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Balk EM, Adam GP, Cao W, Bhuma MR, D’Ambrosio C, Trikalinos TA. Long-term effects on clinical event, mental health, and related outcomes of CPAP for obstructive sleep apnea: a systematic review. J Clin Sleep Med 2024; 20:895-909. [PMID: 38300818 PMCID: PMC11145052 DOI: 10.5664/jcsm.11030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2023] [Revised: 01/10/2024] [Accepted: 01/11/2024] [Indexed: 02/03/2024]
Abstract
STUDY OBJECTIVES We performed a systematic review of long-term health outcomes of continuous positive airway pressure (CPAP) use in adults with obstructive sleep apnea. METHODS We updated prior systematic reviews with searches in multiple databases through January 3, 2023. We included randomized controlled trials (RCTs) and adjusted nonrandomized comparative studies that reported prespecified long-term (mostly > 1 year) health outcomes. We assessed risk of bias, conducted meta-analyses, and evaluated strength of evidence. RESULTS We found 38 eligible studies (16 trials, 22 observational). All conclusions were of low strength of evidence given study and data limitations. RCTs found no evidence of effect of CPAP on mortality (summary effect size [ES] 0.89; 95% confidence interval [CI] 0.66, 1.21); inclusion of adjusted nonrandomized comparative studies yields an association with reduced risk of death (ES 0.57; 95% CI 0.44, 0.73). RCTs found no evidence of effects of CPAP for cardiovascular death (ES 0.99; 95% CI 0.64, 1.53), stroke (ES 0.99; 95% CI 0.73, 1.35), myocardial infarction (ES 1.05; 95% CI 0.78, 1.41), incident atrial fibrillation (ES 0.89; 95% CI 0.48, 1.63), or composite cardiovascular outcomes (all statistically nonsignificant). RCTs found no evidence of effects for incident diabetes (ES 1.02; 95% CI 0.69, 1.51) or accidents (all nonsignificant) and no clinically significant effects on depressive symptoms, anxiety symptoms, or cognitive function. CONCLUSIONS Whether CPAP use for obstructive sleep apnea affects long-term health outcomes remains largely unanswered. RCTs and nonrandomized comparative studies are inconsistent regarding the effect of CPAP on mortality. Current studies are underpowered, with relatively short duration follow-up and methodological limitations. CITATION Balk EM, Adam GP, Cao W, Bhuma MR, D'Ambrosio C, Trikalinos TA. Long-term effects on clinical event, mental health, and related outcomes of CPAP for obstructive sleep apnea: a systematic review. J Clin Sleep Med. 2024;20(6):895-909.
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Affiliation(s)
- Ethan M. Balk
- Center for Evidence Synthesis in Health, Brown University School of Public Health, Providence, Rhode Island
| | - Gaelen P. Adam
- Center for Evidence Synthesis in Health, Brown University School of Public Health, Providence, Rhode Island
| | - Wangnan Cao
- Center for Evidence Synthesis in Health, Brown University School of Public Health, Providence, Rhode Island
| | - Monika Reddy Bhuma
- Center for Evidence Synthesis in Health, Brown University School of Public Health, Providence, Rhode Island
| | - Carolyn D’Ambrosio
- Section of Pulmonary, Critical Care, and Sleep Medicine, Yale University School of Medicine, New Haven, Connecticut
| | - Thomas A. Trikalinos
- Center for Evidence Synthesis in Health, Brown University School of Public Health, Providence, Rhode Island
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Arzt M, Munt O, Pépin JL, Heinzer R, Kübeck R, von Hehn U, Ehrsam-Tosi D, Benjafield AV, Woehrle H. Effects of Adaptive Servo-Ventilation on Quality of Life: The READ-ASV Registry. Ann Am Thorac Soc 2024; 21:651-657. [PMID: 38241012 DOI: 10.1513/annalsats.202310-908oc] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2023] [Accepted: 01/18/2024] [Indexed: 04/04/2024] Open
Abstract
Rationale: Adaptive servo-ventilation (ASV) effectively treats sleep-disordered breathing, including central sleep apnea (CSA) and coexisting obstructive sleep apnea (OSA).Objectives: The prospective, multicenter European READ-ASV (Registry on the Treatment of Central and Complex Sleep-Disordered Breathing with Adaptive Servo-Ventilation) registry investigated the effects of first-time ASV therapy on disease-specific quality of life (QoL).Methods: The registry enrolled adults with CSA with or without OSA who had ASV therapy prescribed between September 2017 and March 2021. The primary endpoint was change in disease-specific QoL (Functional Outcomes of Sleep Questionnaire [FOSQ]) score between baseline and 12-month follow-up. Sleepiness determined using the Epworth Sleepiness Scale (ESS) score was a key secondary outcome. For subgroup analysis, participants were classified as symptomatic (FOSQ score < 17.9 and/or ESS score > 10) or asymptomatic (FOSQ score ⩾ 17.9 and/or ESS score ⩽ 10).Results: A total of 801 individuals (age, 67 ± 12 yr; 14% female; body mass index, 31 ± 5 kg/m2; apnea-hypopnea index, 48 ± 22/h) were enrolled; analyses include those with paired baseline and follow-up data. After 12 ± 3 months on ASV, median (interquartile range) FOSQ score had increased significantly from baseline (+0.8 [-0.2 to 2.2]; P < 0.001; n = 499). This was due to a significantly increased FOSQ score in symptomatic participants (+1.69 [0.38 to 3.05]), with little change in asymptomatic individuals (+0.11 [-0.39 to 0.54]). The median ESS score also improved significantly from baseline during ASV (-2.0 [-5.0 to 0.0]; P < 0.001).Conclusions: ASV treatment of CSA with or without coexisting OSA was associated with improvements in disease-specific QoL and daytime sleepiness, especially in individuals with sleep-disordered breathing symptoms before therapy initiation. These improvements in patient-reported outcomes support the use of ASV in this population.
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Affiliation(s)
- Michael Arzt
- Department of Internal Medicine II, University Hospital Regensburg, Regensburg, Germany
| | | | - Jean-Louis Pépin
- University Grenoble Alpes, Laboratoire HP2, U1300 Inserm, CHU Grenoble Alpes, Grenoble, France
| | - Raphael Heinzer
- Centre d'Investigation et de Recherche sur le Sommeil, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
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Mohamed B, Yarlagadda K, Self Z, Simon A, Rigueiro F, Sohooli M, Eisenschenk S, Doré S. Obstructive Sleep Apnea and Stroke: Determining the Mechanisms Behind their Association and Treatment Options. Transl Stroke Res 2024; 15:239-332. [PMID: 36922470 DOI: 10.1007/s12975-023-01123-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2022] [Revised: 01/02/2023] [Accepted: 01/02/2023] [Indexed: 03/18/2023]
Abstract
Sleep-disordered breathing (SDB) can be a sequela of stroke caused by vascular injury to vital respiratory centers, cerebral edema, and increased intracranial pressure of space-occupying lesions. Likewise, obstructive sleep apnea (OSA) contributes to increased stroke risk through local mechanisms such as impaired ischemic cerebrovascular response and systemic effects such as promoting atherosclerosis, hypercoagulability, cardiac arrhythmias, vascular-endothelial dysfunction, and metabolic syndrome. The impact of OSA on stroke outcomes has been established, yet it receives less attention in national guidelines on stroke management than hyperglycemia and blood pressure dysregulation. Furthermore, whether untreated OSA worsens stroke outcomes is not well-described in the literature. This scoping review provides an updated investigation of the correlation between OSA and stroke, including inter-relational pathophysiology. This review also highlights the importance of OSA treatment and its role in stroke outcomes. Knowledge of pathophysiology, the inter-relationship between these common disorders, and the impact of OSA therapy on outcomes affect the clinical management of patients with acute ischemic stroke. In addition, understanding the relationship between stroke outcomes and pre-existing OSA will allow clinicians to predict outcomes while treating acute stroke.
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Affiliation(s)
- Basma Mohamed
- Department of Anesthesiology, Center for Translational Research in Neurodegenerative Disease, University of Florida College of Medicine, Gainesville, FL, 32610, USA
| | - Keerthi Yarlagadda
- Department of Anesthesiology, Center for Translational Research in Neurodegenerative Disease, University of Florida College of Medicine, Gainesville, FL, 32610, USA
| | - Zachary Self
- Department of Anesthesiology, Center for Translational Research in Neurodegenerative Disease, University of Florida College of Medicine, Gainesville, FL, 32610, USA
| | - Alexandra Simon
- Department of Anesthesiology, Center for Translational Research in Neurodegenerative Disease, University of Florida College of Medicine, Gainesville, FL, 32610, USA
| | - Frank Rigueiro
- Department of Anesthesiology, Center for Translational Research in Neurodegenerative Disease, University of Florida College of Medicine, Gainesville, FL, 32610, USA
| | - Maryam Sohooli
- Department of Anesthesiology, Center for Translational Research in Neurodegenerative Disease, University of Florida College of Medicine, Gainesville, FL, 32610, USA
| | - Stephan Eisenschenk
- Department of Neurology, University of Florida College of Medicine, Gainesville, FL, 32610, USA
| | - Sylvain Doré
- Department of Anesthesiology, Center for Translational Research in Neurodegenerative Disease, University of Florida College of Medicine, Gainesville, FL, 32610, USA.
- Department of Neurology, University of Florida College of Medicine, Gainesville, FL, 32610, USA.
- Departments of Neurology, Psychiatry, Pharmaceutics, and Neuroscience, Center for Translational Research in Neurodegenerative Disease, McKnight Brain Institute, University of Florida College of Medicine, Gainesville, FL, 32610, USA.
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Balk EM, Adam GP, D’Ambrosio CM. Large variability in definitions of sleep apnea indices used in clinical studies. J Clin Sleep Med 2024; 20:461-468. [PMID: 38054476 PMCID: PMC11019218 DOI: 10.5664/jcsm.10918] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2023] [Revised: 11/06/2023] [Accepted: 11/06/2023] [Indexed: 12/07/2023]
Abstract
STUDY OBJECTIVES We explored the variability of sleep apnea indices and definitions of obstructive sleep apnea in clinical studies of continuous positive airway pressure. METHODS In a systematic review of the long-term clinical effects of continuous positive airway pressure, we noted variability across studies in how sleep apnea was defined. We, thus, sought to quantify the heterogeneity. RESULTS Across 57 comparative studies of long-term clinical outcomes of continuous positive airway pressure, only 40% fully and explicitly reported their definitions of apnea and hypopnea. Most studies defined apnea as 100% airflow cessation, but a minority used 90% or even down to 75% thresholds. Almost half of the studies defined hypopnea as ≥ 50% airflow cessation, but the majority used 30% or even 25% thresholds. Similarly, about half of the studies used a 4% desaturation threshold to define oxygen desaturation and about half used a 3% threshold, with 2 studies using both thresholds for different purposes. Randomized trials were no more consistent or better-reported than observational studies. Studies that cited published criteria generally reported definitions that were different from the cited criteria. CONCLUSIONS The criteria used to define sleep apnea indices (apnea, hypopnea, and oxygen desaturation) were highly variable, even among studies stating that definitions were based on the same standard criteria. It was often difficult to discern the actual criteria used. The great variability across studies and lack of transparency about their sleep study methods hampers the interpretability and utility of the studies and calls into question whether studies are generalizable from one setting to another. CITATION Balk EM, Adam GP, D'Ambrosio CM. Large variability in definitions of sleep apnea indices used in clinical studies. J Clin Sleep Med. 2024;20(3):461-468.
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Affiliation(s)
- Ethan M. Balk
- Center for Evidence Synthesis in Health, Brown University School of Public Health, Providence, Rhode Island
| | - Gaelen P. Adam
- Center for Evidence Synthesis in Health, Brown University School of Public Health, Providence, Rhode Island
| | - Carolyn M. D’Ambrosio
- Section of Pulmonary, Critical Care, and Sleep Medicine, Yale University School of Medicine, New Haven, Connecticut
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Fu W, Li L, Zhang S, Liu S, Liu W. Effects of CPAP and Mandibular Advancement Devices on depressive symptoms in patients with obstructive sleep apnea: a meta-analysis of randomized controlled trials. Sleep Breath 2023; 27:2123-2137. [PMID: 37119355 DOI: 10.1007/s11325-023-02829-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2023] [Revised: 03/25/2023] [Accepted: 04/07/2023] [Indexed: 05/01/2023]
Abstract
PURPOSE Studies show that patients with obstructive sleep apnea (OSA) are more likely than the general population to have psychological disorders such as depression. However, it is less clear how OSA treatment affects this association. This meta-analysis aimed to assess whether or not continuous positive airway pressure (CPAP) and mandibular advancement devices (MADs) reduce depression symptoms in patients with OSA. METHODS We searched Pubmed, Embase, Web of Science, and Cochrane Library from creating the databases until November 2022. Our analysis included RCTs that examined CPAP and MAD treatment effectiveness for depression in patients with OSA. RESULTS We identified 17 CPAP studies comprising 1,931 patients for inclusion in the meta-analysis. The results of the meta-analysis using a fixed effects model found that CPAP improved depressed mood in patients with OSA relative to controls (SMD = 0.27;95% CI:0.18,0.36), with small heterogeneity among trials (I2 = 8.1% < 50%, P = 0.359). We performed subgroup analyses on three factors: the length of trial follow-up, patient adherence data, and depression assessment scales. The meta-analysis also identified six MAD studies involving 315 patients. According to this analysis, there was no heterogeneity between studies (I2 = 0%, P = 0.748). MADs did not significantly improve depression symptoms compared to controls, indicating a combined effect of SMD = 0.07 (95% CI: - 0.15,0.29), P > 0.05. CONCLUSION The present findings confirm that CPAP may improve depressive symptoms in patients with OSA. However, the review results suggest that MADs have no significant effect on depressive symptoms in patients with OSA, a finding that is different from the results of previous meta-analyses.
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Affiliation(s)
- Wenli Fu
- The First Clinical Medical College of Lanzhou University, Lanzhou, 730000, China
| | - Leping Li
- The First Clinical Medical College of Lanzhou University, Lanzhou, 730000, China
| | - Sha Zhang
- The First Clinical Medical College of Lanzhou University, Lanzhou, 730000, China
| | - Shengfei Liu
- The First Clinical Medical College of Lanzhou University, Lanzhou, 730000, China
| | - Weiying Liu
- Department of Respiratory and Critical Care Medicine, The First Hospital of Lanzhou University, Lanzhou, 730000, China.
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ALQarni AS, Turnbull CD, Morrell MJ, Kelly JL. Efficacy of vibrotactile positional therapy devices on patients with positional obstructive sleep apnoea: a systematic review and meta-analysis. Thorax 2023; 78:1126-1134. [PMID: 37344178 DOI: 10.1136/thorax-2021-218402] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Accepted: 05/26/2023] [Indexed: 06/23/2023]
Abstract
INTRODUCTION Vibrotactile positional therapy (PT) devices are a new treatment modality for positional obstructive sleep apnoea (POSA). This review aimed to determine the effect of vibrotactile PT on the Apnoea Hypopnoea Index (AHI) and the percentage of time spent in the supine position (%Tsupine) in patients with POSA, compared with baseline. Secondary aims were to investigate the effect on daytime sleepiness, quality of life and sleep quality. METHODS A systematic review and meta-analysis was performed of randomised controlled trials (RCTs) and cohort studies that investigated the effect of vibrotactile PT in POSA patients. Searches were performed via MEDLINE, CENTRAL and Embase up to 29 October 2022. RESULTS 1119 studies were identified, 18 studies met the inclusion criteria (10 RCTs, 8 cohort studies). The use of vibrotactile PT significantly reduced the AHI at follow-up compared with baseline (mean difference (95% CI) -9.19 events/hour (-11.68 to -6.70); p<0.00001). The mean %Tsupine was also significantly reduced (mean difference (95% CI) -32.79% (-38.75% to -26.83%); p<0.00001). The percentage changes in the AHI and %Tsupine were 43% and 70%, respectively. Secondary outcomes were daytime sleepiness, quality of life and sleep indices. These showed minimal change, although follow-up was short. CONCLUSION Vibrotactile PT devices are effective in treating POSA; reducing both AHI and %Tsupine. The effect on sleep quality, daytime sleepiness and disease-specific quality of life was minimal. However, there were limited data and follow-up was often brief, meaning that further research is needed to determine the effect of vibrotactile PT on patient-centred outcomes. PROSPERO REGISTRATION NUMBER CRD42020188617.
