Sleep Apnea Syndrome (SAS) Clinical Practice Guidelines 2020

Quality assessment of clinical practice guidelines for adult obstructive sleep apnea: A systematic review

OBJECTIVE

Clinical Practice Guidelines (CPGs) are crucial in standardizing the management of obstructive sleep apnea (OSA) in adults. However, there has been insufficient evaluation of the overall quality of CPGs for adult OSA. This review aimed to comprehensively assess the overall quality of CPGs in the field of adult OSA.

METHODS

A systematic search was conducted on various literature databases, guideline-related databases, and academic websites from January 2013 to December 2023 to select CPGs relevant to adult OSA. The methodological and reporting quality of the eligible CPGs were thoroughly appraised by three reviewers using the AGREE II instrument and RIGHT checklist, respectively.

RESULTS

This review included 44 CPGs, consisting of 42 CPGs in English and 2 CPGs in Chinese. The assessment of methodological quality revealed that four domains attained an average standardized score above 60%. Among the domains, "clarity of presentation" received the highest standardized score of 85.10%, while the lowest standardized score was observed in the "rigor of development" domain with the value of 56.77%. The evaluation of reporting quality indicated an overall reporting rate of 51.30% for the eligible CPGs, with only three domains achieving an average reporting rate higher than 50%. The domain with the highest reporting rate was "basic information" at 60.61%, while the domain with the lowest reporting rate was "review and quality assurance" at 15.91%. Furthermore, a significantly positive correlation was found between the AGREE II standardized scores and the RIGHT reporting rates (r = 0.808, P < 0.001).

CONCLUSIONS

The overall quality of the currently available guidelines for adult OSA demonstrated considerable variability. Researchers should prioritize the utilization of evidence-based methods and adhere to the items listed in the RIGHT checklist when developing CPGs to enhance efficient clinical decision-making and promote the translation of evidence into practice.

Analysis of the cause of retrolingual obstruction in patients with moderate-severe obstructive sleep apnea

PURPOSE

To evaluate the percentage of obstructive sleep apnea (OSA) patients with retrolingual obstruction in all moderate-severe OSA patients and the proportions of different causes in all moderate-severe OSA patients with retrolingual obstruction and to discuss the accuracy of the Friedman tongue position (FTP) and retrolingual cross-sectional area (RCSA) in assessing the retrolingual obstruction.

METHODS

Two hundred and twenty moderate-severe OSA patients were enrolled. After retrolingual obstruction was diagnosed, the percentage of OSA patients with retrolingual obstruction in all moderate-severe OSA patients was calculated. After that, the different causes of retrolingual obstruction were diagnosed based on different diagnostic criteria, and the proportions of different causes in all moderate-severe OSA patients with retrolingual obstruction were calculated. Finally, the correlations between FTP, RCSA, and apnea-hypopnea index after nasopharyngeal tube insertion (NPT-AHI) were analyzed, and the proportions of different causes of retrolingual obstruction based on different FTP and RCSA were observed.

RESULTS

There were 128 patients with retrolingual obstruction, accounting for 58.2% of all moderate-severe OSA patients. In 128 patients with retrolingual obstruction, the proportions of glossoptosis (48.4%), palatal tonsil hypertrophy (28.1%), and lingual hypertrophy (8.6%) were relatively high. Both FTP and RCSA did not correlate with NPT-AHI. The proportion of lingual hypertrophy increased gradually with the increase of FTP and the proportions of glossoptosis in all FTP classifications were high. The patients with RCSA > 180 mm2 were mainly affected by glossoptosis and palatal tonsil hypertrophy, while patients with RCSA ≤ 180 mm2 were mainly affected by lingual hypertrophy.

CONCLUSION

The percentage of patients with retrolingual obstruction in all moderate-severe OSA patients is relatively high, mainly glossoptosis, palatal tonsil hypertrophy, and lingual hypertrophy. FTP classification and RCSA can only reflect the retrolingual anatomical stenosis, but cannot fully reflect the retrolingual functional stenosis, especially the presence of glossoptosis.

Association between hypoxic burden and common cardiometabolic diseases in patients with severe obstructive sleep apnea

PURPOSE

To determine the possible associations between total sleep time spent with arterial oxygen saturation < 90% (T90) and comorbid cardiometabolic diseases (CMDs) in patients with severe obstructive sleep apnea (OSA).

