women and adolescent girls. We broadly cover the prevalence, risk factors, and mechanisms of sleep problems in PCOS and their relationship with cardiometabolic and psychological health. A brief summary on treatment and intervention strategies for sleep problems in PCOS and future recommendations will be deliberated.

The role of artificial intelligence in the treatment of obstructive sleep apnea

BACKGROUND

The first-line and most common treatment for obstructive sleep apnea is nasal continuous positive airway pressure, which serves as a pneumatic splint to stabilize the upper airway and is effective when used with appropriate adherence. Continuous positive airway pressure compliance rates remain significantly low despite machine improvements and compliance intervention. Other treatment options include oral appliances, myofunctional therapy, and surgery. The aim of this project is to elucidate the role of artificial intelligence within improving the treatment of obstructive sleep apnea.

METHODS

Related publications between 1999 and 2022 were reviewed from PubMed and Embase databases utilizing search terms "artificial intelligence," "machine learning," "obstructive sleep apnea," and "treatment." Both authors independently screened the results by title/abstract then by full text review. 126 non-duplicate articles were screened, 38 articles were included after title and abstract screen and 30 articles were included after full text review. The inclusion criteria are outline in the PICO framework and involved studies focused on artificial intelligence application in guiding and evaluating obstructive sleep apnea treatment. Non-English articles were excluded.

RESULTS

The role of artificial intelligence in the treatment of OSA was categorized into the following sections: Predicting treatment outcomes of various treatment options, Improving/Evaluating treatment, and Personalizing treatment with improving understanding of underlying mechanisms of OSA.

CONCLUSIONS

Artificial intelligence has the capacity to improve the treatment of OSA through predicting outcomes of treatment options, evaluating the treatment the patient is currently utilizing and increasing understanding of the mechanisms that contribute to OSA disease process and physiology. Implementing AI in guiding treatment decisions allows patients to connect with treatment methods that would be most effective on an individual basis.

Genome-Wide Association Study of Obstructive Sleep Apnea and Objective Sleep-related Traits Identifies Novel Risk Loci in Han Chinese Individuals

Rationale: Previous genetic studies of obstructive sleep apnea (OSA) have limitations in terms of precise case definition, integrated quantitative traits, and interpretation of genetic functions; thus, the heritability of OSA remains poorly explained. Objectives: To identify novel genetic variants associated with OSA and objective sleep-related traits and to explore their functional roles. Methods: A genome-wide association study was performed in 20,590 Han Chinese individuals (5,438 OSA and 15,152 control samples). Human samples and point mutation knockin mice were used for follow-up investigation of gene functions. Measurements and Main Results: Two characteristic study-wide significant loci (P < 2.63 × 10^-9) for OSA were identified: the PACRG intronic variant rs6455893 on 6q26 (odds ratio [OR] = 1.62; 95% confidence interval [CI], 1.39-1.89; P = 6.98 × 10^-10) and the missense variant rs3746804 (p.Pro267Leu) in the riboflavin transporter SLC52A3 on 20p13 (OR = 0.83; 95% CI, 0.79-0.88; P = 7.57 × 10^-10). In addition, 18 genome-wide significant loci associated with quantitative OSA and objective sleep-related traits were identified, 5 of which exceeded the study-wide significance threshold. Rs3746804 was associated with elevated serum riboflavin concentrations, and the corresponding mutation in mice increased riboflavin concentrations, suggesting that this variant may facilitate riboflavin uptake and riboflavin-dependent physiological activity. Conclusions: We identified several novel genome-wide significant loci associated with OSA and objective sleep-related traits. Our findings provide insight into the genetic architecture of OSA and suggest that SLC52A3 might be a therapeutic target, whereas riboflavin might be a therapeutic agent.