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Affiliation(s)
- Abdullah S ALQarni
- National Heart and Lung Institute, Imperial College London, London, UK
- Department of Sleep and Ventilation, Royal Brompton Hospital, London, UK
- Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia
| | - Chris D Turnbull
- NIHR Oxford Biomedical Research Centre, Oxford, UK
- Nuffield Department of Experimental Medicine, University of Oxford, Oxford, UK
- Oxford Centre for Respiratory Medicine, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Mary J Morrell
- National Heart and Lung Institute, Imperial College London, London, UK
| | - Julia L Kelly
- National Heart and Lung Institute, Imperial College London, London, UK
- Department of Sleep and Ventilation, Royal Brompton Hospital, London, UK
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Jiang W, Li W, Cheng J, Li W, Cheng F. Efficacy and safety of liraglutide in patients with type 2 diabetes mellitus and severe obstructive sleep apnea. Sleep Breath 2023; 27:1687-1694. [PMID: 36542275 PMCID: PMC10539428 DOI: 10.1007/s11325-022-02768-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2022] [Revised: 12/08/2022] [Accepted: 12/12/2022] [Indexed: 12/24/2022]
Abstract
OBJECTIVES To observe the efficacy and side effects of liraglutide in the treatment of type 2 diabetes mellitus (T2DM) patients with severe obstructive sleep apnea (OSA). METHODS The study conducted in an outpatient setting was a two-center, prospective randomized controlled study. T2DM patients with severe OSA were randomized to the control group (continuous positive airway pressure [CPAP] and drug treatment without liraglutide) or the liraglutide group (CPAP and drug treatment including liraglutide). Demographic and clinical characteristics, sleep-disordered breathing indices, cardiac function indices, and side effects were evaluated and compared between the two groups before and after 3 months. RESULTS Of 90 patients, 45 were randomized to the intervention arm (with liraglutide) and 45 to the control arm (without liraglutide). One patient in the liraglutide group dropped out of the study on day 8 after enrollment due to obvious gastrointestinal symptoms. No significant differences were found between the two groups in baseline demographics, clinical characteristics, cardiac function indicators, or sleep disorder respiratory indices (P > 0.05). After 3 months, the body mass index (BMI), apnea hypopnea index (AHI), and mean systolic blood pressure in the liraglutide treatment group were significantly lower than those in the control group (P < 0.05). The minimum oxygen saturation was significantly higher in the liraglutide group compared with that in the control group after 3 months of follow-up (P < 0.05). No difference was found between the two groups in the summary of side effects (P > 0.05). CONCLUSIONS Liraglutide combined with CPAP can effectively reduce BMI, lower mean systolic blood pressure, and improve AHI scores and hypoxia in T2DM patients with severe OSA. Liraglutide did not increase side effects.
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Affiliation(s)
- Wenlong Jiang
- Department of Cardiovascular, Shenzhen Yantian District People's Hospital, Shenzhen, China
| | - Weiguo Li
- Department of Cardiovascular, Longyan First Hospital Affiliated to Fujian Medical University, Longyan, Fujian, China
| | - Jing Cheng
- Department of Cardiovascular, Shenzhen Yantian District People's Hospital, Shenzhen, China
| | - Wen Li
- Department of Cardiovascular, Shenzhen Yantian District People's Hospital, Shenzhen, China
| | - Fangzhou Cheng
- Department of Cardiovascular, Shenzhen Yantian District People's Hospital, Shenzhen, China.
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Redline S, Azarbarzin A, Peker Y. Obstructive sleep apnoea heterogeneity and cardiovascular disease. Nat Rev Cardiol 2023; 20:560-573. [PMID: 36899115 DOI: 10.1038/s41569-023-00846-6] [Citation(s) in RCA: 29] [Impact Index Per Article: 29.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/02/2023] [Indexed: 03/12/2023]
Abstract
Obstructive sleep apnoea (OSA), characterized by recurrent periods of upper airway obstruction and intermittent hypoxaemia, is prevalent in patients with cardiovascular disease (CVD), and is therefore important to consider in the prevention and management of CVD. Observational studies indicate that OSA is a risk factor for incident hypertension, poorly controlled blood pressure, stroke, myocardial infarction, heart failure, cardiac arrhythmias, sudden cardiac death and all-cause death. However, clinical trials have not provided consistent evidence that treatment with continuous positive airway pressure (CPAP) improves cardiovascular outcomes. These overall null findings might be explained by limitations in trial design and low levels of adherence to CPAP. Studies have also been limited by the failure to consider OSA as a heterogeneous disorder that consists of multiple subtypes resulting from variable contributions from anatomical, physiological, inflammatory and obesity-related risk factors, and resulting in different physiological disturbances. Novel markers of sleep apnoea-associated hypoxic burden and cardiac autonomic response have emerged as predictors of OSA-related susceptibility to adverse health outcomes and treatment response. In this Review, we summarize our understanding of the shared risk factors and causal links between OSA and CVD and emerging knowledge on the heterogeneity of OSA. We discuss the varied mechanistic pathways that result in CVD that also vary across subgroups of OSA, as well as the potential role of new biomarkers for CVD risk stratification.
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Affiliation(s)
- Susan Redline
- Division of Sleep and Circadian Disorders, Brigham and Women's Hospital, Boston, MA, USA.
- Harvard Medical School, Boston, MA, USA.
| | - Ali Azarbarzin
- Division of Sleep and Circadian Disorders, Brigham and Women's Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Yüksel Peker
- Division of Sleep and Circadian Disorders, Brigham and Women's Hospital, Boston, MA, USA
- Koc University School of Medicine, Istanbul, Turkey
- University of Gothenburg, Gothenburg, Sweden
- University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
- Lund University School of Medicine, Lund, Sweden
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Turnbull CD, Stradling JR. Endotyping, phenotyping and personalised therapy in obstructive sleep apnoea: are we there yet? Thorax 2023; 78:726-732. [PMID: 37217289 DOI: 10.1136/thorax-2023-220037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Accepted: 05/02/2023] [Indexed: 05/24/2023]
Abstract
Obstructive sleep apnoea (OSA) was traditionally thought to be mainly caused by obesity and upper airway crowding, and hence OSA management was not personalised according to particular characteristics, with most symptomatic patients receiving continuous positive airway pressure therapy. Recent advances in our understanding have identified additional potential and distinct causes of OSA (endotypes), and subgroups of patients (phenotypes) with increased risk of cardiovascular complications. In this review, we discuss the evidence to date as to whether there are distinct clinically useful endotypes and phenotypes of OSA, and the challenges to the field in moving towards delivering personalised therapy in OSA.
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Affiliation(s)
- Chris D Turnbull
- Oxford Centre for Respiratory Medicine, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
- Nuffield Department of Medicine, University of Oxford, Oxford, UK
- Oxford Centre for Respiratory Medicine, NIHR Oxford Biomedical Research Centre, Oxford, UK
- NIHR Oxford Biomedical Research Centre, University of Oxford, Oxford, UK
| | - John R Stradling
- NIHR Oxford Biomedical Research Centre, University of Oxford, Oxford, UK
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Tawaranurak K, Werathammo M. Effect of positive airway pressure compliance on laryngopharyngeal reflux in obstructive sleep apnea patients. BMC Res Notes 2023; 16:124. [PMID: 37370165 DOI: 10.1186/s13104-023-06390-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2022] [Accepted: 06/15/2023] [Indexed: 06/29/2023] Open
Abstract
OBJECTIVES To determine the effect of continuous positive airway pressure (CPAP) compliance on symptoms and signs of laryngopharyngeal reflux (LPR) in patients with obstructive sleep apnea (OSA). RESULTS Thirty patients were included. The participants were divided into good compliance (n = 21) and poor compliance (n = 9) groups. After 6-month CPAP treatment, the reflux symptom index score significantly decreased in both the good compliance group (20 (17,24) vs. 14 (10,18), p < 0.001) and the poor compliance group (21 (18,25) vs. 10 (5,16), p < 0.05). Reflux finding score was significantly reduced in both the good compliance group (8 (6,9) vs. 4 (3,5), p < 0.001) and the poor compliance group (6 (4,8) vs. 3 (2,4), p < 0.05). However, there were no statistically significant differences between the groups. CPAP treatment reduces the symptoms and signs of LPR. However, CPAP compliance does not correlate with improvement in LPR in patients with OSA.
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Affiliation(s)
- Krongthong Tawaranurak
- Department of Otolaryngology Head and Neck Surgery, Faculty of Medicine, Prince of Songkla University, Hat Yai, 90110, Songkhla, Thailand.
| | - Methini Werathammo
- Department of Otolaryngology Head and Neck Surgery, Faculty of Medicine, Prince of Songkla University, Hat Yai, 90110, Songkhla, Thailand
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Gomase VG, Deshmukh P, Lekurwale VY. Obstructive Sleep Apnea and Its Management: A Narrative Review. Cureus 2023; 15:e37359. [PMID: 37182079 PMCID: PMC10174073 DOI: 10.7759/cureus.37359] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2023] [Accepted: 04/10/2023] [Indexed: 05/16/2023] Open
Abstract
Obstructive sleep apnea (OSA) is a disorder in which there is repeated collapse of the upper airway when the person is in sleep, which causes oxygen desaturation and interrupted sleep. While asleep, airway blockages and collapse are accompanied by awakenings with or without oxygen desaturation. OSA is a prevalent disorder, especially in people with known risk factors and other illnesses. Pathogenesis is variable, and the risk factors include low chest volume, erratic respiratory regulation, and muscular dysfunction in the upper airway dilators. The high-risk factors include overweight, male sex, aging, adenotonsillar hypertrophy, interruption of the menstrual cycle, preservation of liquids, and smoking. The signs are snoring, drowsiness, and apneas. A sleep history, assessment of symptoms, and physical examination are all part of the screening process for OSA, and the data can help determine which people need to be tested for the condition. The results of the polysomnogram or at-home sleep apnea test assist in determining the presence and severity of OSA. Still, it is seen many times that the accuracy of home sleep apnea tests is significantly less, so one should take an expert opinion for the same. OSA results in systemic hypertension, drowsiness, and driving accidents. It is additionally related to diabetes mellitus, congestive heart failure (CHF), cerebral infarction, and myocardial infarction, but the exact mechanism is not known. The preferred treatment is continuous positive airway pressure with 60-70% adherence. Other management options include reducing weight, therapy of oral appliances, and correcting any anatomical obstruction (narrow pharyngeal airway, adenoid hypertrophy, and mass in the pharynx). OSA indirectly causes headaches just after awakening and daytime sleepiness. However, there are no age boundaries in OSA as it can occur in any age group. Still, more prevalence is seen in individuals of more than 60 years of age.
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Affiliation(s)
- Vrushabh G Gomase
- Otorhinolaryngology, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Prasad Deshmukh
- Otolaryngology and Head and Neck Surgery, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Vedant Y Lekurwale
- Medical School, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
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Cattazzo F, Pengo MF, Giontella A, Soranna D, Bilo G, Zambon A, Karalliedde J, Gnudi L, Martinez-Garcia MÁ, Minuz P, Lombardi C, Parati G, Fava C. Effect of Continuous Positive Airway Pressure on Glucose and Lipid Profiles in Patients With Obstructive Sleep Apnoea: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. Arch Bronconeumol 2023:S0300-2896(23)00111-4. [PMID: 37024342 DOI: 10.1016/j.arbres.2023.03.012] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2023] [Revised: 03/04/2023] [Accepted: 03/07/2023] [Indexed: 03/29/2023]
Abstract
BACKGROUND AND AIM Continuous Positive Airway Pressure (CPAP) is the most effective therapy for symptomatic obstructive sleep apnoea (OSA). However, uncertainty remains about the effectiveness of CPAP in improving OSA-related metabolic dysregulation. This meta-analysis of randomized controlled trials (RCTs) aimed to investigate whether CPAP, compared to other control treatments, could improve glucose or lipid metabolism in OSA patients. METHODS Relevant articles were searched in three different databases (MEDLINE, EMBASE and Web of Science) from inception to 6th Feb 2022 through specific search terms and selection criteria. RESULTS From a total of 5553 articles, 31 RCTs were included. CPAP modestly improved insulin sensitivity as determined by mean fasting plasma insulin and Homeostasis Model Assessment of Insulin Resistance reduction of 1.33mU/L and 0.287, respectively. In subgroup analyses pre-diabetic/type 2 diabetic patients as well as those with sleepy OSA showed a greater response to CPAP. Regarding lipid metabolism, CPAP was associated with a mean total cholesterol reduction of 0.064mmol/L. In subgroup analyses, the benefit was higher in patients that showed more severe OSA and oxygen desaturations at the baseline sleep study as well as in younger and obese subjects. Neither glycated haemoglobin nor triglycerides, HDL- and LDL-cholesterol were reduced by CPAP. CONCLUSION CPAP treatment may improve insulin sensitivity and total cholesterol levels in OSA patients but with low effect size. Our results suggest that CPAP does not substantially improve metabolic derangements in an unselected OSA population, but the effect may be higher in specific subgroups of OSA patients.
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Affiliation(s)
- Filippo Cattazzo
- Department of Medicine, University of Verona, Section of General Medicine and Hypertension, Verona, Italy
| | - Martino F Pengo
- IRCCS, Istituto Auxologico Italiano, Department of Cardiovascular, Neural and Metabolic Sciences, S. Luca Hospital, Milan, Italy; Department of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
| | - Alice Giontella
- Department of Medicine, University of Verona, Section of General Medicine and Hypertension, Verona, Italy
| | - Davide Soranna
- IRCCS, Istituto Auxologico Italiano, Biostatistics Unit, Milan, Italy
| | - Grzegorz Bilo
- IRCCS, Istituto Auxologico Italiano, Department of Cardiovascular, Neural and Metabolic Sciences, S. Luca Hospital, Milan, Italy; Department of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
| | - Antonella Zambon
- IRCCS, Istituto Auxologico Italiano, Biostatistics Unit, Milan, Italy
| | - Janaka Karalliedde
- School of Cardiovascular Medicine & Sciences, Section Vascular Biology and Inflammation, Unit for Metabolic Medicine, King's College London, London, UK
| | - Luigi Gnudi
- School of Cardiovascular Medicine & Sciences, Section Vascular Biology and Inflammation, Unit for Metabolic Medicine, King's College London, London, UK
| | - Miguel Ángel Martinez-Garcia
- Department of Pneumology, Hospital Universitari i Politècnic la Fe, Valencia, Spain; CIBER de Enfermedades Respiratorias, ISCIII, Madrid, Spain
| | - Pietro Minuz
- Department of Medicine, University of Verona, Section of General Medicine and Hypertension, Verona, Italy
| | - Carolina Lombardi
- IRCCS, Istituto Auxologico Italiano, Department of Cardiovascular, Neural and Metabolic Sciences, S. Luca Hospital, Milan, Italy; Department of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
| | - Gianfranco Parati
- IRCCS, Istituto Auxologico Italiano, Department of Cardiovascular, Neural and Metabolic Sciences, S. Luca Hospital, Milan, Italy; Department of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
| | - Cristiano Fava
- Department of Medicine, University of Verona, Section of General Medicine and Hypertension, Verona, Italy.
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13
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Samaranayake CB, Turnbull C, Neubauer S, Kylintireas I, Stradling J, Craig S, McCabe C. Right ventricular responses to CPAP therapy in obstructive sleep apnea: CMR analysis of the MOSAIC randomized trial. Pulm Circ 2023; 13:e12201. [PMID: 36814585 PMCID: PMC9939623 DOI: 10.1002/pul2.12201] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2022] [Revised: 01/23/2023] [Accepted: 02/07/2023] [Indexed: 02/11/2023] Open
Abstract
Effects of continuous positive airway pressure (CPAP) on right ventricular (RV) function in patients with untreated mild-to-moderate obstructive sleep apnea (OSA) are unclear. In this exploratory analysis of cardiac magnetic resonance (CMR)-derived indices of RV function in patients with minimally symptomatic OSA from the MOSAIC randomized control trial we found no effect of CPAP on RV CMR parameters. In those with lower RV ejection fraction and higher RV end-diastolic volume (EDV) at baseline, CPAP treatment appeared to improve RV function with a significant reduction in both RV EDV and RV end-systolic volume although between-group effects were not observed. These data suggest potential merit in a larger randomized study of CPAP in patients with mild-to-moderate OSA and a greater breadth of RV dysfunction.