METHODS

A retrospective review of the chart was conducted in patients with severe OSA diagnosed by in-lab polysomnography (PSG) between January 2018 and December 2019 at Siriraj Hospital. The patients were divided into two groups: hypoxic (T90 ≥ 10%) and nonhypoxic (T90 < 10%). The association between common CMDs including hypertension (HT), type 2 diabetes mellitus (T2DM), and impaired fasting glucose (IFG) was investigated and compared between the two groups.

RESULTS

Data were collected from 450 patients with severe OSA, 289 males/161 females with a mean age of 53.5 ± 14.2 years and an apnea-hypopnea index (AHI) of 49.6 events/h. Among these, 114 patients (25.3%) were defined as the hypoxic group (T90 ≥ 10%). When compared between the hypoxic and nonhypoxic groups, the patients in the hypoxic group were significantly younger and more obese, and had a higher proportion of male patients. The majority of patients (80%) had at least one CMD; however, the most common comorbidities significantly associated with hypoxic OSA (T90 ≥ 10%) were HT and IFG.

CONCLUSION

Hypoxic burden is significantly associated with an increased prevalence of HT and IFG in patients with severe OSA. T90 may be potentially useful for predicting CMDs in these patients. However, prospective studies are still required.

Non-pharmacological interventions for improving sleep in people living with HIV: a systematic narrative review

Background

Sleep disturbances are common in people living with Human Immunodeficiency Virus (HIV) and may lead to poor adherence to antiretroviral therapy and worsen HIV symptom severity. Due to the side effects of pharmacotherapy for sleep disturbances, there is more room for non-pharmacological interventions, but knowledge of how these non-pharmacological interventions have been used to improve sleep in people living with HIV (PLWH) is still missing.

Objective

To investigate the content of non-pharmacological interventions, sleep measurements, and the impact of these interventions on improving sleep in PLWH.

Methods

Following PRISMA guidelines, we conducted a systematic search on PubMed, EMBASE, Cochrane Central Registry of Controlled Trials, Cumulative Index to Nursing and Allied Health Literature, Web of Science, China National Knowledge Infrastructure, Wanfang Data, and China Biology Medicine disc. Non-pharmacological interventions for improving sleep in PLWH were included, and study quality was assessed using the Joanna Briggs Institute (JBI) critical appraisal checklists. We performed a narrative approach to synthesize the data to better understand the details and complexity of the interventions.

Results

Fifteen experimental studies in three categories for improving sleep in PLWH were included finally, including psychological interventions (components of cognitive-behavioral therapy for insomnia or mindfulness-based cognitive therapy, n = 6), physical interventions (auricular plaster therapy, acupuncture, and exercise, n = 8), and elemental interventions (speed of processing training with transcranial direct current stimulation, n = 1). Wrist actigraphy, sleep diary, and self-reported scales were used to measure sleep. Psychological interventions and physical interventions were found to have short-term effects on HIV-related sleep disturbances.

Conclusions

Psychological and physical interventions of non-pharmacological interventions can potentially improve sleep in PLWH, and the combination of patient-reported outcomes and actigraphy devices can help measure sleep comprehensively. Future non-pharmacological interventions need to follow protocols with evidence-based dosing, contents, and measures to ensure their sustainable and significant effects.

Sleep apnea severity in patients undergoing atrial fibrillation ablation: Home sleep apnea-test and polysomnography comparison

BACKGROUND

Sleep apnea (SA) is highly prevalent and should be treated in patients referred for catheter ablation (CA) of atrial fibrillation (AF). Watch-type peripheral arterial tonometry (WP) for home SA testing has demonstrated a high correlation of the apnea-hypopnea index (AHI) with Polysomnography (PSG), but the evidence of its accuracy in AF patients is not adequate.

METHODS

This study was conducted under a retrospective, single-center, observational design. We included 464 consecutive AF patients (age 65 ± 11 years, 76.5% male, 45.0% paroxysmal-AF) who received both WP and PSG during the periprocedural period of the CA. We compared the AHI using the WP (WP-AHI) to that using PSG (PSG-AHI).

RESULTS

The WP-AHI was 25.9 ± 12.7 and PSG-AHI 31.4 ± 18.9 (r = .48). Among 325 patients with a WP-AHI < 30, 116 (35.7%) exhibited a PSG-AHI ≥ 30. Only 12.5% of the patients were indicated for continuous positive airway pressure (CPAP) treatment only by the WP-AHI, while 70.9% were indicated for CPAP by the PSG-AHI according to the Japanese health insurance system. The best cut-off value of the WP-AHI was 18.1 to predict a PSG-AHI ≥ 20 with an area under the curve of 0.72 (95% confidence interval, 0.67-0.76).