Obstructive sleep apnea in young Asian adults with sleep-related complaints

This study aimed to investigate the proportion of young OSA adults with sleep-related complaints in a sleep center, affiliated with a tertiary medical center for over a decade. This study presents a chronicle change in the numbers of young adults receiving polysomnography (PSG) and young patients with OSA from 2000 to 2017. We further analyzed 371 young patients with OSA among 2378 patients receiving PSG in our sleep center from 2016 to 2017 to capture their characteristics. Young adults constituted a substantial and relatively steady portion of examinees of PSG (25.1% ± 2.8%) and confirmed OSA cases (19.8 ± 2.4%) even though the total numbers increased with the years. Young adults with OSA tend to be sleepier, have a greater body mass index, and have a higher percentage of cigarette smoking and alcohol consumption. They also complained more about snoring and daytime sleepiness. They had a higher apnea-hypopnea index on average and experienced more hypoxemia during their sleep, both in terms of duration and the extent of desaturation. Even though the prevalence of comorbidities increased with age, hypertension in young male adults carried higher risks for OSA. Young adults with OSA have constituted a relatively constant portion of all confirmed OSA cases across time. The young adults with OSA were heavier, more symptomatic, and with more severe severity.Clinical trial: The Institutional Review Board of Taipei Veterans General Hospital approved the study (VGHIRB No. 2018-10-002CC). The study is registered with ClinicalTrials.gov, number NCT03885440.

Cancer Risk Associated with Continuous Positive Airway Pressure: A National Study

OBJECTIVE

In 2021 the U.S. FDA issued a Class 1 safety recall notice for specific devices due to a risk of carcinogen exposure. The objective of this study was to evaluate reports of cancer linked to CPAP devices to understand implications for the field of sleep medicine.

METHODS

Cases of cancer involving CPAP devices were retrieved from the MAUDE database from 2014 to 2021 and analyzed with descriptive statistics.

RESULTS

A total of 2571 patient injuries were associated with CPAP. Reports of cancer (n = 209; 4.62%) were the second most commonly documented patient problem associated with CPAP, although 1950 (43.13%) patients had a device problem without an associated injury. Of the 209 cancer cases associated with CPAP, 200 (95.7%) of the adverse event reports were received by the FDA in 2021. There were 174 (9.15%) descriptions of the CPAP polyurethane sound abatement foam degrading in association with a cancer diagnosis, but degradation was more commonly not associated with malignancy (n = 1728; 90.85%). Other frequently documented CPAP device problems included broken devices (n = 279; 6.92%), fire (n = 182; 4.51%), and patient-device incompatibility (n = 144; 3.57%).

CONCLUSION

Malignancy associated with CPAP devices has been reported; however, future studies are required to establish causation. Given 95.7% of those documented cases were reported in 2021, otolaryngologists should be prepared to discuss the risks of carcinogenesis associated with CPAP. The otolaryngology community should also be aware of the potential bandwagon effect and the implications for CPAP compliance.

LEVEL OF EVIDENCE

4 Laryngoscope, 132:2270-2274, 2022.

Correlations between Morphology, the Functional Properties of Upper Airways, and the Severity of Sleep Apnea

Obstructive sleep apnea (OSA) is considered the silent killer pathology of the new millennium. This is due to increased risk factors such as obesity. Healthcare systems face an increasing burden from severe cases of OSA. We performed a study on a group of 152 Romanian patients with OSA recording data obtained through polysomnography and cephalometric variables, recorded in lateral plain X-rays. The results confirmed some of the data available from previous studies worldwide, but some of the variables presented a positive statistical correlation specific to our study group. For example, the apnea-hypopnea index (AHI) correlated with the uvula length but surprisingly did not correlate with body mass index (BMI) because obesity tends to become endemic in Romania. To our knowledge, this is one of the first studies focusing on cephalometric data in Romanian OSA patients. The results obtained through this study will be further analyzed in research on larger groups of Romanian OSA patients.