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Affiliation(s)
| | - Christopher Turnbull
- Oxford Centre for Respiratory MedicineOxford University Hospitals NHS Foundation TrustOxfordUK,Nuffield Department of Experimental MedicineUniversity of OxfordOxfordUK
| | - Stefan Neubauer
- Nuffield Department of Experimental MedicineUniversity of OxfordOxfordUK,Radcliffe Department of Medicine, Division of Cardiovascular Medicine, Oxford Centre for Clinical Magnetic Resonance ResearchUniversity of OxfordOxfordUK
| | - Ilias Kylintireas
- Nuffield Department of Experimental MedicineUniversity of OxfordOxfordUK,Radcliffe Department of Medicine, Division of Cardiovascular Medicine, Oxford Centre for Clinical Magnetic Resonance ResearchUniversity of OxfordOxfordUK
| | - John Stradling
- Nuffield Department of Experimental MedicineUniversity of OxfordOxfordUK
| | - Sonya Craig
- Oxford Centre for Respiratory MedicineOxford University Hospitals NHS Foundation TrustOxfordUK
| | - Colm McCabe
- National Pulmonary Hypertension ServiceRoyal Brompton HospitalLondonUK,National Heart and Lung InstituteImperial College LondonLondonUK
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14
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Feltner C, Wallace IF, Aymes S, Cook Middleton J, Hicks KL, Schwimmer M, Baker C, Balio CP, Moore D, Voisin CE, Jonas DE. Screening for Obstructive Sleep Apnea in Adults: Updated Evidence Report and Systematic Review for the US Preventive Services Task Force. JAMA 2022; 328:1951-1971. [PMID: 36378203 DOI: 10.1001/jama.2022.18357] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
IMPORTANCE Obstructive sleep apnea (OSA) is associated with adverse health outcomes. OBJECTIVE To review the evidence on screening for OSA in asymptomatic adults or those with unrecognized OSA symptoms to inform the US Preventive Services Task Force. DATA SOURCES PubMed/MEDLINE, Cochrane Library, Embase, and trial registries through August 23, 2021; surveillance through September 23, 2022. STUDY SELECTION English-language studies of screening test accuracy, randomized clinical trials (RCTs) of screening or treatment of OSA reporting health outcomes or harms, and systematic reviews of treatment reporting changes in blood pressure and apnea-hypopnea index (AHI) scores. DATA EXTRACTION AND SYNTHESIS Dual review of abstracts, full-text articles, and study quality. Meta-analysis of intervention trials. MAIN OUTCOMES AND MEASURES Test accuracy, excessive daytime sleepiness, sleep-related and general health-related quality of life (QOL), and harms. RESULTS Eighty-six studies were included (N = 11 051). No study directly compared screening with no screening. Screening accuracy of the Multivariable Apnea Prediction score followed by unattended home sleep testing for detecting severe OSA syndrome (AHI ≥30 and Epworth Sleepiness Scale [ESS] score >10) measured as the area under the curve in 2 studies (n = 702) was 0.80 (95% CI, 0.78 to 0.82) and 0.83 (95% CI, 0.77 to 0.90). Five studies assessing the accuracy of other screening tools were heterogeneous and results were inconsistent. Compared with inactive control, positive airway pressure was associated with a significant improvement in ESS score from baseline (pooled mean difference, -2.33 [95% CI, -2.75 to -1.90]; 47 trials; n = 7024), sleep-related QOL (standardized mean difference, 0.30 [95% CI, 0.19 to 0.42]; 17 trials; n = 3083), and general health-related QOL measured by the 36-Item Short Form Health Survey (SF-36) mental health component summary score change (pooled mean difference, 2.20 [95% CI, 0.95 to 3.44]; 15 trials; n = 2345) and SF-36 physical health component summary score change (pooled mean difference, 1.53 [95% CI, 0.29 to 2.77]; 13 trials; n = 2031). Use of mandibular advancement devices was also associated with a significantly larger ESS score change compared with controls (pooled mean difference, -1.67 [95% CI, 2.09 to -1.25]; 10 trials; n = 1540). Reporting of other health outcomes was sparse; no included trial found significant benefit associated with treatment on mortality, cardiovascular events, or motor vehicle crashes. In 3 systematic reviews, positive airway pressure was significantly associated with reduced blood pressure; however, the difference was relatively small (2-3 mm Hg). CONCLUSIONS AND RELEVANCE The accuracy and clinical utility of OSA screening tools that could be used in primary care settings were uncertain. Positive airway pressure and mandibular advancement devices reduced ESS score. Trials of positive airway pressure found modest improvement in sleep-related and general health-related QOL but have not established whether treatment reduces mortality or improves most other health outcomes.
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Affiliation(s)
- Cynthia Feltner
- RTI International-University of North Carolina at Chapel Hill Evidence-based Practice Center
- Department of Medicine, University of North Carolina at Chapel Hill
- Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill
| | - Ina F Wallace
- RTI International-University of North Carolina at Chapel Hill Evidence-based Practice Center
- RTI International, Research Triangle Park, North Carolina
| | - Shannon Aymes
- Department of Medicine, University of North Carolina at Chapel Hill
| | - Jennifer Cook Middleton
- RTI International-University of North Carolina at Chapel Hill Evidence-based Practice Center
- Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill
| | - Kelli L Hicks
- Department of Otolaryngology-Head and Neck Surgery, University of North Carolina at Chapel Hill
| | - Manny Schwimmer
- RTI International-University of North Carolina at Chapel Hill Evidence-based Practice Center
- Department of Internal Medicine, The Ohio State University, Columbus
| | - Claire Baker
- RTI International-University of North Carolina at Chapel Hill Evidence-based Practice Center
- Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill
| | - Casey P Balio
- Center for Rural Health Research, Department of Health Services Management and Policy, College of Public Health, East Tennessee State University, Johnson City
| | - Daniel Moore
- Department of Medicine, University of North Carolina at Chapel Hill
| | - Christiane E Voisin
- RTI International-University of North Carolina at Chapel Hill Evidence-based Practice Center
- Department of Internal Medicine, The Ohio State University, Columbus
| | - Daniel E Jonas
- RTI International-University of North Carolina at Chapel Hill Evidence-based Practice Center
- Department of Internal Medicine, The Ohio State University, Columbus
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15
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Xu Y, Wu H, Lu X. Influence of continuous positive airway pressure on lipid profiles of obstructive sleep apnea: A systematic review and meta-analysis. Medicine (Baltimore) 2022; 101:e31258. [PMID: 36281141 PMCID: PMC9592280 DOI: 10.1097/md.0000000000031258] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
BACKGROUND To investigate the influence of continuous positive airway pressure (CPAP) on lipid profiles of the patients with obstructive sleep apnea (OSA) in this meta-analysis. METHODS Relevant studies reporting the correlation between CPAP and lipid profiles of OSA patients were searched in Pubmed, Cochrane Library and Embase before January 1, 2021. Data of eligible studies were extracted and analyzed using the fixed-effect or random-effect model. Standard mean difference (SMD) and 95% confidence interval (95% CI) were calculated to assess such influence. Subgroup analysis based on CPAP duration was further performed. STATA 12.0 was used in this meta-analysis. RESULTS A total of 12 independent randomized controlled studies involved 1129 OSA patients were recruited in this meta-analysis. The analyzed lipid profiles included total cholesterol (TC), triglyceride (TG), low density lipoprotein (LDL) and high density lipoprotein (HDL). CPAP was not correlated to TC (SMD = -0.07, 95% CI = -0.33 to 0.19), TG (SMD = -0.01, 95% CI = -0.19 to 0.17), LDL (SMD = -0.01, 95% CI = -0.23 to 0.21) and HDL (SMD = 0.10, 95% CI = -0.03 to 0.22) in OSA patients. Moreover, CPAP duration (=12 weeks; >12 weeks; <12 weeks) also did not influence lipid profiles of OSA patients as well. CONCLUSIONS Regardless of the treatment in CPAP duration, it doses does not influence lipid profiles of OSA patients, including TC, TG, LDL and HDL. The results are inconsistent with previous findings, which should be further validated in the multi-center, long-term randomized controlled trials.
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Affiliation(s)
- Yinghua Xu
- Department of Anesthesiology, 904th Hospital of Joint Logistic Support Force of PLA, Wuxi, Jiangsu, PR China
- * Correspondence: Yinghua Xu, Department of Anesthesiology, 904th Hospital of Joint Logistic Support Force of PLA, Wuxi 214044, Jiangsu Province, PR China (e-mail: )
| | - Haiyan Wu
- Department of Respiratory, Zhejiang Hospital, 12 Lingyin Road, West Lake District, Hangzhou, Zhejiang, PR China
| | - Xiaoling Lu
- Department of Respiratory, Zhejiang Hospital, 12 Lingyin Road, West Lake District, Hangzhou, Zhejiang, PR China
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16
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Scharf MT, Zhang P, Walker NA, Mirza M, Jobanputra AM, Aurora RN, Sunderram J, Lu SE. Sex differences in Epworth Sleepiness Scale normalization with continuous positive airway pressure. J Clin Sleep Med 2022; 18:2273-2279. [PMID: 35499278 PMCID: PMC9435344 DOI: 10.5664/jcsm.10048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Revised: 04/05/2022] [Accepted: 04/05/2022] [Indexed: 11/13/2022]
Abstract
STUDY OBJECTIVES Continuous positive airway pressure (CPAP) improves sleepiness in patients with obstructive sleep apnea, but some patients remain sleepy. The objective of this study was to identify determinants that are associated with improvements in self-reported sleepiness in patients with obstructive sleep apnea on CPAP therapy. METHODS A retrospective cohort study was performed in a clinic-based population to determine which variables contributed to the improvement in the Epworth Sleepiness Scale (ESS) in patients on CPAP therapy for OSA, stratified by baseline ESS score (< 11 or ≥ 11). Variables associated with ESS scores normalizing with CPAP were also assessed. RESULTS Patients with a baseline high ESS score showed greater improvements in the ESS with CPAP. When looking at interactions between baseline ESS classification and changes in ESS, we found that a higher apnea-hypopnea index was only associated with improvement in the ESS among patients with a high baseline ESS. Other assessed factors or covariates were not significantly different. When looking at ESS normalization, we found that female sex and lower body mass index were associated with a lower likelihood of ESS normalization. The difference in the rate of ESS normalization between females and males was higher with more days on CPAP. CONCLUSIONS Of all the assessed factors and covariates, only the apnea-hypopnea index was associated with the change in the ESS differently in patients with a high or normal baseline ESS score. ESS normalization rates were lower in females than in males, and this disparity was amplified by more days on CPAP. CITATION Scharf MT, Zhang P, Walker NA, et al. Sex differences in Epworth Sleepiness Scale normalization with continuous positive airway pressure. J Clin Sleep Med. 2022;18(9):2273-2279.
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Affiliation(s)
- Matthew T. Scharf
- Department of Neurology, Rutgers/Robert Wood Johnson Medical School, New Brunswick, New Jersey
- Sleep Center, Division of Pulmonary and Critical Care Medicine, Department of Medicine, Rutgers/Robert Wood Johnson Medical School, New Brunswick, New Jersey
| | - Peng Zhang
- School of Public Health, Rutgers University, Piscataway, New Jersey
| | - Nathan A. Walker
- Sleep Center, Department of Neurology, University of North Carolina, Chapel Hill, North Carolina
| | - Mariam Mirza
- School of Arts and Science, Rutgers University, New Brunswick, New Jersey
| | - Aesha M. Jobanputra
- Sleep Center, Division of Pulmonary and Critical Care Medicine, Department of Medicine, Rutgers/Robert Wood Johnson Medical School, New Brunswick, New Jersey
| | - R. Nisha Aurora
- Sleep Center, Division of Pulmonary and Critical Care Medicine, Department of Medicine, Rutgers/Robert Wood Johnson Medical School, New Brunswick, New Jersey
| | - Jag Sunderram
- Sleep Center, Division of Pulmonary and Critical Care Medicine, Department of Medicine, Rutgers/Robert Wood Johnson Medical School, New Brunswick, New Jersey
| | - Shou-En Lu
- School of Public Health, Rutgers University, Piscataway, New Jersey
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17
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Nocturnal hypoxemia and central apneas increase mortality, but not recurrent ischemic events after ischemic stroke. Sleep Med 2022; 97:1-9. [DOI: 10.1016/j.sleep.2022.05.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Revised: 05/13/2022] [Accepted: 05/18/2022] [Indexed: 12/18/2022]
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Martínez-García MÁ, Sierra-Párraga JM, Garcia-Ortega A A. Obstructive sleep apnea in women: WE can do more and better. Sleep Med Rev 2022; 64:101645. [DOI: 10.1016/j.smrv.2022.101645] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2022] [Revised: 04/28/2022] [Accepted: 04/28/2022] [Indexed: 11/28/2022]
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Carneiro-Barrera A, Amaro-Gahete FJ, Guillén-Riquelme A, Jurado-Fasoli L, Sáez-Roca G, Martín-Carrasco C, Buela-Casal G, Ruiz JR. Effect of an Interdisciplinary Weight Loss and Lifestyle Intervention on Obstructive Sleep Apnea Severity: The INTERAPNEA Randomized Clinical Trial. JAMA Netw Open 2022; 5:e228212. [PMID: 35452108 PMCID: PMC9034401 DOI: 10.1001/jamanetworkopen.2022.8212] [Citation(s) in RCA: 29] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
IMPORTANCE Obesity is the leading cause of obstructive sleep apnea (OSA); however, the effects of weight loss and lifestyle interventions on OSA and comorbidities remain uncertain. OBJECTIVE To evaluate the effect of an interdisciplinary weight loss and lifestyle intervention on OSA and comorbidities among adults with moderate to severe OSA and overweight or obesity. DESIGN, SETTING, AND PARTICIPANTS The Interdisciplinary Weight Loss and Lifestyle Intervention for OSA (INTERAPNEA) study was a parallel-group open-label randomized clinical trial conducted at a hospital-based referral center in Granada, Spain, from April 1, 2019, to October 23, 2020. The study enrolled 89 Spanish men aged 18 to 65 years with moderate to severe OSA and a body mass index (calculated as weight in kilograms divided by height in meters squared) of 25 or greater who were receiving continuous positive airway pressure (CPAP) therapy. The sole inclusion of men was based on the higher incidence and prevalence of OSA in this population, the differences in OSA phenotypes between men and women, and the known effectiveness of weight loss interventions among men vs women. INTERVENTIONS Participants were randomized to receive usual care (CPAP therapy) or an 8-week weight loss and lifestyle intervention involving nutritional behavior change, aerobic exercise, sleep hygiene, and alcohol and tobacco cessation combined with usual care. MAIN OUTCOMES AND MEASURES The primary end point was the change in the apnea-hypopnea index (AHI) from baseline to the intervention end point (8 weeks) and 6 months after intervention. Secondary end points comprised changes in other OSA sleep-related outcomes, body weight and composition, cardiometabolic risk, and health-related quality of life. RESULTS Among 89 men (mean [SD] age, 54.1 [8.0] years; all of Spanish ethnicity; mean [SD] AHI, 41.3 [22.2] events/h), 49 were randomized to the control group and 40 were randomized to the intervention group. The intervention group had a greater decrease in AHI (51% reduction; change, -21.2 events/h; 95% CI, -25.4 to -16.9 events/h) than the control group (change, 2.5 events/h; 95% CI, -2.0 to 6.9 events/h) at the intervention end point, with a mean between-group difference of -23.6 events/h (95% CI, -28.7 to -18.5 events/h). At 6 months after intervention, the reduction in AHI was 57% in the intervention group, with a mean between-group difference of -23.8 events/h (95% CI, -28.3 to -19.3 events/h). In the intervention group, 18 of 40 participants (45.0%) no longer required CPAP therapy at the intervention end point, and 6 of 40 participants (15.0%) attained complete OSA remission. At 6 months after intervention, 21 of 34 participants (61.8%) no longer required CPAP therapy, and complete remission of OSA was attained by 10 of 34 participants (29.4%). In the intervention vs control group, greater improvements in body weight (change, -7.1 kg [95% CI, -8.6 to -5.5 kg] vs -0.3 kg [95% CI, -1.9 to 1.4 kg]) and composition (eg, change in fat mass, -2.9 kg [95% CI, -4.5 to -1.3 kg] vs 1.4 kg [95% CI, -0.3 to 3.1 kg]), cardiometabolic risk (eg, change in blood pressure, -6.5 mm Hg [95% CI, -10.3 to -2.6 mm Hg] vs 2.2 mm Hg [95% CI, -2.1 to 6.6 mm Hg]), and health-related quality of life (eg, change in Sleep Apnea Quality of Life Index, 0.8 points [95% CI, 0.5-1.1 points] vs 0.1 points [95% CI, -0.3 to 0.4 points]) were also found at the intervention end point. CONCLUSIONS AND RELEVANCE In this study, an interdisciplinary weight loss and lifestyle intervention involving Spanish men with moderate to severe OSA and had overweight or obesity and were receiving CPAP therapy resulted in clinically meaningful and sustainable improvements in OSA severity and comorbidities as well as health-related quality of life. This approach may therefore be considered as a central strategy to address the substantial impact of this increasingly common sleep-disordered breathing condition. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT03851653.