CONCLUSIONS

The WP-AHI and PSG-AHI were weakly correlated in AF patients receiving CA. About one-third of the patients with moderate SA using the WP was diagnosed with severe SA evaluated by PSG. The majority required PSG for the CPAP indication.

Effects of a single night of continuous positive airway pressure on spontaneous brain activity in severe obstructive sleep apnea

This study aimed to investigate the effect of a single night of continuous positive airway pressure (CPAP) treatment on spontaneous brain activity and the underlying neuropathological mechanisms in patients with severe obstructive sleep apnea (OSA). The study involved 30 severe OSA patients and 19 healthy controls (HC). Fractional amplitude of low-frequency fluctuation (fALFF) and regional homogeneity (ReHo) methods were employed to evaluate spontaneous brain activity in all participants. Following a single night of CPAP treatment, ReHo values increased in the bilateral caudate and decreased in the right superior frontal gyrus. The fALFF values increased in the left orbital part of the middle frontal gyrus and the right orbital of the inferior frontal gyrus (Frontal_Inf_Orb_R). However, fALFF values decreased in the medial part of the left superior frontal gyrus and the right supramarginal part of the inferior parietal lobe. Pearson correlation analysis revealed a positive relationship between the change in the fALFF in the Frontal_Inf_Orb_R and the change in REM sleep duration (r = 0.437, p = 0.016) following a single night of CPAP treatment. We concluded that observing changes in abnormal fALFF and ReHo in OSA patients before and after a single night of CPAP treatment may enhance our understanding of the neurological mechanisms in patients with severe OSA.

Control of Tongue Position in Patients with Obstructive Sleep Apnea: Concept and Protocol for a Randomized Controlled Crossover Trial

We hypothesize that the control of tongue position using a newly developed tongue position retainer, where the tongue is held in a protruded position (i.e., intervention A) or in its resting position (i.e., intervention B), is effective for maintaining upper airway patency in obstructive sleep apnea (OSA) compared with no control of tongue position. This is a randomized, controlled, non-blinded, crossover, and two-armed trial (i.e., sequence AB/BA) in 26 male participants (i.e., sample size) who are scheduled to undergo a dental operation under intravenous sedation with OSA (10 ≤ respiratory event index < 30/h). Participants will be randomly allocated into either sequence by a permuted block method, stratified by body mass index. Under intravenous sedation, participants will undergo two interventions, separated by a washout period after receiving intervention A or intervention B using a tongue position retainer after baseline evaluation, before each intervention is provided. The primary outcome is the abnormal breathing index of apnea as determined by the frequency of apnea per hour. We expect that, compared with no control of tongue position, both intervention A and intervention B will improve the abnormal breathing events with superior effects achieved by the former, offering a therapeutic option for OSA.

Effects of continuous positive airway pressure on very short-term blood pressure variability associated with sleep-disordered breathing by pulse transit time-based blood pressure measurements

BACKGROUND

Blood pressure (BP) variability (BPV) is a predictor of cardiovascular outcomes independently of BP absolute values. We previously reported that pulse transit time (PTT) enables monitoring beat-to-beat BP, identifying a strong relationship between the extent of very short-term BPV and the severity of sleep-disordered breathing (SDB). Here, we investigated the effects of continuous positive airway pressure (CPAP) on very short-term BPV.

METHODS

We studied 66 patients (mean age 62 years old, 73% male) with newly diagnosed SDB who underwent full polysomnography on two consecutive days for diagnosis (baseline) and CPAP, together with PTT-driven BP continuous recording. PTT index was defined as the average number of acute transient rises in BP (≥12 mmHg) within 30 s/h.

RESULTS

CPAP treatment effectively improved SDB parameters, and attenuated PTT-based BP absolute values during the night-time. Very short-term BPV that includes PTT index and standard deviation (SD) of systolic PTT-BP was significantly reduced by CPAP therapy. The changes in PTT index from baseline to CPAP were positively correlated with the changes in apnea-hypopnea index, obstructive apnea index (OAI), oxygen desaturation index, minimal SpO 2 , and mean SpO 2 . Multivariate regression analysis revealed that changes in OAI and minimal SpO 2 , as well as heart failure, were the independent factors in determining the reduction of PTT index following CPAP.

CONCLUSION

PTT-driven BP monitoring discovered the favorable effects of CPAP on very short-term BPV associated with SDB events. Targeting very short-term BPV may be a novel approach to identifying individuals who experience greater benefits from CPAP.