The usefulness of the Spanish version of the STOP-Bang questionnaire for screening for moderate or severe sleep apnea syndrome in primary care

Rationale

Sleep apnea-hypopnea syndrome (OSA) is a highly prevalent disease and has been related to cardiovascular diseases and occupational and traffic accidents. Currently, it is estimated that there is a significant underdiagnosis of OSA, mainly due to the difficulty accessing the tests for that purpose.

Objective

To determine the usefulness of the Spanish version of the STOP-Bang questionnaire (SBQ) for screening for moderate or severe OSA in the adult population attending primary care.

Methods

A descriptive observational multicenter study was conducted. Through an opportunistic search, (patients over 18 years old), were recruited in seven primary care centers. The SBQ was applied to them and home respiratory polygraphy (HRP) was subsequently performed to confirm the diagnosis of OSA. The criterion validity of the SBQ was analyzed, comparing the score obtained by the SBQ with the apnea-hypopnea index (AHI) obtained by RP, establishing the diagnosis of OSA for an AHI>5. The reliability of the questionnaire was evaluated.

Results

A total of 255 subjects, 54.1% men, with a mean age of 54.76 ± 10 years, were recruited in the study. The results showed that 61.57% (95% Confidence Interval: 55.57-67.57) of the subjects presented OSA, presenting 22.75% (17.57-57.92) a mild OSA (530) (11.54-20.62). The Kuder and Richardson coefficient was 0.623 (0.335-0.788) and Cohen's Kappa coefficient was 0.871 (0.520-1.00; p < 0.001). For moderate/severe OSA screening (AHI>15) the SBQ obtained an ROC curve of 0.769 (0.704-0.833) that with an optimal cutoff of 3, achieved a sensitivity of 84.85% (77.28-92.42) and a specificity of 55.10% (44.74-65.46).

Conclusions

The SBQ is very effective for detecting moderate/severe OSA. Its psychometric properties are similar to those obtained in studies on other populations. Because of its ease of use, the SBQ is a very useful tool for primary health care professionals.

The association between sleep and depressive symptoms in US adults: data from the NHANES (2007-2014)

AIMS

To assess the association of sleep factors (sleep duration, trouble sleeping, sleep disorder) and combined sleep behaviours with the risk of clinically relevant depression (CRD).

METHODS

A total of 17 859 participants (8806 males and 9053 females) aged 20-79 years from the National Health and Nutrition Examination Survey (NHANES) 2007-2014 waves were included. Sleep duration, trouble sleeping and sleep disorder were asked in the home by trained interviewers using the Computer-Assisted Personal Interviewing (CAPI) system. The combined sleep behaviours were referred to as 'sleep patterns (healthy, intermediate and poor)', with a 'healthy sleep pattern' defined as sleeping 7-9 h per night with no self-reported trouble sleeping or sleep disorders. And intermediate and poor sleep patterns indicated 1 and 2-3 sleep problems, respectively. Weighted logistic regression was performed to evaluate the association of sleep factors and sleep patterns with the risk of depressive symptoms.

RESULTS

The total prevalence of CRD was 9.5% among the 17 859 participants analysed, with females having almost twice as frequency than males. Compared to normal sleep duration (7-9 h), both short and long sleep duration were linked with a higher risk of CRD (short sleep: OR: 1.66, 95% CI: 1.39-1.98; long sleep: OR: 2.75, 95% CI: 1.93-3.92). The self-reported sleep complaints, whether trouble sleeping or sleep disorder, were significantly related with CRD (trouble sleeping: OR: 3.04, 95% CI: 2.59-3.56; sleep disorder: OR: 1.83, 95% CI: 1.44-2.34). Furthermore, the correlations appeared to be higher for individuals with poor sleep pattern (OR: 5.98, 95% CI: 4.91-7.29).

CONCLUSIONS

In this national representative survey, it was shown that there was a dose-response relationship between sleep patterns and CRD.