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Affiliation(s)
- Almudena Carneiro-Barrera
- Sleep and Health Promotion Laboratory, Mind, Brain and Behavior Research Centre, University of Granada, Granada, Spain
- Clinical Psychophysiology and Health Promotion Research Group, Ciencias y Técnicas de la Salud 261, University of Granada, Granada, Spain
- Department of Personality, Evaluation and Psychological Treatment, Faculty of Psychology, University of Granada, Granada, Spain
- Promoting Fitness and Health Through Physical Activity Research Group, Sport and Health University Research Institute, Department of Physical Education and Sports, Faculty of Sport Sciences, University of Granada, Granada, Spain
| | - Francisco J. Amaro-Gahete
- Promoting Fitness and Health Through Physical Activity Research Group, Sport and Health University Research Institute, Department of Physical Education and Sports, Faculty of Sport Sciences, University of Granada, Granada, Spain
- EFFECTS-262 Research Group, Department of Medical Physiology, School of Medicine, University of Granada, Granada, Spain
| | - Alejandro Guillén-Riquelme
- Sleep and Health Promotion Laboratory, Mind, Brain and Behavior Research Centre, University of Granada, Granada, Spain
- Clinical Psychophysiology and Health Promotion Research Group, Ciencias y Técnicas de la Salud 261, University of Granada, Granada, Spain
| | - Lucas Jurado-Fasoli
- Promoting Fitness and Health Through Physical Activity Research Group, Sport and Health University Research Institute, Department of Physical Education and Sports, Faculty of Sport Sciences, University of Granada, Granada, Spain
- EFFECTS-262 Research Group, Department of Medical Physiology, School of Medicine, University of Granada, Granada, Spain
| | - Germán Sáez-Roca
- Unidad de Trastornos Respiratorios del Sueño, Servicio de Neumología, Hospital Universitario Virgen de las Nieves, Granada, Spain
| | - Carlos Martín-Carrasco
- Unidad de Trastornos Respiratorios del Sueño, Servicio de Neumología, Hospital Universitario Virgen de las Nieves, Granada, Spain
| | - Gualberto Buela-Casal
- Sleep and Health Promotion Laboratory, Mind, Brain and Behavior Research Centre, University of Granada, Granada, Spain
- Clinical Psychophysiology and Health Promotion Research Group, Ciencias y Técnicas de la Salud 261, University of Granada, Granada, Spain
- Department of Personality, Evaluation and Psychological Treatment, Faculty of Psychology, University of Granada, Granada, Spain
| | - Jonatan R. Ruiz
- Promoting Fitness and Health Through Physical Activity Research Group, Sport and Health University Research Institute, Department of Physical Education and Sports, Faculty of Sport Sciences, University of Granada, Granada, Spain
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20
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Akashiba T, Inoue Y, Uchimura N, Ohi M, Kasai T, Kawana F, Sakurai S, Takegami M, Tachikawa R, Tanigawa T, Chiba S, Chin K, Tsuiki S, Tonogi M, Nakamura H, Nakayama T, Narui K, Yagi T, Yamauchi M, Yamashiro Y, Yoshida M, Oga T, Tomita Y, Hamada S, Murase K, Mori H, Wada H, Uchiyama M, Ogawa H, Sato K, Nakata S, Mishima K, Momomura SI. Sleep Apnea Syndrome (SAS) Clinical Practice Guidelines 2020. Respir Investig 2022; 60:3-32. [PMID: 34986992 DOI: 10.1016/j.resinv.2021.08.010] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Revised: 08/20/2021] [Accepted: 08/24/2021] [Indexed: 11/25/2022]
Abstract
The prevalence of sleep disordered breathing (SDB) is reportedly very high. Among SDBs, the incidence of obstructive sleep apnea (OSA) is higher than previously believed, with patients having moderate-to-severe OSA accounting for approximately 20% of adult males and 10% of postmenopausal women not only in Western countries but also in Eastern countries, including Japan. Since 1998, when health insurance coverage became available, the number of patients using continuous positive airway pressure (CPAP) therapy for sleep apnea has increased sharply, with the number of patients about to exceed 500,000 in Japan. Although the "Guidelines for Diagnosis and Treatment of Sleep Apnea Syndrome (SAS) in Adults" was published in 2005, a new guideline was prepared in order to indicate the standard medical care based on the latest trends, as supervised by and in cooperation with the Japanese Respiratory Society and the "Survey and Research on Refractory Respiratory Diseases and Pulmonary Hypertension" Group, of Ministry of Health, Labor and Welfare and other related academic societies, including the Japanese Society of Sleep Research, in addition to referring to the previous guidelines. Because sleep apnea is an interdisciplinary field covering many areas, this guideline was prepared including 36 clinical questions (CQs). In the English version, therapies and managements for SAS, which were written from CQ16 to 36, were shown. The Japanese version was published in July 2020 and permitted as well as published as one of the Medical Information Network Distribution Service (Minds) clinical practice guidelines in Japan in July 2021.
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Affiliation(s)
| | - Yuichi Inoue
- Department of Somnology, Tokyo Medical University, Tokyo, Japan
| | - Naohisa Uchimura
- Department of Neuropsychiatry, Kurume University School of Medicine, Fukuoka, Japan
| | - Motoharu Ohi
- Sleep Medical Center, Osaka Kaisei Hospital, Osaka, Japan
| | - Takatoshi Kasai
- Department of Cardiovascular Medicine, Juntendo University Graduate School of Medicine, Tokyo, Japan
| | - Fusae Kawana
- Department of Cardiovascular Respiratory Sleep Medicine, Juntendo University Graduate School of Medicine, Tokyo, Japan
| | - Shigeru Sakurai
- Division of Behavioral Sleep Medicine, Iwate Medical University School of Medicine, Iwate, Japan
| | - Misa Takegami
- Department of Preventive Medicine and Epidemiologic Informatics, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Rho Tachikawa
- Department of Respiratory Medicine, Kobe City Medical Center General Hospital, Hyogo, Japan
| | - Takeshi Tanigawa
- Department of Public Health, Juntendo University Graduate School of Medicine, Tokyo, Japan
| | - Shintaro Chiba
- Ota Memorial Sleep Center, Ota General Hospital, Kanagawa, Japan
| | - Kazuo Chin
- Department of Sleep Medicine and Respiratory Care, Division of Sleep Medicine, Nihon University of Medicine, Tokyo, Japan; Department of Human Disease Genomics, Center for Genomic Medicine, Graduate School Medicine, Kyoto University, Japan.
| | | | - Morio Tonogi
- Department of Oral and Maxillofacial Surgery, Nihon University School of Dentistry, Tokyo, Japan
| | | | - Takeo Nakayama
- Department of Health Informatics, Kyoto University School of Public Health, Kyoto, Japan
| | - Koji Narui
- Sleep Center, Toranomon Hospital, Tokyo, Japan
| | - Tomoko Yagi
- Ota Memorial Sleep Center, Ota General Hospital, Kanagawa, Japan
| | - Motoo Yamauchi
- Department of Respiratory Medicine, Nara Medical University, Nara, Japan
| | | | - Masahiro Yoshida
- Department of Hemodialysis and Surgery, Ichikawa Hospital, International University of Health and Welfare, Chiba, Japan
| | - Toru Oga
- Department of Respiratory Medicine, Kawasaki Medical School, Okayama, Japan
| | - Yasuhiro Tomita
- Department of Health Informatics, Kyoto University School of Public Health, Kyoto, Japan
| | - Satoshi Hamada
- Department of Advanced Medicine for Respiratory Failure, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Kimihiko Murase
- Department of Respiratory Care and Sleep Control Medicine, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Hiroyuki Mori
- Department of Neuropsychiatry, Kurume University School of Medicine, Fukuoka, Japan
| | - Hiroo Wada
- Department of Public Health, Juntendo University Graduate School of Medicine, Tokyo, Japan
| | - Makoto Uchiyama
- Department of Psychiatry, Nihon University School of Medicine, Tokyo, Japan
| | - Hiromasa Ogawa
- Department of Occupational Health, Tohoku University Graduate School of Medicine, Miyagi, Japan
| | - Kazumichi Sato
- Department of Dental and Oral Surgery, International University of Health and Welfare, Chiba, Japan
| | - Seiichi Nakata
- Department of Otorhinolaryngology, Second Hospital, Fujita Health University School of Medicine, Aichi, Japan
| | - Kazuo Mishima
- Department of Neuropsychiatry, Akita University Graduate School of Medicine, Akita, Japan
| | - Shin-Ichi Momomura
- Division of Cardiovascular Medicine, Saitama Medical Center, Jichi Medical University, Saitama, Japan
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21
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Pham LV, Jun J, Polotsky VY. Obstructive sleep apnea. HANDBOOK OF CLINICAL NEUROLOGY 2022; 189:105-136. [PMID: 36031300 DOI: 10.1016/b978-0-323-91532-8.00017-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
Obstructive sleep apnea (OSA) is a disease that results from loss of upper airway muscle tone leading to upper airway collapse during sleep in anatomically susceptible persons, leading to recurrent periods of hypoventilation, hypoxia, and arousals from sleep. Significant clinical consequences of the disorder cover a wide spectrum and include daytime hypersomnolence, neurocognitive dysfunction, cardiovascular disease, metabolic dysfunction, respiratory failure, and pulmonary hypertension. With escalating rates of obesity a major risk factor for OSA, the public health burden from OSA and its sequalae are expected to increase, as well. In this chapter, we review the mechanisms responsible for the development of OSA and associated neurocognitive and cardiometabolic comorbidities. Emphasis is placed on the neural control of the striated muscles that control the pharyngeal passages, especially regulation of hypoglossal motoneuron activity throughout the sleep/wake cycle, the neurocognitive complications of OSA, and the therapeutic options available to treat OSA including recent pharmacotherapeutic developments.
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Affiliation(s)
- Luu V Pham
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University, Baltimore, MD, United States.
| | - Jonathan Jun
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University, Baltimore, MD, United States
| | - Vsevolod Y Polotsky
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University, Baltimore, MD, United States
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22
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Akashiba T, Inoue Y, Uchimura N, Ohi M, Kasai T, Kawana F, Sakurai S, Takegami M, Tachikawa R, Tanigawa T, Chiba S, Chin K, Tsuiki S, Tonogi M, Nakamura H, Nakayama T, Narui K, Yagi T, Yamauchi M, Yamashiro Y, Yoshida M, Oga T, Tomita Y, Hamada S, Murase K, Mori H, Wada H, Uchiyama M, Ogawa H, Sato K, Nakata S, Mishima K, Momomura SI. Sleep Apnea Syndrome (SAS) Clinical Practice Guidelines 2020. Sleep Biol Rhythms 2022; 20:5-37. [PMID: 38469064 PMCID: PMC10900032 DOI: 10.1007/s41105-021-00353-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2021] [Accepted: 10/28/2021] [Indexed: 12/17/2022]
Abstract
The prevalence of sleep-disordered breathing (SDB) is reportedly very high. Among SDBs, the incidence of obstructive sleep apnea (OSA) is higher than previously believed, with patients having moderate-to-severe OSA accounting for approximately 20% of adult males and 10% of postmenopausal women not only in Western countries but also in Eastern countries, including Japan. Since 1998, when health insurance coverage became available, the number of patients using continuous positive airway pressure (CPAP) therapy for sleep apnea has increased sharply, with the number of patients about to exceed 500,000 in Japan. Although the "Guidelines for Diagnosis and Treatment of Sleep Apnea Syndrome (SAS) in Adults" was published in 2005, a new guideline was prepared to indicate the standard medical care based on the latest trends, as supervised by and in cooperation with the Japanese Respiratory Society and the "Survey and Research on Refractory Respiratory Diseases and Pulmonary Hypertension" Group, of Ministry of Health, Labor and Welfare and other related academic societies, including the Japanese Society of Sleep Research, in addition to referring to the previous guidelines. Since sleep apnea is an interdisciplinary field covering many areas, this guideline was prepared including 36 clinical questions (CQs). In the English version, therapies and managements for SAS, which were written from CQ16 to 36, were shown. The Japanese version was published in July 2020 and permitted as well as published as one of the Medical Information Network Distribution Service (Minds) clinical practice guidelines in Japan in July 2021.
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Affiliation(s)
| | - Yuichi Inoue
- Department of Somnology, Tokyo Medical University, Tokyo, Japan
| | - Naohisa Uchimura
- Department of Neuropsychiatry, Kurume University School of Medicine, Fukuoka, Japan
| | - Motoharu Ohi
- Sleep Medical Center, Osaka Kaisei Hospital, Osaka, Japan
| | - Takatoshi Kasai
- Department of Cardiovascular Medicine, Juntendo University Graduate School of Medicine, Tokyo, Japan
| | - Fusae Kawana
- Department of Cardiovascular Respiratory Sleep Medicine, Juntendo University Graduate School of Medicine, Tokyo, Japan
| | - Shigeru Sakurai
- Division of Behavioral Sleep Medicine, Iwate Medical University School of Medicine, Iwate, Japan
| | - Misa Takegami
- Department of Preventive Medicine and Epidemiologic Informatics, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Ryo Tachikawa
- Department of Respiratory Medicine, Kobe City Medical Center General Hospital, Hyogo, Japan
| | - Takeshi Tanigawa
- Department of Public Health, Juntendo University Graduate School of Medicine, Tokyo, Japan
| | - Shintaro Chiba
- Ota Memorial Sleep Center, Ota General Hospital, Kanagawa, Japan
| | - Kazuo Chin
- Department of Sleep Medicine and Respiratory Care, Division of Sleep Medicine, Nihon University of Medicine, 30-1 Oyaguchikami-cho, Itabashi-ku, Tokyo, 173-8610 Japan
- Department of Human Disease Genomics, Center for Genomic Medicine, Graduate School Medicine, Kyoto University, Kyoto, Japan
| | | | - Morio Tonogi
- Department of Oral and Maxillofacial Surgery, Nihon University School of Dentistry, Tokyo, Japan
| | | | - Takeo Nakayama
- Department of Health Informatics, Kyoto University School of Public Health, Kyoto, Japan
| | - Koji Narui
- Sleep Center, Toranomon Hospital, Tokyo, Japan
| | - Tomoko Yagi
- Ota Memorial Sleep Center, Ota General Hospital, Kanagawa, Japan
| | - Motoo Yamauchi
- Department of Respiratory Medicine, Nara Medical University, Nara, Japan
| | | | - Masahiro Yoshida
- Department of Hemodialysis and Surgery, Ichikawa Hospital, International University of Health and Welfare, Chiba, Japan
| | - Toru Oga
- Department of Respiratory Medicine, Kawasaki Medical School, Okayama, Japan
| | - Yasuhiro Tomita
- Department of Health Informatics, Kyoto University School of Public Health, Kyoto, Japan
| | - Satoshi Hamada
- Department of Advanced Medicine for Respiratory Failure, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Kimihiko Murase
- Department of Respiratory Care and Sleep Control Medicine, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Hiroyuki Mori
- Department of Neuropsychiatry, Kurume University School of Medicine, Fukuoka, Japan
| | - Hiroo Wada
- Department of Somnology, Tokyo Medical University, Tokyo, Japan
| | - Makoto Uchiyama
- Department of Psychiatry, Nihon University School of Medicine, Tokyo, Japan
| | - Hiromasa Ogawa
- Department of Occupational Health, Tohoku University Graduate School of Medicine, Miyagi, Japan
| | - Kazumichi Sato
- Department of Dental and Oral Surgery, International University of Health and Welfare, Chiba, Japan
| | - Seiichi Nakata
- Department of Otorhinolaryngology, Second Hospital, Fujita Health University School of Medicine, Aichi, Japan
| | - Kazuo Mishima
- Department of Neuropsychiatry, Akita University Graduate School of Medicine, Akita, Japan
| | - Shin-Ichi Momomura
- Division of Cardiovascular Medicine, Saitama Medical Center, Jichi Medical University, Saitama, Japan
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23
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Low-Calorie Ketogenic Diet with Continuous Positive Airway Pressure to Alleviate Severe Obstructive Sleep Apnea Syndrome in Patients with Obesity Scheduled for Bariatric/Metabolic Surgery: a Pilot, Prospective, Randomized Multicenter Comparative Study. Obes Surg 2021; 32:634-642. [PMID: 34802065 PMCID: PMC8605892 DOI: 10.1007/s11695-021-05811-1] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2021] [Revised: 11/11/2021] [Accepted: 11/14/2021] [Indexed: 01/10/2023]
Abstract
Obstructive sleep apnea syndrome (OSAS) and obesity are frequently associated with hypertension (HTN), dyslipidemia (DLP), and insulin resistance (IR). In patients with obesity and OSAS scheduled for bariatric surgery (BS), guidelines recommend at least 4 weeks of preoperative continuous positive airway pressure (CPAP). Low-calorie ketogenic diets (LCKDs) promote pre-BS weight loss (WL) and improve HTN, DLP, and IR. However, it is unclear whether pre-BS LCKD with CPAP improves OSAS more than CPAP alone. We assessed the clinical advantage of pre-BS CPAP and LCKD in patients with obesity and OSAS. Seventy patients with obesity and OSAS were randomly assigned to CPAP or CPAP+LCKD groups for 4 weeks. The effect of each intervention on the apnea–hypopnea index (AHI) was the primary endpoint. WL, C-reactive protein (CRP) levels, HTN, DLP, and IR were secondary endpoints. AHI scores improved significantly in both groups (CPAP, p=0.0231; CPAP+LCKD, p=0.0272). However, combining CPAP and LCKD registered no advantage on the AHI score (p=0.863). Furthermore, body weight, CRP levels, and systolic/diastolic blood pressure were significantly reduced in the CPAP+LCKD group after 4 weeks (p=0.0052, p=0.0161, p=0.0008, and p=0.0007 vs baseline, respectively), and CPAP+LCKD had a greater impact on CRP levels than CPAP alone (p=0.0329). The CPAP+LCKD group also registered a significant reduction in serum cholesterol, LDL, and triglyceride levels (p=0.0183, p=0.0198, and p<0.001, respectively). Combined with CPAP, LCKD-induced WL seems to not have a significant incremental effect on AHI, HTN, DLP, and IR but lower CRP levels demonstrated a positive impact on chronic inflammatory status.