The relationship between adherence to continuous positive airway pressure and nasal resistance measured by rhinomanometry in patients with obstructive sleep apnea syndrome

Nasal breathing disorders are associated with obstructive sleep apnea (OSA) syndrome and influence the availability of continuous positive airway pressure (CPAP) therapy. However, information is scarce about the impact of nasal resistance assessed by rhinomanometry on CPAP therapy. This study aimed to examine the relationship between CPAP adherence and nasal resistance evaluated by rhinomanometry, and to identify clinical findings that can affect adherence to CPAP therapy for patients with OSA. This study included 260 patients (199 men, 61 women; age 58 [interquartile ranges (IQR) 50-66] years) with a new diagnosis of OSA who underwent rhinomanometry (before, and 1 and 3 months after CPAP introduction) between January 2011 and December 2018. CPAP use was recorded, and the good and poor CPAP adherence groups at the time of patient registration were compared. Furthermore, those with improved and unimproved pre-CPAP high rhinomanometry values were also compared. Their apnea-hypopnea index (AHI) by polysomnography at diagnosis was 45.6 (IQR 33.7-61.6)/hour, but the residual respiratory event (estimated AHI) at enrollment was 2.5 (IQR 1.4-3.9)/hour and the usage time was 318 (IQR 226-397) minutes, indicating that CPAP was effective and adherence was good. CPAP adherence was negatively correlated with nasal resistance (r = -0.188, p = 0.002). The participants were divided into good (n = 153) and poor (n = 107) CPAP adherence groups. In the poor adherence group, rhinomanometry values before CPAP introduction were worse (inspiration, p = 0.003; expiration, p = 0.006). There was no significant difference in patient background when comparing those with improved (n = 16) and unimproved (n = 12) pre-CPAP high rhinomanometry values. However, CPAP usage time was significantly longer in the improved group 1 month (p = 0.002) and 3 months (p = 0.026) after CPAP introduction. The results suggest that nasal resistance evaluated by rhinomanometry is a useful predictor of CPAP adherence, and that improved rhinomanometry values may contribute to extending the duration of CPAP use.

The role of ferroptosis in chronic intermittent hypoxia-induced lung injury

PURPOSE

Chronic intermittent hypoxia (CIH) causes lung injury but the mechanism is unclear. Ferroptosis is a novel form of programmed cell death. In this research, we attempted to explore the role of ferroptosis in CIH-induced lung injury both in vitro and in vivo.

METHODS

Sprague-Dawley rats were randomly separated into control group, CIH group and CIH + ferrostatin-1 group (CIH + Fer-1). Rats in the CIH group and CIH + Fer-1 group were exposed to intermittent hypoxia for 12 weeks. Human bronchial epithelial cell line (BEAS-2B) was cultivated for 24 h in either conventional culture medium or under CIH conditions. Fer-1 was applied to observe its treatment effects. Histological changes were evaluated by Hematoxylin-eosin (HE) staining and masson staining. The expression levels of Acyl-CoA synthetase long-chain family member 4 (ACSL4), glutathione peroxidase 4 (GPX4), interleukin-6 (IL-6) and tumour necrosis factor α (TNFα) were detected via qRT-PCR or Western blot. Cell counting kit-8 (CCK-8) was used to assess cell viability. The apoptotic rate and reactive oxygen species (ROS) was calculated by flow cytometry.

RESULTS

Histology showed that CIH treatment induced lung injury and pulmonary fibrosis in lung tissue. After Fer-1 treatment, the pathological changes caused by CIH alleviated. The mRNA and protein levels of GPX4 decreased significantly in lung tissues of CIH-treated rats and BEAS-2B, (p < 0.05). The mRNA and protein levels of ACSL4 increased significantly in lung tissues of CIH-treated rats and BEAS-2B, (p < 0.05). The mRNA levels of IL-6 and TNFα in BEAS-2B increased after CIH treatment, (p < 0.05). Cell viability decreased, apoptosis rate and ROS increased in CIH-treated BEAS-2B, (p < 0.05). Cotreatment with Fer-1 reversed CIH-induced apoptosis, cell viability, ROS accumulation, mRNA and protein levels of GPX4, ACSL4, IL-6 and TNFα both in vitro and in vivo (p < 0.05).

CONCLUSIONS

Ferroptosis occurred in CIH-induced lung injury, both in vitro and in vivo. The ferroptosis inhibitor Fer-1 alleviated cell injury and ferroptosis in CIH-treated BEAS-2B and lung tissues of rats.