Ketogenic Diet for Preoperative Weight Reduction in Bariatric Surgery: A Narrative Review

Bariatric surgery (BS) is the most effective treatment in reducing weight and the burden of comorbidities in patients with severe obesity. Despite the overall low mortality rate, intra- and post-operative complications remains quite common. Weight loss before BS reduces surgical risk, but studies are inconclusive regarding which is the best approach to apply. In this review, we summarize the current evidence on the effect of a ketogenic diet (KD) before BS. All studies agree that KD leads to considerable weight loss and important improvements in terms of surgical risk, but populations, interventions and outcomes are very heterogeneous. KD appears to be a safe and effective approach to induce weight loss before BS. However, randomized controlled trials with better-defined dietary protocols and homogeneous outcomes are necessary in order to draw firm conclusions.

Evaluation and Treatment of Central Sleep Apnea in Patients with Heart Failure

Sleep-disordered breathing (SDB) is a common comorbidity in patients with heart failure (HF). Prevalence of the most common subtypes of SDB, central sleep apnea (CSA) and obstructive sleep apnea (OSA), is increasing, which is concerning due to the association of SDB with increased mortality in patients with heart failure. Despite an increasing burden of CSA in HF, it is difficult to detect using current diagnostic tools and the treatment modalities are limited by variable efficacy and patient adherence. Though positive airway pressure therapies remain the cornerstone of OSA treatment, the management of CSA in the setting of HF continues to evolve. The association of the presence of CSA with worse prognosis in HF patients warrants the need for routine screening for signs and symptoms of CSA in this population. In this review, we examine the connection between CSA and HF, highlighting advancements in timely diagnostics, treatment modalities, and strategies to promote facilitation of compliance in this high-risk cohort.

Brazilian Thoracic Association Consensus on Sleep-disordered Breathing

Sleep is essential for the proper functioning of all individuals. Sleep-disordered breathing can occur at any age and is a common reason for medical visits. The objective of this consensus is to update knowledge about the main causes of sleep-disordered breathing in adult and pediatric populations, with an emphasis on obstructive sleep apnea. Obstructive sleep apnea is an extremely prevalent but often underdiagnosed disease. It is often accompanied by comorbidities, notably cardiovascular, metabolic, and neurocognitive disorders, which have a significant impact on quality of life and mortality rates. Therefore, to create this consensus, the Sleep-Disordered Breathing Department of the Brazilian Thoracic Association brought together 14 experts with recognized, proven experience in sleep-disordered breathing.

Changes in Periodic Limb Movements of Sleep After the Use of Continuous Positive Airway Pressure Therapy: A Meta-Analysis

Background

Both obstructive sleep apnea (OSA) and periodic limb movements of sleep (PLMS) are common in the sleep laboratory. The severity of OSA can be improved by using continuous positive airway pressure (CPAP). However, increasing evidence has shown an elevated periodic limb movement index (PLMI) in patients with OSA who use CPAP, although the pathophysiology is still unknown. This meta-analysis aimed to investigate changes in PLMS after using CPAP and the potential pathophysiology of these changes.

Methods

Clinical trials in adult humans investigating the comorbidity between PLMS and CPAP were identified and analyzed using random-effects model meta-analysis.

Results

This meta-analysis included 14 studies comprising 2,938 patients with OSA. The PLMI was significantly increased after using CPAP with a difference in means of 1.894 (95% confidence interval = 0.651–3.138, p = 0.003). Subgroup analysis showed that CPAP was only significantly associated with an increase in PLMI in the patients without PLMS at baseline (p = 0.045) and in those with a baseline body-mass index <30 kg/m² (p = 0.045). The use of CPAP, apnea-hypopnea index, and arousal index were positively correlated with changes in PLMI.

Conclusion

These characteristics may serve as qualitative predictive indicators of changes in PLMI after CPAP usage. Further analysis of the quantitative relationships between PLMI and the predictive indicators may be warranted.

Trial Registration

PROSPERO (registration number: CRD42021252635).