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24
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Javaheri S, Peker Y, Yaggi HK, Bassetti CLA. Obstructive sleep apnea and stroke: The mechanisms, the randomized trials, and the road ahead. Sleep Med Rev 2021; 61:101568. [PMID: 34906778 DOI: 10.1016/j.smrv.2021.101568] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2021] [Revised: 11/02/2021] [Accepted: 11/03/2021] [Indexed: 10/19/2022]
Abstract
When considered separately from cardiovascular disease, stroke is the third leading cause of death in the U.S. and is the leading cause of long-term disability in adults. New approaches that can be offered to the majority of ischemic stroke patients, can be continued throughout post-stroke care, can limit stroke severity, and can complement or even enhance rehabilitation, would transform ischemic stroke recovery. The treatment of obstructive sleep apnea (OSA) in patients with acute ischemic stroke may represent one such approach. This manuscript reviews the epidemiologic studies of the bidirectional association between OSA and stroke, and the mechanisms and molecular signatures of OSA leading to transient ischemic attack and stroke as well as the randomized controlled trials and observational cohort studies examining continuous positive airway treatment efficacy on the impact of stroke outcomes. Finally, the insights these studies provide on future research are also discussed.
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Affiliation(s)
- Shahrokh Javaheri
- Division of Pulmonary and Sleep Medicine, Bethesda North Hospital, Cincinnati, OH, USA; Division of Pulmonary, Critical Care and Sleep Medicine, University of Cincinnati College of Medicine, Cincinnati, OH, USA; Division of Cardiology, The Ohio State University, Columbus, OH, USA.
| | - Yüksel Peker
- Department of Pulmonary Medicine, Koc University School of Medicine, Istanbul, Turkey; Department of Molecular and Clinical Medicine/Cardiology, Sahlgrenska Academy, University of Gothenburg, Sweden; Department of Clinical Sciences, Respiratory Medicine and Allergology, Faculty of Medicine, Lund University, Lund, Sweden; Division of Pulmonary, Allergy, and Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - H Klar Yaggi
- Department of Medicine, Yale University School of Medicine, New Haven, CT, USA; Clinical Epidemiology Research Center, Veterans Affairs Connecticut Healthcare System, West Haven, CT, USA
| | - Claudio L A Bassetti
- Department of Neurology, Inselspital, University of Bern, Switzerland; Department of Neurology, Sechenow University Faculty of Medicine, Moscow, Russia
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25
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Elbadawi A, Elgendy IY, Shnoda M, Abuzaid AS, Barssoum K, Gouda M, Megaly M, Bansal A, Gulati M, Jneid H. Impact of continuous positive airway pressure ventilation on cardiovascular outcomes among patients with obstructive sleep apnea: A meta-analysis of randomized trials. AMERICAN HEART JOURNAL PLUS : CARDIOLOGY RESEARCH AND PRACTICE 2021; 11:100056. [PMID: 38559317 PMCID: PMC10978146 DOI: 10.1016/j.ahjo.2021.100056] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/18/2021] [Revised: 08/24/2021] [Accepted: 08/26/2021] [Indexed: 04/04/2024]
Abstract
Background The impact of continuous positive airway pressure (CPAP) on cardiovascular outcomes among patients with obstructive sleep apnea (OSA) is controversial. Objective To evaluate the impact of CPAP on reducing cardiovascular outcomes in patients with OSA. Methods We performed a computerized search of MEDLINE, EMBASE and COCHRANE databases through April 2021 for randomized trials evaluating the impact of CPAP versus control on cardiovascular outcomes in patients with OSA. Summary estimates were reported using both fixed and random effects model. The main study outcome was major adverse cardiac events (MACE). Results The final analysis included 8 randomized trials with total of 5684 patients. The weighted mean follow-up was 42.6 months. There was no difference between the CPAP and control groups in the risk of MACE (14.4% versus 14.8%, risk ratio [RR]: 0.97; 95% confidence interval [CI]: 0.85 to 1.10; p = 0.60; I2 = 21%). Subgroup analysis suggested that CPAP was associated with lower MACE (by 36%) in CPAP-adherent patients (≥4 h/night) (Pinteraction = 0.08). There was no difference between the CPAP and control groups in the risk of all-cause mortality, cardiovascular mortality, acute stroke, acute myocardium infarction or hospitalizations for angina. Conclusions and relevance CPAP use might not be associated with lower cardiovascular events among patients with OSA. However, patients adherent to CPAP (≥4 h/night) might derive a benefit on cardiovascular outcomes. Future studies are warranted to evaluate the impact of CPAP in reducing cardiovascular events among patients with severe OSA and with optimal adherence rates to CPAP therapy.
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Affiliation(s)
- Ayman Elbadawi
- Division of Cardiovascular Medicine, Baylor College of Medicine, Houston, TX, United States of America
| | - Islam Y. Elgendy
- Department of Medicine, Weill Cornell Medicine-Qatar, Doha, Qatar
| | - Mina Shnoda
- Division of Internal Medicine, Allegheny General Hospital, Pittsburgh, PA, United States of America
| | - Ahmed S. Abuzaid
- Division of Cardiology, University of California San Francisco, San Francisco, CA
| | - Kirolos Barssoum
- Department of Cardiovascular Medicine, University of Texas Medical Branch, Galveston, TX, United States of America
| | - Mahmoud Gouda
- Department of Internal Medicine, Conemaugh Memorial Medical Center, Johnstown, PA, United States of America
| | - Michael Megaly
- Division of Cardiology, University of Arizona, Phoenix, United States of America
| | - Amit Bansal
- Department of Cardiology, UHS Wilson Medical Center, Johnson City, NY, United States of America
| | - Martha Gulati
- Division of Cardiology, University of Arizona, Phoenix, United States of America
| | - Hani Jneid
- Division of Cardiovascular Medicine, Baylor College of Medicine, Houston, TX, United States of America
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26
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Serino M, Cardoso C, Carneiro RJ, Ferra J, Aguiar F, Rodrigues D, Redondo M, van Zeller M, Drummond M. OSA patients not treated with PAP - Evolution over 5 years according to the Baveno classification and cardiovascular outcomes. Sleep Med 2021; 88:1-6. [PMID: 34710706 DOI: 10.1016/j.sleep.2021.09.010] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2021] [Revised: 08/21/2021] [Accepted: 09/13/2021] [Indexed: 11/28/2022]
Abstract
INTRODUCTION The evolution of patients with obstructive sleep apnea (OSA) non-eligible for PAP-therapy at diagnosis is unknown. Currently, the severity of OSA is based on the apnea-hypopnea index (AHI), but its prognostic relevance has raised concerns. The Baveno classification may allow a better stratification of severity and therapeutic guidance in OSA. METHODS Patients with AHI≥5/h in 2015, classified into Baveno groups A and B and non-eligible for PAP therapy at diagnosis and over 5 years, were analyzed. Patients were reclassified into Baveno groups (A-D) and changes in groups over 5 years were explored. Patients in Baveno groups C and D, who developed major cardiovascular comorbidities (CVC) or end-organ damage (EOD group), were compared with patients in Baveno groups A and B (non-EOD group). To identify predictors of the development of major CVC or EOD, a logistic regression analysis was performed. RESULTS There were 76 patients, 58% male, mean age 51.9 ± 10.1 years, mean body mass index (BMI) of 30.3 ± 5.0 kg/m2 and median AHI of 8.9 (5.9-12.0) events/h. At diagnosis, 46% and 54% of patients were classified into Baveno group A and group B, respectively. In total, 21% of patients developed major CVC or EOD (Baveno group C or D); higher age (p = 0.011) and BMI (p = 0.004) and a higher percentage of central apneas (p = 0.012) at diagnosis significantly predicted it, while sex, sleepiness, insomnia, AHI, ODI and T90 were not. CONCLUSIONS A significant percentage of patients non-eligible for PAP-therapy at diagnosis of OSA developed CVC or EOD; higher age and BMI and a higher percentage of central apneas were significant predictors.
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Affiliation(s)
- M Serino
- Department of Pneumology, Centro Hospitalar São João, Porto, Portugal.
| | - C Cardoso
- Department of Pneumology, Centro Hospitalar São João, Porto, Portugal
| | - R J Carneiro
- Department of Pneumology, Centro Hospitalar Oeste, Hospital Torres Vedras, Torres Vedras, Portugal
| | - J Ferra
- Department of Pneumology, Hospital de Egas Moniz, Centro Hospitalar Lisboa Ocidental, LisboaVedras, Portugal
| | - F Aguiar
- Department of Pneumology, Hospital de Braga, Braga, Portugal
| | - D Rodrigues
- Pulmonology Department, Centro Hospitalar Universitário São João, Sleep and Non-Invasive Ventilation Unit, Centro Hospitalar Universitário São João, Porto, Portugal
| | - M Redondo
- Pulmonology Department, Centro Hospitalar Universitário São João, Sleep and Non-Invasive Ventilation Unit, Centro Hospitalar Universitário São João, Porto, Portugal
| | - M van Zeller
- Sleep and Non-Invasive Ventilation Unit, Centro Hospitalar Universitário São João, Faculty of Medicine, University of Porto, Porto, Portugal
| | - M Drummond
- Sleep and Non-Invasive Ventilation Unit, Centro Hospitalar Universitário São João, Faculty of Medicine, University of Porto, Porto, Portugal
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Abstract
Es hat sich viel getan in der Welt der Schlafmedizin in der Kardiologie, weshalb eine vollwertige Überarbeitung des Positionspapiers „Schlafmedizin in der Kardiologie“ erforderlich wurde. In der aktuellen neuartigen Version finden sich nicht nur alle verfügbaren Studien, Literaturstellen und Updates zu Pathophysiologie, Diagnostik- und Therapieempfehlungen, sondern auch Ausblicke auf neue Entwicklungen und zukünftige Forschungserkenntnisse. Dieses überarbeitete Positionspapier gibt Empfehlungen für Diagnostik und Therapie von Patienten mit kardiovaskulären Erkrankungen mit schlafassoziierten Atmungsstörungen und erteilt darüber hinaus einen fundierten Überblick über verfügbare Therapien und Evidenzen, gibt aber ebenso Ratschläge wie mit Komorbiditäten umzugehen ist. Insbesondere enthält dieses überarbeitete Positionspapier aktualisierte Stellungnahmen zu schlafassoziierten Atmungsstörungen bei Patienten mit koronarer Herzerkrankung, Herzinsuffizienz, arterieller Hypertonie, aber auch für Patienten mit Vorhofflimmern. Darüber hinaus finden sich erstmals Empfehlungen zur Telemedizin als eigenes, neues Kapitel. Dieses Positionspapier bietet Kardiologen sowie Ärzten in der Behandlung von kardiovaskulären Patienten die Möglichkeit einer evidenzbasierten Behandlung der wachsend bedeutsamen und mit zunehmender Aufmerksamkeit behafteten Komorbidität schlafassoziierter Atmungsstörungen. Und nicht zuletzt besteht mit diesem neuen Positionspapier eine enge Verknüpfung mit dem neuen Curriculum Schlafmedizin der Deutschen Gesellschaft für Kardiologie, weshalb dieses Positionspapier eine Orientierung für die erworbenen Fähigkeiten des Curriculums im Umgang von kardiovaskulären Patienten mit schlafassoziierten Atmungsstörungen darstellt.
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28
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Wu J, Hu R, Li M, Liu S, Zhang X, He J, Chen J, Li X. Diagnosis of sleep disorders in traditional Chinese medicine based on adaptive neuro-fuzzy inference system. Biomed Signal Process Control 2021. [DOI: 10.1016/j.bspc.2021.102942] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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29
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Adler D, Bailly S, Soccal PM, Janssens JP, Sapène M, Grillet Y, Stach B, Tamisier R, Pépin JL. Symptomatic response to CPAP in obstructive sleep apnea versus COPD- obstructive sleep apnea overlap syndrome: Insights from a large national registry. PLoS One 2021; 16:e0256230. [PMID: 34383866 PMCID: PMC8360593 DOI: 10.1371/journal.pone.0256230] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2021] [Accepted: 08/02/2021] [Indexed: 01/10/2023] Open
Abstract
Background The symptomatic response to continuous positive airway pressure (CPAP) therapy in COPD-obstructive sleep apnea overlap syndrome (OVS) compared to OSA syndrome (OSA) alone has not been well studied so far. The aim of this study is to explore main differences in the clinical response to CPAP treatment in OVS compared to OSA alone. Study design and methods Using prospective data from the French National Sleep Apnea Registry, we conducted an observational study among 6320 patients with moderate-to-severe OSA, available spirometry, and at least one follow-up visit under CPAP therapy. Results CPAP efficacy measured on the residual apnea-hypopnea index and median adherence were similar between OVS and OSA patients. In both groups, the overall burden of symptoms related to sleep apnea improved with CPAP treatment. In a multivariable model adjusted for age, gender, body mass index, adherence to treatment and residual apnea-hypopnea index, OVS was associated with higher odds for persistent morning headaches (OR: 1.37 [95% CI; 1.04; 1.79]; P = 0.02), morning tiredness (OR: 1.33 [95% CI: 1.12; 1.59]; P<0.01), daytime sleepiness (OR; 1.24 [95% CI: 1.4; 1.46]: P<0.01) and exertional dyspnea (OR: 1.26 [95% CI: 1.00;1.58]; P = 0.04) when compared with OSA alone. Interpretation CPAP therapy was effective in normalizing the apnea-hypopnea index and significantly improved OSA-related symptoms, regardless of COPD status. CPAP should be offered to patients with OVS on a trial basis as a significant improvement in OSA-related symptoms can be expected, although the range of response may be less dramatic than in OSA alone.
