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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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2
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Xu L, Yi H, Pi M, Zhang C, Keenan BT, Glick HA, Dong X, Pack AI, Han F, Kuna ST. Telemedicine management of obstructive sleep apnea disorder in China: a randomized, controlled, non-inferiority trial. Sleep Breath 2024:10.1007/s11325-024-02994-6. [PMID: 38225441 DOI: 10.1007/s11325-024-02994-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2023] [Revised: 12/22/2023] [Accepted: 01/04/2024] [Indexed: 01/17/2024]
Abstract
PURPOSE Previous studies assessed different components of telemedicine management pathway for OSA instead of the whole pathway. This randomized, controlled, and non-inferiority trial aimed to assess whether telemedicine management is clinically inferior to in-person care in China. METHODS Adults suspected of OSA were randomized to telemedicine (web-based questionnaires, self-administered home sleep apnea test [HSAT], automatically adjusting positive airway pressure [APAP], and video-conference visits) or in-person management (paper questionnaires, in-person HSAT set-up, APAP, and face-to-face visits). Participants with an apnea-hypopnea index (AHI) ≥ 15 events/hour received APAP for 3 months. The non-inferiority analysis was based on the change in Functional Outcomes of Sleep Questionnaire (FOSQ) score and APAP adherence. Cost-effectiveness analysis was performed. RESULTS In the modified intent-to-treat analysis set (n = 111 telemedicine, 111 in-person), FOSQ scores improved 1.73 (95% confidence interval [CI], 1.31-2.14) points with telemedicine and 2.05 (1.64-2.46) points with in-person care. The lower bound of the one-sided 95% non-inferiority CI for the difference in change between groups of - 0.812 was larger than the non-inferiority threshold of - 1. APAP adherence at 3 months was 243.3 (223.1-263.5) minutes/night for telemedicine and 241.6 (221.3-261.8) minutes/night for in-person care. The lower bound of the one-sided 95% non-inferiority CI of - 22.2 min/night was higher than the non-inferiority delta of - 45 min/night. Telemedicine had lower total costs than in-person management (CNY 1482.7 ± 377.2 vs. 1912.6 ± 681.3; p < 0.0001), driven by patient costs, but no significant difference in QALYs. CONCLUSIONS Functional outcomes and adherence were not clinically inferior in patients managed by a comprehensive telemedicine approach compared to those receiving in-person care in China. CLINICAL TRIAL REGISTRATION https://www.chictr.org.cn , Registration number ChiCTR2000030546. Retrospectively registered on March 06, 2020.
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Affiliation(s)
- Liyue Xu
- Department of Sleep Medicine, Peking University People's Hospital, No. 11, South Avenue, Beijing, China
| | - Huijie Yi
- Department of Sleep Medicine, Peking University People's Hospital, No. 11, South Avenue, Beijing, China
- Nursing School, Peking University, Beijing, China
| | - Mengyuan Pi
- Department of Sleep Medicine, Peking University People's Hospital, No. 11, South Avenue, Beijing, China
| | - Chi Zhang
- Department of Sleep Medicine, Peking University People's Hospital, No. 11, South Avenue, Beijing, China
| | - Brendan T Keenan
- Division of Sleep Medicine, Department of Medicine, University of Pennsylvania School of Medicine, Philadelphia, PA, USA
| | - Henry A Glick
- Division of General Internal Medicine, Department of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Xiaosong Dong
- Department of Sleep Medicine, Peking University People's Hospital, No. 11, South Avenue, Beijing, China
| | - Allan I Pack
- Division of Sleep Medicine, Department of Medicine, University of Pennsylvania School of Medicine, Philadelphia, PA, USA
| | - Fang Han
- Department of Sleep Medicine, Peking University People's Hospital, No. 11, South Avenue, Beijing, China.