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Affiliation(s)
- Dan Adler
- Division of Pneumology, Geneva University Hospitals, Geneva, Switzerland
- University of Geneva Faculty of Medicine, Geneva, Switzerland
- * E-mail:
| | - Sébastien Bailly
- HP2 Laboratory, INSERM U1042, University Grenoble Alpes, Grenoble, France
- EFCR Laboratory, Pole Thorax et Vaisseaux, Grenoble Alpes University Hospital, Grenoble, France
| | - Paola Marina Soccal
- Division of Pneumology, Geneva University Hospitals, Geneva, Switzerland
- University of Geneva Faculty of Medicine, Geneva, Switzerland
| | - Jean-Paul Janssens
- Division of Pneumology, Geneva University Hospitals, Geneva, Switzerland
- University of Geneva Faculty of Medicine, Geneva, Switzerland
| | - Marc Sapène
- Private Practice Sleep and Respiratory Disease Center, Nouvelle Clinique Bel Air, Bordeaux, France
| | - Yves Grillet
- Private Practice Sleep and Respiratory Disease Center, Valence, France
| | - Bruno Stach
- Private Practice Sleep and Respiratory Disease Center, Valenciennes, France
| | - Renaud Tamisier
- HP2 Laboratory, INSERM U1042, University Grenoble Alpes, Grenoble, France
- EFCR Laboratory, Pole Thorax et Vaisseaux, Grenoble Alpes University Hospital, Grenoble, France
| | - Jean-Louis Pépin
- Division of Pneumology, Geneva University Hospitals, Geneva, Switzerland
- HP2 Laboratory, INSERM U1042, University Grenoble Alpes, Grenoble, France
- EFCR Laboratory, Pole Thorax et Vaisseaux, Grenoble Alpes University Hospital, Grenoble, France
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30
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Kent D, Stanley J, Aurora RN, Levine CG, Gottlieb DJ, Spann MD, Torre CA, Green K, Harrod CG. Referral of adults with obstructive sleep apnea for surgical consultation: an American Academy of Sleep Medicine systematic review, meta-analysis, and GRADE assessment. J Clin Sleep Med 2021; 17:2507-2531. [PMID: 34351849 DOI: 10.5664/jcsm.9594] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
INTRODUCTION This systematic review provides supporting evidence for the accompanying clinical practice guideline on the referral of adults with obstructive sleep apnea (OSA) for surgical consultation. METHODS The American Academy of Sleep Medicine commissioned a task force of experts in sleep medicine. A systematic review was conducted to identify studies that compared the use of upper airway sleep apnea surgery or bariatric surgery to no treatment as well as studies that reported on patient-important and physiologic outcomes pre- and postoperatively. Statistical analyses were performed to determine the clinical significance of using surgery to treat obstructive sleep apnea in adults. Finally, the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) process was used to assess the evidence for making recommendations. RESULTS The literature search resulted in 274 studies that provided data suitable for statistical analyses. The analyses demonstrated that surgery as a rescue therapy results in a clinically significant reduction in excessive sleepiness, snoring, blood pressure (BP), apnea-hypopnea index (AHI), respiratory disturbance index (RDI), oxygen desaturation index (ODI), increase in lowest oxygen saturation (LSAT), sleep quality, and improvement in quality of life in adults with OSA who are intolerant or unaccepting of positive airway pressure (PAP) therapy. The analyses demonstrated that surgery as an adjunctive therapy results in a clinically significant reduction in optimal PAP pressure and improvement in PAP adherence in adults with OSA who are intolerant or unaccepting of PAP due to side effects associated with high pressure requirements. The analyses also demonstrated that surgery as an initial treatment results in a clinically significant reduction in AHI/RDI, sleepiness, snoring, BP, and ODI, and increase in LSAT in adults with OSA and major anatomical obstruction. Analysis of bariatric surgery data showed a clinically significant reduction in BP, AHI/RDI, sleepiness, snoring, optimal PAP level, BMI, ODI, and an increase in LSAT in adults with OSA and obesity. Analyses of very limited evidence suggest that upper airway surgery does not result in a clinically significant increase in risk of serious persistent adverse events and suggested that bariatric surgery may result in a clinically significant risk of iron malabsorption that may be managed with iron supplements. The task force provided a detailed summary of the evidence along with the quality of evidence, the balance of benefits and harms, patient values and preferences, and resource use considerations.
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Affiliation(s)
- David Kent
- Vanderbilt University Medical Center, Nashville, TN
| | | | - R Nisha Aurora
- Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ
| | | | - Daniel J Gottlieb
- VA Boston Healthcare System, Brigham and Women's Hospital, Boston, MA
| | | | - Carlos A Torre
- University of Miami, Miller School of Medicine, Miami FL
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Pang KP, Pang EB, Rotenberg B. Holistic Treatment Outcomes in OSA: Clinical Evidence for the SLEEP GOAL. CURRENT OTORHINOLARYNGOLOGY REPORTS 2021. [DOI: 10.1007/s40136-021-00365-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Wigston CA, Stradling JR, Turnbull CD. Period-to-Period Variability of Moderate/Severe Obstructive Sleep Apnoea. Pulm Ther 2021; 7:445-453. [PMID: 33991325 PMCID: PMC8589892 DOI: 10.1007/s41030-021-00159-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Accepted: 05/01/2021] [Indexed: 10/31/2022] Open
Abstract
INTRODUCTION The severity of obstructive sleep apnoea (OSA) is highly variable on a night-to-night basis. Patients are commonly categorised based on the severity of their OSA, and this is then used to influence management and reimbursement, including continuous positive airway pressure (CPAP). We aimed to establish to what extent the OSA severity category changes during two periods of OSA, based on mean and maximum oxygen desaturation index (ODI). METHODS Patients with a diagnosis of moderate to severe OSA who had been on CPAP for greater than 1 year were included in this study. Subjects underwent two periods of CPAP withdrawal for four nights each. RESULTS Twenty-five patients completed the study. Based on the mean ODI of the four nights, 14 (56%) patients changed OSA severity categorisation, with three (12%) changing category to mild. Based on the maximum ODI of the four nights, nine (36%) patients changed OSA severity categorisation, with one (4%) changing category to mild. One third to a half of patients' OSA severity category changed between the two periods of four night's CPAP withdrawal. CONCLUSIONS OSA is highly variable on a period-to-period basis as well as on a night-to-night basis. We believe the concept of patients having a definable and 'real' level of OSA severity is therefore flawed. OSA severity should be based mainly on symptoms, as these are the dominant reasons for treatment, and the sleep study should be used qualitatively to ascertain whether respiratory events are the likely cause of the symptoms. TRIAL REGISTRATION ISRCTN17987510.
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Affiliation(s)
- Charlotte A Wigston
- Department of General Medicine, Fiona Stanley Hospital, Murdoch, Perth, WA, Australia.,Department of Respiratory Medicine, Oxford Centre for Respiratory Medicine, Churchill Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, OX3 7LE, UK
| | - John R Stradling
- Department of Respiratory Medicine, Oxford Centre for Respiratory Medicine, Churchill Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, OX3 7LE, UK.,NIHR Oxford Biomedical Research Centre, University of Oxford, Oxford, UK
| | - Chris D Turnbull
- Department of Respiratory Medicine, Oxford Centre for Respiratory Medicine, Churchill Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, OX3 7LE, UK. .,NIHR Oxford Biomedical Research Centre, University of Oxford, Oxford, UK.
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Pack AI, Magalang UJ, Singh B, Kuna ST, Keenan BT, Maislin G. Randomized clinical trials of cardiovascular disease in obstructive sleep apnea: understanding and overcoming bias. Sleep 2021; 44:5963957. [PMID: 33165616 DOI: 10.1093/sleep/zsaa229] [Citation(s) in RCA: 65] [Impact Index Per Article: 21.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2020] [Revised: 10/28/2020] [Indexed: 12/11/2022] Open
Abstract
Three recent randomized control trials (RCTs) found that treatment of obstructive sleep apnea (OSA) with continuous positive airway pressure (CPAP) did not reduce rates of future cardiovascular events. This article discusses the biases in these RCTs that may explain their negative results, and how to overcome these biases in future studies. First, sample selection bias affected each RCT. The subjects recruited were not patients typically presenting for treatment of OSA. In particular, subjects with excessive sleepiness were excluded due to ethical concerns. As recent data indicate that the excessively sleepy OSA subtype has increased cardiovascular risk, subjects most likely to benefit from treatment were excluded. Second, RCTs had low adherence to therapy. Reported adherence is lower than found clinically, suggesting it is in part related to selection bias. Each RCT showed a CPAP benefit consistent with epidemiological studies when restricting to adherent patients, but was underpowered. Future studies need to include sleepy individuals and maximize adherence. Since it is unethical and impractical to randomize very sleepy subjects to no therapy, alternative designs are required. Observational designs using propensity scores, which are accepted by FDA for studies of medical devices, provide an opportunity. The design needs to ensure covariate balance, including measures assessing healthy user and healthy adherer biases, between regular users of CPAP and non-users. Sensitivity analyses can evaluate the robustness of results to unmeasured confounding, thereby improving confidence in conclusions. Thus, these designs can robustly assess the cardiovascular benefit of CPAP in real-world patients, overcoming biases in RCTs.
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Affiliation(s)
- Allan I Pack
- Division of Sleep Medicine/Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Ulysses J Magalang
- Division of Pulmonary, Critical Care and Sleep Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Bhajan Singh
- West Australian Sleep Disorders Research Institute, Department of Pulmonary Physiology & Sleep Medicine, Sir Charles Gairdner Hospital, Nedlands, WA, Australia
| | - Samuel T Kuna
- Sleep Medicine Section, Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, Pennsylvania
| | - Brendan T Keenan
- Division of Sleep Medicine/Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania.,Biostatistics Core, Division of Sleep Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Greg Maislin
- Division of Sleep Medicine/Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania.,Biostatistics Core, Division of Sleep Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
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The impact of sleep disorders on microvascular complications in patients with type 2 diabetes (SLEEP T2D): the protocol of a cohort study and feasibility randomised control trial. Pilot Feasibility Stud 2021; 7:80. [PMID: 33752759 PMCID: PMC7982768 DOI: 10.1186/s40814-021-00817-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Accepted: 03/09/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Obstructive sleep apnoea (OSA) is very common in patients with type 2 diabetes (T2D). We and others have shown that OSA was associated with diabetes-related microvascular complications in patients with T2D in cross-sectional and longitudinal studies and that compliance with continuous positive airway pressure (CPAP) reduced the progression of microvascular complications. Hence, we hypothesised that adequate CPAP reduces the development of microvascular complication in patients with T2D. METHODS SLEEP T2D is a cohort study with embedded feasibility, open-label, parallel-arm, randomised control trial (RCT) over 2 years. The primary aim is the feasibility of conducting a definitive RCT assessing the impact of CPAP on chronic kidney disease and other microvascular complications in patients with T2D. The main parameters are to assess willingness of participants to be randomised, follow-up rates, CPAP adherence/compliance, to optimise the choice of outcome measures for a substantive trial, and to identify the parameters for sample size calculations. The secondary aims of the study are related to the impact of CPAP, sleep-related disorders, and sleep chronotype on a variety of diabetes-related end points. The study participants were recruited from the T2D services in multiple NHS trusts across England. The main exclusion criteria for the cohort study are as follows: T1D, eGFR < 15 mL/min/1.73 m2, known OSA, active malignancy or chronic kidney disease from reasons other than diabetes, pregnancy, professional drivers, and a history of falling asleep whilst driving within last 2 years. The main exclusion criteria from the RCT were as follows: Apnoea-Hypopnoea Index < 10 and Epworth Sleepiness Score ≥ 11. Study participants were extensively phenotyped clinically and biochemically. The OSA diagnosis was based on multichannel portable device (ApneaLink AirTM, Resmed). DISCUSSION The feasibility RCT will help us design the future RCT to assess the impact of CPAP on diabetes-related microvascular complications. The cohort study will generate preliminary data regarding the impact of sleep quality, duration, and chronotype on diabetes-related outcomes which could lead to further mechanistic and interventional studies. TRIAL REGISTRATION ISRCTN, ISRCTN12361838 . Registered 04 April 2018, Protocol version: v5.0 02.12.19.
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Kermelly SB, Lajoie AC, Boucher ME, Sériès F. Impact of continuous positive airway pressure mode on adherence to treatment in obstructive sleep apnea patients awaiting bariatric surgery. J Sleep Res 2021; 30:e13288. [PMID: 33547713 DOI: 10.1111/jsr.13288] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2020] [Revised: 12/22/2020] [Accepted: 12/24/2020] [Indexed: 11/27/2022]
Abstract
Obstructive sleep apnea is prevalent in the bariatric population, and is associated with various complications. Despite increasing popularity, automatic positive airway pressure has not yet been studied in this population. The objective was to compare treatment adherence between automatic positive airway pressure and fixed positive airway pressure (continuous positive airway pressure) in obstructive sleep apnea patients awaiting bariatric surgery. This randomized controlled trial involved obese patients newly diagnosed with severe obstructive sleep apnea and awaiting bariatric surgery. The primary outcome was the difference in adherence between automatic positive airway pressure and continuous positive airway pressure pre-operatively. Secondary outcomes included positive airway pressure efficacy, adherence at 1 month, adverse effects, quality of life and peri-operative complications. Analyses were conducted using a modified intention-to-treat methodology. Fifty patients were randomized. Baseline characteristics and duration of positive airway pressure therapy were comparable between groups. At the time of surgery, the percentage of overall nights positive airway pressure used was 96.9% [95% confidence interval: 93.5-100] and 86.0% [95% confidence interval: 66.9-100] in the automatic positive airway pressure and continuous positive airway pressure groups, respectively (p = .047). Average use was 6.3 hr per night [95% confidence interval: 5.1-7.2] and 5.9 hr per night [95% confidence interval: 3.0-8.8], with a difference of 0.4 hr favouring automatic positive airway pressure (p = .75). Nightly use ≥ 4 hr per night was 86.4% and 74.0% in the automatic positive airway pressure and fixed continuous positive airway pressure groups, respectively (p = .22). There were no statistically significant differences regarding adherence at 1 month, efficacy parameters, adverse effects, quality of life and peri-operative complications. With no difference on the safety profile and efficiency parameters, treatment adherence is not improved with automatic positive airway pressure compared with fixed continuous positive airway pressure in obstructive sleep apnea patients awaiting bariatric surgery.
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Affiliation(s)
- Sophie B Kermelly
- Centre de Pneumologie, Institut Universitaire de Cardiologie et de Pneumologie de Québec, Université Laval, Québec, QC, Canada
| | - Annie C Lajoie
- Centre de Pneumologie, Institut Universitaire de Cardiologie et de Pneumologie de Québec, Université Laval, Québec, QC, Canada
| | | | - Frédéric Sériès
- Centre de Pneumologie, Institut Universitaire de Cardiologie et de Pneumologie de Québec, Université Laval, Québec, QC, Canada
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Where to Next for Optimizing Adherence in Large-Scale Trials of Continuous Positive Airway Pressure? Sleep Med Clin 2020; 16:125-144. [PMID: 33485525 DOI: 10.1016/j.jsmc.2020.10.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Large-scale randomized trials of positive airway pressure (PAP) efficacy have been largely negative but PAP adherence was notably suboptimal across the trials. To address this limitation, evidence-based PAP adherence protocols embedded within the larger trial protocol are recommended. The complexity of such protocols depends on adequacy of resources, including funding and inclusion of behavioral scientist experts on the scientific team, and trial-specific considerations (eg, target population) and methods. Recommendations for optimizing PAP adherence in large-scale trials are set forth that address rigor and reproducibility.
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Lin HJ, Yeh JH, Hsieh MT, Hsu CY. Continuous positive airway pressure with good adherence can reduce risk of stroke in patients with moderate to severe obstructive sleep apnea: An updated systematic review and meta-analysis. Sleep Med Rev 2020; 54:101354. [DOI: 10.1016/j.smrv.2020.101354] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2019] [Revised: 04/23/2020] [Accepted: 04/24/2020] [Indexed: 01/23/2023]
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Tang I, Turnbull CD, Sen D, Craig S, Kohler M, Stradling JR. Effect of CPAP on cardiovascular events in minimally symptomatic OSA: long-term follow-up of the MOSAIC randomised controlled trial. BMJ Open Respir Res 2020; 7:7/1/e000742. [PMID: 32928788 PMCID: PMC7490925 DOI: 10.1136/bmjresp-2020-000742] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2020] [Accepted: 08/16/2020] [Indexed: 01/01/2023] Open
Abstract
The effect of continuous positive airway pressure (CPAP) on cardiovascular events is uncertain in minimally symptomatic obstructive sleep apnoea. Previous 2-year follow-up data from the Multicentre Obstructive Sleep Apnoea Intervention Cardiovascular (MOSAIC) trial showed a marginal reduction in cardiovascular events with CPAP therapy. We now present long-term MOSAIC study follow-up data. Median (first quartile, third quartile) follow-up was 5.0 (2.2, 5.0) and 3.7 (1.5, 5.0) years for CPAP and standard care, respectively. Compared to standard care, CPAP had no statistically significant effect on the risk of cardiovascular events (HR=0.83, p=0.54, 95% CI 0.46–1.51).
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Affiliation(s)
- Ivan Tang
- Department of Anaesthesia and Intensive Care, Milton Keynes University Hospital, Milton Keynes, UK
| | - Chris D Turnbull
- Oxford Centre for Respiratory Medicine, Oxford University Hospitals NHS Foundation Trust, Oxford, Oxfordshire, UK .,NIHR Biomedical Research Centre Oxford, University of Oxford, Oxford, Oxfordshire, UK
| | - Dushendree Sen
- Oxford Centre for Respiratory Medicine, Oxford University Hospitals NHS Foundation Trust, Oxford, Oxfordshire, UK
| | - Sonya Craig
- Liverpool Sleep and Ventilation Centre, University Hospital Aintree, Liverpool, UK
| | - Malcolm Kohler
- Centre for Interdisciplinary Sleep Research, University of Zurich, Zurich, Switzerland
| | - John R Stradling
- NIHR Biomedical Research Centre Oxford, University of Oxford, Oxford, Oxfordshire, UK
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Labarca G, Dreyse J, Drake L, Jorquera J, Barbe F. Efficacy of continuous positive airway pressure (CPAP) in the prevention of cardiovascular events in patients with obstructive sleep apnea: Systematic review and meta-analysis. Sleep Med Rev 2020; 52:101312. [DOI: 10.1016/j.smrv.2020.101312] [Citation(s) in RCA: 37] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2019] [Revised: 02/17/2020] [Accepted: 03/08/2020] [Indexed: 10/24/2022]
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Sprung VS, Kemp GJ, Wilding JP, Adams V, Murphy K, Burgess M, Emegbo S, Thomas M, Needham AJ, Weimken A, Schwab RJ, Manuel A, Craig SE, Cuthbertson DJ. Randomised, cOntrolled Multicentre trial of 26 weeks subcutaneous liraglutide (a glucagon-like peptide-1 receptor Agonist), with or without contiNuous positive airway pressure (CPAP), in patients with type 2 diabetes mellitus (T2DM) and obstructive sleep apnoEa (OSA) (ROMANCE): study protocol assessing the effects of weight loss on the apnea-hypnoea index (AHI). BMJ Open 2020; 10:e038856. [PMID: 32699168 PMCID: PMC7380950 DOI: 10.1136/bmjopen-2020-038856] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
INTRODUCTION Obstructive sleep apnoea (OSA) and type 2 diabetes mellitus (T2DM) often occur concurrently, and untreated OSA may potentially amplify the high risk of cardiovascular disease in T2DM. Compliance with continuous positive airway pressure (CPAP), the conventional treatment for OSA, can be poor and considering weight loss is the most effective treatment for OSA. This trial examines whether the glucagon-like peptide-1 receptor agonist liraglutide, a glucose-lowering therapy associated with significant weight loss used in T2DM, can improve the severity and symptoms of OSA. METHODS AND ANALYSIS This is an outpatient, single-centred, open-labelled, prospective, phase IV randomised controlled trial in a two-by-two factorial design. One hundred and thirty-two patients with newly diagnosed OSA (apnoea-hypopnoea index (AHI) ≥15 events/hour), and existing obesity and T2DM (glycated haemoglobin (HbA1c) ≥47 mmol/mol), will be recruited from diabetes and sleep medicine outpatient clinics in primary and secondary care settings across Liverpool. Patients will be allocated equally, using computer-generated random, permuted blocks of unequal sizes, to each of the four treatment arms for 26 weeks: (i) liraglutide (1.8 mg once per day) alone, (ii) liraglutide 1.8 mg once per day with CPAP, (iii) CPAP alone (conventional care) or (iv) no treatment (control). The primary outcome measure is change in OSA severity, determined by AHI. Secondary outcome measures include effects on glycaemic control (glycated haemoglobin (HbA1c)), body weight and quality of life measures. Exploratory measures include measures of physical activity, MRI-derived measures of regional body composition including fat mass (abdominal subcutaneous, visceral, neck and liver fat) and skeletal muscle mass (cross-sectional analysis of thigh), indices of cardiac function (using transthoracic echocardiography) and endothelial function. ETHICAL APPROVAL The study has been approved by the North West Liverpool Central Research Ethics Committee (14/NW/1019) and it is being conducted in accordance with the Declaration of Helsinki and Good Clinical Practice. TRIAL REGISTRATION NUMBERS ISRCTN16250774. EUDRACT No. 2014-000988-41. UTN U1111-1139-0677.
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Affiliation(s)
- Victoria S Sprung
- Research Institute for Sport & Exercise Sciences, Liverpool John Moores University, Liverpool, UK
- Department of Cardiovascular & Metabolic Medicine, University of Liverpool, Liverpool, UK
- Metabolism & Nutrition Research Group, Liverpool University Hospitals NHS Foundation Trust, Liverpool, Merseyside, UK
| | - Graham J Kemp
- Department of Musculoskeletal & Ageing Science, University of Liverpool, Liverpool, Merseyside, UK
- Liverpool Magnetic Resonance Imaging Centre (LiMRIC), University of Liverpool, Liverpool, UK
| | - John Ph Wilding
- Department of Cardiovascular & Metabolic Medicine, University of Liverpool, Liverpool, UK
- Metabolism & Nutrition Research Group, Liverpool University Hospitals NHS Foundation Trust, Liverpool, Merseyside, UK
| | - Valerie Adams
- Liverpool Magnetic Resonance Imaging Centre (LiMRIC), University of Liverpool, Liverpool, UK
| | - Kieran Murphy
- Liverpool Magnetic Resonance Imaging Centre (LiMRIC), University of Liverpool, Liverpool, UK
| | - Malcolm Burgess
- Department of Cardiology, Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK
| | - Stephen Emegbo
- Liverpool Sleep & Ventilation Unit, Aintree University Hospitals NHS Foundation Trust, Liverpool, UK
| | - Matthew Thomas
- Liverpool Sleep & Ventilation Unit, Aintree University Hospitals NHS Foundation Trust, Liverpool, UK
| | | | - Andrew Weimken
- Center for Sleep & Circadian Neurobiology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Richard J Schwab
- Center for Sleep & Circadian Neurobiology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Ari Manuel
- Liverpool Sleep & Ventilation Unit, Aintree University Hospitals NHS Foundation Trust, Liverpool, UK
| | - Sonya E Craig
- Liverpool Sleep & Ventilation Unit, Aintree University Hospitals NHS Foundation Trust, Liverpool, UK
| | - Daniel J Cuthbertson
- Department of Cardiovascular & Metabolic Medicine, University of Liverpool, Liverpool, UK
- Metabolism & Nutrition Research Group, Liverpool University Hospitals NHS Foundation Trust, Liverpool, Merseyside, UK
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Lebkuchen A, Freitas LS, Cardozo KHM, Drager LF. Advances and challenges in pursuing biomarkers for obstructive sleep apnea: Implications for the cardiovascular risk. Trends Cardiovasc Med 2020; 31:242-249. [PMID: 32413393 DOI: 10.1016/j.tcm.2020.04.003] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2020] [Revised: 03/31/2020] [Accepted: 04/06/2020] [Indexed: 12/14/2022]
Abstract
Obstructive sleep apnea (OSA) is a common clinical condition associated with increased cardiovascular morbidity and mortality. Recent evidence from clinical studies and animal models suggest that OSA can promote cardiovascular disease by inducing autonomic, hemodynamic, inflammatory and metabolic dysregulation. However, most of the evidence addressing hard endpoints in humans is derived from observational studies. Several challenges have been noted in the pursuit of a comprehensive knowledge base about the impact of OSA including: 1) the precise mechanisms by which OSA causes metabolic and cardiovascular consequences are not clear, which limits our current ability to address potential targets in OSA; 2) several patients with OSA, even with severe forms, present with no or mild daytime symptoms. Beyond the obvious challenges for obtaining good adherence for conventional OSA treatments, there is evidence that symptomatic vs. asymptomatic patients with OSA do not necessarily have the same metabolic and cardiovascular outcomes; and 3) the cardiovascular response to OSA treatment may vary even in those patients with good adherence. In this scenario, there is an obvious need to develop biomarkers in the OSA research area. This review focuses on describing the advances that have occurred so far in exploring potential OSA biomarkers with clear emphasis for the cardiovascular risk. Particular attention will be devoted to discuss molecular biomarkers including the potential role of microRNAs, proteomics and metabolomics. We also discuss the major challenges and perspectives in this growing research field.
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Affiliation(s)
| | - Lunara S Freitas
- Hypertension Unit, Heart Institute (InCor), University of Sao Paulo Medical School
| | | | - Luciano F Drager
- Hypertension Unit, Heart Institute (InCor), University of Sao Paulo Medical School; Hypertension Unit, Renal Division, University of Sao Paulo Medical School.
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Pengo MF, Soranna D, Giontella A, Perger E, Mattaliano P, Schwarz EI, Lombardi C, Bilo G, Zambon A, Steier J, Parati G, Minuz P, Fava C. Obstructive sleep apnoea treatment and blood pressure: which phenotypes predict a response? A systematic review and meta-analysis. Eur Respir J 2020; 55:13993003.01945-2019. [PMID: 32079643 DOI: 10.1183/13993003.01945-2019] [Citation(s) in RCA: 90] [Impact Index Per Article: 22.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2019] [Accepted: 02/06/2020] [Indexed: 11/05/2022]
Abstract
The treatment for obstructive sleep apnoea (OSA) with continuous positive airway pressure (CPAP) or mandibular advancement devices (MADs) is associated with blood pressure (BP) reduction; however, the overall effect is modest. The aim of this systematic review and meta-analysis of randomised controlled trials (RCTs) comparing the effect of such treatments on BP was to identify subgroups of patients who respond best to treatment.The article search was performed in three different databases with specific search terms and selection criteria. From 2289 articles, we included 68 RCTs that compared CPAP or MADs with either passive or active treatment. When all the studies were pooled together, CPAP and MADs were associated with a mean BP reduction of -2.09 (95% CI -2.78- -1.40) mmHg for systolic BP and -1.92 (95% CI -2.40- -1.43) mmHg for diastolic BP and -1.27 (95% CI -2.34- -0.20) mmHg for systolic BP and -1.11 (95% CI -1.82- -0.41) mmHg for diastolic BP, respectively. The subgroups of patients who showed a greater response were those aged <60 years (systolic BP -2.93 mmHg), with uncontrolled BP at baseline (systolic BP -4.14 mmHg) and with severe oxygen desaturations (minimum arterial oxygen saturation measured by pulse oximetry <77%) at baseline (24-h systolic BP -7.57 mmHg).Although this meta-analysis shows that the expected reduction of BP by CPAP/MADs is modest, it identifies specific characteristics that may predict a pronounced benefit from CPAP in terms of BP control. These findings should be interpreted with caution; however, they are particularly important in identifying potential phenotypes associated with BP reduction in patients treated for OSA.
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Affiliation(s)
- Martino F Pengo
- Dept of Cardiovascular, Neural and Metabolic Sciences, IRCCS Istituto Auxologico Italiano, Milan, Italy
| | - Davide Soranna
- Dept of Cardiovascular, Neural and Metabolic Sciences, IRCCS Istituto Auxologico Italiano, Milan, Italy.,These authors are joint co-authors
| | - Alice Giontella
- Section of General Medicine and Hypertension, Dept of Medicine, University of Verona, Verona, Italy.,These authors are joint co-authors
| | - Elisa Perger
- Dept of Cardiovascular, Neural and Metabolic Sciences, IRCCS Istituto Auxologico Italiano, Milan, Italy
| | - Paola Mattaliano
- Dept of Cardiovascular, Neural and Metabolic Sciences, IRCCS Istituto Auxologico Italiano, Milan, Italy
| | - Esther Irene Schwarz
- Dept of Pulmonology and Sleep Disorders Centre, University Hospital of Zurich, Zurich, Switzerland
| | - Carolina Lombardi
- Dept of Cardiovascular, Neural and Metabolic Sciences, IRCCS Istituto Auxologico Italiano, Milan, Italy
| | - Grzegorz Bilo
- Dept of Cardiovascular, Neural and Metabolic Sciences, IRCCS Istituto Auxologico Italiano, Milan, Italy
| | - Antonella Zambon
- Dept of Statistics and Quantitative Methods, Università di Milano-Bicocca, Milan, Italy
| | - Joerg Steier
- CHAPS, Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Gianfranco Parati
- Dept of Cardiovascular, Neural and Metabolic Sciences, IRCCS Istituto Auxologico Italiano, Milan, Italy.,Dept of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
| | - Pietro Minuz
- Section of General Medicine and Hypertension, Dept of Medicine, University of Verona, Verona, Italy
| | - Cristiano Fava
- Section of General Medicine and Hypertension, Dept of Medicine, University of Verona, Verona, Italy
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Yang X, Yang J, Yang C, Niu L, Song F, Wang L. Continuous positive airway pressure can improve depression in patients with obstructive sleep apnoea syndrome: a meta-analysis based on randomized controlled trials. J Int Med Res 2020; 48:300060519895096. [PMID: 32208858 PMCID: PMC7370809 DOI: 10.1177/0300060519895096] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2019] [Accepted: 11/25/2019] [Indexed: 11/28/2022] Open
Abstract
Objective Substantial research indicates a clear relationship between obstructive sleep apnoea syndrome (OSAS) and depression. The study aim was to quantitatively evaluate whether continuous positive airway pressure (CPAP) therapy improves mood symptoms in OSAS patients. Methods PubMed and Embase databases were systematically searched up to 2017 for publications on the impact of CPAP on mood symptoms in OSAS patients. Results For the final analysis, nine randomized controlled trials comprising 1,052 patients were selected. The pooled standard mean difference (SMD) of the effect of CPAP on depression was 0.31 (95% confidence interval 0.18, 0.43). A subgroup analysis showed that when CPAP use was greater than 4 hours per night, it tended to be effective in improving patients’ mood symptoms (SMD = 0.38; confidence interval 0.23, 0.54). Analysis of publication bias using Egger’s test found no evidence of publication bias. Conclusion CPAP treatment can improve depression in OSAS patients.
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Affiliation(s)
- Xiangli Yang
- Department of Otolaryngology Head and Neck Surgery, Tianjin Union Medical Center, Tianjin, China
| | - Jun Yang
- Department of Otolaryngology Head and Neck Surgery, Tianjin HaiBin People’s Hospital, Tianjin, China
| | - Chunwei Yang
- Department of Otolaryngology Head and Neck Surgery, Tianjin Union Medical Center, Tianjin, China
| | - Lin Niu
- Department of Otolaryngology Head and Neck Surgery, Tianjin Union Medical Center, Tianjin, China
| | - Fucun Song
- Department of Otolaryngology Head and Neck Surgery, Tianjin Union Medical Center, Tianjin, China
| | - Lin Wang
- Department of Otolaryngology Head and Neck Surgery, Tianjin Union Medical Center, Tianjin, China
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Owens RL, Campana LM, Foster AM, Schomer AM, Israel E, Malhotra A. Nocturnal bilevel positive airway pressure for the treatment of asthma. Respir Physiol Neurobiol 2020; 274:103355. [PMID: 31805396 PMCID: PMC8884694 DOI: 10.1016/j.resp.2019.103355] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2019] [Revised: 11/08/2019] [Accepted: 12/02/2019] [Indexed: 11/29/2022]
Abstract
Nocturnal worsening of asthma may be due to reduced lung volumes and fewer sigh breaths, which have been shown to increase airway resistance and bronchoreactivity. We hypothesized that mimicking deep inspiration using nocturnal mechanical support would improve symptoms in patients with asthma. Subjects with asthma underwent usual care and bilevel positive airway pressure (PAP) therapy for 4 weeks, separated by 4 weeks, and methacholine challenge (PC20) and subjective assessments. 13 patients with asthma alone and 8 with asthma + OSA completed the protocol. Change in bronchoreactivity (ratio of Post/Pre PC20) was not significantly different during usual care and bilevel PAP [0.86 (IQR 0.19, 1.82) vs 0.94 (IQR 0.56, 2.5), p = 0.88], nor was the change in Asthma Control Test different: 0.1 ± 2.2 vs. -0.2 ± 2.9, p = 0.79, respectively. Bilevel PAP therapy for four weeks did not improve subjective or objective measures of asthma severity in patients with asthma or those with asthma and OSA, although there was heterogeneity in response.
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Affiliation(s)
- Robert L Owens
- Division of Pulmonary, Critical Care and Sleep Medicine, University of California San Diego, San Diego, CA, United States.
| | | | | | | | - Elliot Israel
- Brigham and Women's Hospital, Boston, MA, United States
| | - Atul Malhotra
- Division of Pulmonary, Critical Care and Sleep Medicine, University of California San Diego, San Diego, CA, United States
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45
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Barros D, García-Río F. Obstructive sleep apnea and dyslipidemia: from animal models to clinical evidence. Sleep 2020; 42:5204276. [PMID: 30476296 DOI: 10.1093/sleep/zsy236] [Citation(s) in RCA: 60] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2018] [Revised: 10/02/2018] [Accepted: 11/22/2018] [Indexed: 01/11/2023] Open
Abstract
Lipid metabolism deregulation constitutes the pathogenic basis for the development of atherosclerosis and justifies a high incidence of cardiovascular-related morbidity and mortality. Some data suggest that dyslipidemia may be associated with sleep-disordered breathing, mainly obstructive sleep apnea (OSA), due to alterations in fundamental biochemical processes, such as intermittent hypoxia (IH). The aim of this systematic review was to identify and critically evaluate the current evidence supporting the existence of a possible relationship between OSA and alterations in lipid metabolism. Much evidence shows that, during the fasting state, OSA and IH increase lipid delivery from the adipose tissue to the liver through an up-regulation of the sterol regulatory element-binding protein-1 and stearoyl-CoA desaturase-1, increasing the synthesis of cholesterol esters and triglycerides. In the postprandial state, lipoprotein clearance is delayed due to lower lipoprotein lipase activity, probably secondary to IH-up-regulation of angiopoietin-like protein 4 and decreased activity of the peroxisome proliferator-activated receptor alpha. Moreover, oxidative stress can generate dysfunctional oxidized lipids and reduce the capacity of high-density lipoproteins (HDL) to prevent low-density lipoprotein (LDL) oxidation. In the clinical field, several observational studies and a meta-regression analysis support the existence of a link between OSA and dyslipidemia. Although there is evidence of improved lipid profile after apnea-hypopnea suppression with continuous positive airway pressure (CPAP), the majority of the data come from observational studies. In contrast, randomized controlled trials evaluating the effects of CPAP on lipid metabolism present inconclusive results and two meta-analyses provide contradictory evidence.
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Affiliation(s)
- David Barros
- Servicio de Neumología, Hospital Montecelo, Pontevedra, Spain
| | - Francisco García-Río
- Servicio de Neumología, Hospital Universitario La Paz-IdiPAZ, Madrid, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Madrid, Spain.,Facultad de Medicina, Universidad Autónoma de Madrid, Madrid, Spain
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46
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Tsuyumu M, Tsurumoto T, Iimura J, Nakajima T, Kojima H. Ten-year adherence to continuous positive airway pressure treatment in patients with moderate-to-severe obstructive sleep apnea. Sleep Breath 2020; 24:1565-1571. [PMID: 32076950 PMCID: PMC7679333 DOI: 10.1007/s11325-020-02033-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2019] [Revised: 01/28/2020] [Accepted: 02/05/2020] [Indexed: 12/03/2022]
Abstract
Purpose This study aimed to evaluate the 10-year adherence to and identify the predictors of dropout from continuous positive airway pressure (CPAP) treatment for patients with moderate-to-severe obstructive sleep apnea (OSA). Methods We retrospectively analyzed the continuity, dropout, or other behaviors of 181 patients who initiated CPAP treatment at the Tokyo Dental College Ichikawa General Hospital from January 2003 to June 2005. Results Among a total of 181 patients, 56 (30.9%) dropped out of the treatment. Among the 125 patients who did not dropout, 54 continued CPAP treatment for > 10 years, 16 completed the treatment with OSA improvement, and 7 could not complete the treatment owing to unavoidable reasons such as death, dementia, hospitalization for serious illness, or migration to other countries. Further, 47 patients moved to another facility, whereas 1 patient purchased a CPAP device and stopped visiting our facility. Among the 56 patients who dropped out, approximately 50% of the patients dropped out within a year, and all dropped out within 76 months. Comparing demographics, OSA parameters, and CPAP parameters between the patients who did and did not drop out of the treatment, Cox regression analysis indicated that body mass index (BMI) and the first-month utilization rate were clinical variables that were independently associated with discontinuation of CPAP treatment. Conclusion The results of this study show that BMI and the first-month utilization rate of CPAP treatment are the predictors of the long-term adherence to this treatment. Electronic supplementary material The online version of this article (10.1007/s11325-020-02033-0) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Matsusato Tsuyumu
- Department of Otorhinolaryngology, Tokyo Dental College Ichikawa General Hospital, Chiba, Japan. .,Department of Otorhinolaryngology, Jikei University School of Medicine, 3-25-8 Nishi-shimbashi, Minato-ku, Tokyo, 105-8461, Japan.
| | - Tadao Tsurumoto
- Department of Otorhinolaryngology, Tokyo Dental College Ichikawa General Hospital, Chiba, Japan
| | - Jiro Iimura
- Department of Otorhinolaryngology, Tokyo Dental College Ichikawa General Hospital, Chiba, Japan
| | - Tsuneya Nakajima
- Department of Otorhinolaryngology, Tokyo Dental College Ichikawa General Hospital, Chiba, Japan
| | - Hiromi Kojima
- Department of Otorhinolaryngology, Jikei University School of Medicine, 3-25-8 Nishi-shimbashi, Minato-ku, Tokyo, 105-8461, Japan
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Hu ST, Tsao LI, Yu CC, Liu CY. Development and validation of a Chinese version of the Sleep Apnea Quality of Life Index. Sleep Breath 2020; 24:591-597. [PMID: 31938992 DOI: 10.1007/s11325-020-02012-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2019] [Revised: 12/25/2019] [Accepted: 01/07/2020] [Indexed: 11/26/2022]
Abstract
OBJECTIVE A Chinese version of the Sleep Apnea Quality of Life Index (SAQLI) for patients with obstructive sleep apnea (OSA) undergoing treatment with continuous positive airway pressure (CPAP) was developed and validated. No Chinese versions of the SAQLI have been previously validated. METHODS A convenience sample of 78 patients with OSA who received CPAP therapy at a Taiwanese teaching hospital was enrolled. The SAQLI is organized into four domains: daily functioning, social interactions, emotional functioning, and symptoms. This study evaluated the equivalence (forward translation and back translation), validity, and reliability of a Chinese version of the SAQLI. RESULTS The content validity index (CVI) values of the daily functioning, social interactions, emotional functioning, and symptom domains were .93, .93, .96, and 1.00, respectively. Construct validity of one factor was generated by exploratory factor analysis, and the factor explained the following: (A) daily functioning 54%, (B) social interactions 59%, (C) emotional functioning 64%, and (D) symptoms 75% of total explained variance. The Cronbach's α internal consistency values for the daily functioning, social interactions, emotional functioning, and symptom domains were 0.68, 0.94, 0.93, and 0.92, respectively. The repeatability of the SAQLI at 7 days and 30 days after the first administration showed reliability coefficients of .94 and .93 (p = 0.001), respectively. CONCLUSIONS The results indicate that the Chinese version of the SAQLI has good reliability and validity, as well as refined indicators for assessing the tool's accuracy. Clinicians may thus use the scale to examine the quality of life in Chinese-speaking patients with OSA undergoing CPAP therapy.
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Affiliation(s)
- Shui-Tao Hu
- Department of Nursing, Chang Gung Memorial Hospital, Keelung, Taiwan.
- College of Nursing, Chang Gung University of Science and Technology, Taoyuan, Taiwan.
| | - Lee-Ing Tsao
- College of Nursing, National Taipei University of Nursing and Health Sciences, Taipei, Taiwan
| | - Chung-Chieh Yu
- Division of Pulmonary, Critical Care, & Sleep Medicine, and College of Medicine, Chang Gung Memorial Hospital and Chang Gung University, Keelung/Taoyuan, Taiwan
| | - Chieh-Yu Liu
- Department of Speech Language Pathology and Audiology, National Taipei University of Nursing and Health Sciences, Taipei, Taiwan
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48
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Pépin JL, Letesson C, Le-Dong NN, Dedave A, Denison S, Cuthbert V, Martinot JB, Gozal D. Assessment of Mandibular Movement Monitoring With Machine Learning Analysis for the Diagnosis of Obstructive Sleep Apnea. JAMA Netw Open 2020; 3:e1919657. [PMID: 31968116 PMCID: PMC6991283 DOI: 10.1001/jamanetworkopen.2019.19657] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
IMPORTANCE Given the high prevalence of obstructive sleep apnea (OSA), there is a need for simpler and automated diagnostic approaches. OBJECTIVE To evaluate whether mandibular movement (MM) monitoring during sleep coupled with an automated analysis by machine learning is appropriate for OSA diagnosis. DESIGN, SETTING, AND PARTICIPANTS Diagnostic study of adults undergoing overnight in-laboratory polysomnography (PSG) as the reference method compared with simultaneous MM monitoring at a sleep clinic in an academic institution (Sleep Laboratory, Centre Hospitalier Universitaire Université Catholique de Louvain Namur Site Sainte-Elisabeth, Namur, Belgium). Patients with suspected OSA were enrolled from July 5, 2017, to October 31, 2018. MAIN OUTCOMES AND MEASURES Obstructive sleep apnea diagnosis required either evoking signs or symptoms or related medical or psychiatric comorbidities coupled with a PSG-derived respiratory disturbance index (PSG-RDI) of at least 5 events/h. A PSG-RDI of at least 15 events/h satisfied the diagnosis criteria even in the absence of associated symptoms or comorbidities. Patients who did not meet these criteria were classified as not having OSA. Agreement analysis and diagnostic performance were assessed by Bland-Altman plot comparing PSG-RDI and the Sunrise system RDI (Sr-RDI) with diagnosis threshold optimization via receiver operating characteristic curves, allowing for evaluation of the device sensitivity and specificity in detecting OSA at 5 events/h and 15 events/h. RESULTS Among 376 consecutive adults with suspected OSA, the mean (SD) age was 49.7 (13.2) years, the mean (SD) body mass index was 31.0 (7.1), and 207 (55.1%) were men. Reliable agreement was found between PSG-RDI and Sr-RDI in patients without OSA (n = 46; mean difference, 1.31; 95% CI, -1.05 to 3.66 events/h) and in patients with OSA with a PSG-RDI of at least 5 events/h with symptoms (n = 107; mean difference, -0.69; 95% CI, -3.77 to 2.38 events/h). An Sr-RDI underestimation of -11.74 (95% CI, -20.83 to -2.67) events/h in patients with OSA with a PSG-RDI of at least 15 events/h was detected and corrected by optimization of the Sunrise system diagnostic threshold. The Sr-RDI showed diagnostic capability, with areas under the receiver operating characteristic curve of 0.95 (95% CI, 0.92-0.96) and 0.93 (95% CI, 0.90-0.93) for corresponding PSG-RDIs of 5 events/h and 15 events/h, respectively. At the 2 optimal cutoffs of 7.63 events/h and 12.65 events/h, Sr-RDI had accuracy of 0.92 (95% CI, 0.90-0.94) and 0.88 (95% CI, 0.86-0.90) as well as posttest probabilities of 0.99 (95% CI, 0.99-0.99) and 0.89 (95% CI, 0.88-0.91) at PSG-RDIs of at least 5 events/h and at least 15 events/h, respectively, corresponding to positive likelihood ratios of 14.86 (95% CI, 9.86-30.12) and 5.63 (95% CI, 4.92-7.27), respectively. CONCLUSIONS AND RELEVANCE Automatic analysis of MM patterns provided reliable performance in RDI calculation. The use of this index in OSA diagnosis appears to be promising.
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Affiliation(s)
- Jean-Louis Pépin
- Pôle Thorax et Vaisseaux, Centre Hospitalier Universitaire (CHU) de Grenoble-Alpes (CHUGA), Université Grenoble Alpes, Institut National de la Santé et de la Recherche Medicale, Grenoble, France
| | | | | | | | | | - Valérie Cuthbert
- Sleep Laboratory, CHU Université Catholique de Louvain (UCL) Namur Site Sainte-Elisabeth, Namur, Belgium
| | - Jean-Benoît Martinot
- Sleep Laboratory, CHU Université Catholique de Louvain (UCL) Namur Site Sainte-Elisabeth, Namur, Belgium
- Institute of Experimental and Clinical Research, UCL Bruxelles Woluwe, Brussels, Belgium
| | - David Gozal
- Department of Child Health, University of Missouri, Columbia
- Child Health Research Institute, University of Missouri, Columbia
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49
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Turnbull C. Editorial on paper: The prevalence of sleep-disordered breathing in Northwest Russia - A problem worth knowing about? Chron Respir Dis 2020; 17:1479973120931863. [PMID: 32515219 PMCID: PMC7285929 DOI: 10.1177/1479973120931863] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Affiliation(s)
- Chris Turnbull
- Oxford Centre for Respiratory Medicine, Oxford Universities Hospitals NHS Foundation Trust, Oxford, UK
- NIHR Biomedical Research Centre Oxford, University of Oxford, Oxford, UK
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50
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Wang F, Liu Y, Xu H, Qian Y, Zou J, Yi H, Guan J, Yin S. Association between Upper-airway Surgery and Ameliorative Risk Markers of Endothelial Function in Obstructive Sleep Apnea. Sci Rep 2019; 9:20157. [PMID: 31882827 PMCID: PMC6934655 DOI: 10.1038/s41598-019-56601-w] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2019] [Accepted: 12/13/2019] [Indexed: 12/01/2022] Open
Abstract
The objective of our study was to evaluate the effects of upper-airway surgery on improvement of endothelial function-related markers in patients with obstructive sleep apnea (OSA). Subjects with moderate to severe OSA who underwent upper-airway surgery, with a follow-up duration of at least 6 months, were included. Pre- and postoperative polysomnographic variables and endothelial function-related markers were compared. Subgroup and correlation analyses were conducted to find possible indicators for better endothelial function-related markers after upper-airway surgery. In total, 44 patients with OSA were included. The mean follow-up duration was 1.72 ± 0.92 years. Serum VEGFA [-20.29 (CI: -35.27, -5.31), p < 0.05], Ang2 [-0.06 (CI: -0.16, 0.03), p < 0.05], E-selectin [-7.21 (CI: -11.01, -3.41), p < 0.001], VWF [-58.83 (CI: -103.93, -13.73), p < 0.05], VWFCP [-33.52 (CI: -66.34, -0.70), p < 0.05], and TM [-0.06 (CI: -0.09, -0.03), p < 0.05] were significantly lower after upper-airway surgery. However, other risk markers of endothelial function, such as Ang1, ICAM1, VEGFR1, and VCAM, did not change significantly. Correlations between improved endothelial function-related markers and ameliorated oxyhemoglobin saturation and glucolipid metabolism were established. Upper-airway surgery might be associated with an improvement in endothelial function in patients with OSA. These changes may be associated with improved oxygen saturation after upper-airway surgery.
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Affiliation(s)
- Fan Wang
- Department of Otolaryngology Head and Neck Surgery & Center of Sleep Medicine, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Yishan Road 600, Shanghai, 200233, China
- Shanghai Key Laboratory of Sleep Disordered Breathing, Yishan Road 600, Shanghai, 200233, China
| | - Yuenan Liu
- Department of Otolaryngology Head and Neck Surgery & Center of Sleep Medicine, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Yishan Road 600, Shanghai, 200233, China
- Shanghai Key Laboratory of Sleep Disordered Breathing, Yishan Road 600, Shanghai, 200233, China
| | - Huajun Xu
- Department of Otolaryngology Head and Neck Surgery & Center of Sleep Medicine, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Yishan Road 600, Shanghai, 200233, China.
- Shanghai Key Laboratory of Sleep Disordered Breathing, Yishan Road 600, Shanghai, 200233, China.
- Clinical Research Center, Shanghai Jiao Tong University School of Medicine, South Chongqing Road 225, 200020, Shanghai, China.
| | - Yingjun Qian
- Department of Otolaryngology Head and Neck Surgery & Center of Sleep Medicine, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Yishan Road 600, Shanghai, 200233, China
- Shanghai Key Laboratory of Sleep Disordered Breathing, Yishan Road 600, Shanghai, 200233, China
- Clinical Research Center, Shanghai Jiao Tong University School of Medicine, South Chongqing Road 225, 200020, Shanghai, China
| | - Jianyin Zou
- Department of Otolaryngology Head and Neck Surgery & Center of Sleep Medicine, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Yishan Road 600, Shanghai, 200233, China.
- Shanghai Key Laboratory of Sleep Disordered Breathing, Yishan Road 600, Shanghai, 200233, China.
- Clinical Research Center, Shanghai Jiao Tong University School of Medicine, South Chongqing Road 225, 200020, Shanghai, China.
| | - Hongliang Yi
- Department of Otolaryngology Head and Neck Surgery & Center of Sleep Medicine, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Yishan Road 600, Shanghai, 200233, China
- Shanghai Key Laboratory of Sleep Disordered Breathing, Yishan Road 600, Shanghai, 200233, China
- Clinical Research Center, Shanghai Jiao Tong University School of Medicine, South Chongqing Road 225, 200020, Shanghai, China
| | - Jian Guan
- Department of Otolaryngology Head and Neck Surgery & Center of Sleep Medicine, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Yishan Road 600, Shanghai, 200233, China
- Shanghai Key Laboratory of Sleep Disordered Breathing, Yishan Road 600, Shanghai, 200233, China
- Clinical Research Center, Shanghai Jiao Tong University School of Medicine, South Chongqing Road 225, 200020, Shanghai, China
| | - Shankai Yin
- Department of Otolaryngology Head and Neck Surgery & Center of Sleep Medicine, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Yishan Road 600, Shanghai, 200233, China
- Shanghai Key Laboratory of Sleep Disordered Breathing, Yishan Road 600, Shanghai, 200233, China
- Clinical Research Center, Shanghai Jiao Tong University School of Medicine, South Chongqing Road 225, 200020, Shanghai, China
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