| | - Samuel T Kuna
- Department of Medicine, Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, PA, USA
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3
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Chang JL, Goldberg AN, Alt JA, Alzoubaidi M, Ashbrook L, Auckley D, Ayappa I, Bakhtiar H, Barrera JE, Bartley BL, Billings ME, Boon MS, Bosschieter P, Braverman I, Brodie K, Cabrera-Muffly C, Caesar R, Cahali MB, Cai Y, Cao M, Capasso R, Caples SM, Chahine LM, Chang CP, Chang KW, Chaudhary N, Cheong CSJ, Chowdhuri S, Cistulli PA, Claman D, Collen J, Coughlin KC, Creamer J, Davis EM, Dupuy-McCauley KL, Durr ML, Dutt M, Ali ME, Elkassabany NM, Epstein LJ, Fiala JA, Freedman N, Gill K, Boyd Gillespie M, Golisch L, Gooneratne N, Gottlieb DJ, Green KK, Gulati A, Gurubhagavatula I, Hayward N, Hoff PT, Hoffmann OM, Holfinger SJ, Hsia J, Huntley C, Huoh KC, Huyett P, Inala S, Ishman SL, Jella TK, Jobanputra AM, Johnson AP, Junna MR, Kado JT, Kaffenberger TM, Kapur VK, Kezirian EJ, Khan M, Kirsch DB, Kominsky A, Kryger M, Krystal AD, Kushida CA, Kuzniar TJ, Lam DJ, Lettieri CJ, Lim DC, Lin HC, Liu SY, MacKay SG, Magalang UJ, Malhotra A, Mansukhani MP, Maurer JT, May AM, Mitchell RB, Mokhlesi B, Mullins AE, Nada EM, Naik S, Nokes B, Olson MD, Pack AI, Pang EB, Pang KP, Patil SP, Van de Perck E, Piccirillo JF, Pien GW, Piper AJ, Plawecki A, Quigg M, Ravesloot MJ, Redline S, Rotenberg BW, Ryden A, Sarmiento KF, Sbeih F, Schell AE, Schmickl CN, Schotland HM, Schwab RJ, Seo J, Shah N, Shelgikar AV, Shochat I, Soose RJ, Steele TO, Stephens E, Stepnowsky C, Strohl KP, Sutherland K, Suurna MV, Thaler E, Thapa S, Vanderveken OM, de Vries N, Weaver EM, Weir ID, Wolfe LF, Tucker Woodson B, Won CH, Xu J, Yalamanchi P, Yaremchuk K, Yeghiazarians Y, Yu JL, Zeidler M, Rosen IM. International Consensus Statement on Obstructive Sleep Apnea. Int Forum Allergy Rhinol 2023; 13:1061-1482. [PMID: 36068685 PMCID: PMC10359192 DOI: 10.1002/alr.23079] [Citation(s) in RCA: 34] [Impact Index Per Article: 34.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2022] [Revised: 08/12/2022] [Accepted: 08/18/2022] [Indexed: 11/08/2022]
Abstract
BACKGROUND Evaluation and interpretation of the literature on obstructive sleep apnea (OSA) allows for consolidation and determination of the key factors important for clinical management of the adult OSA patient. Toward this goal, an international collaborative of multidisciplinary experts in sleep apnea evaluation and treatment have produced the International Consensus statement on Obstructive Sleep Apnea (ICS:OSA). METHODS Using previously defined methodology, focal topics in OSA were assigned as literature review (LR), evidence-based review (EBR), or evidence-based review with recommendations (EBR-R) formats. Each topic incorporated the available and relevant evidence which was summarized and graded on study quality. Each topic and section underwent iterative review and the ICS:OSA was created and reviewed by all authors for consensus. RESULTS The ICS:OSA addresses OSA syndrome definitions, pathophysiology, epidemiology, risk factors for disease, screening methods, diagnostic testing types, multiple treatment modalities, and effects of OSA treatment on multiple OSA-associated comorbidities. Specific focus on outcomes with positive airway pressure (PAP) and surgical treatments were evaluated. CONCLUSION This review of the literature consolidates the available knowledge and identifies the limitations of the current evidence on OSA. This effort aims to create a resource for OSA evidence-based practice and identify future research needs. Knowledge gaps and research opportunities include improving the metrics of OSA disease, determining the optimal OSA screening paradigms, developing strategies for PAP adherence and longitudinal care, enhancing selection of PAP alternatives and surgery, understanding health risk outcomes, and translating evidence into individualized approaches to therapy.
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Affiliation(s)
- Jolie L. Chang
- University of California, San Francisco, California, USA
| | | | | | | | - Liza Ashbrook
- University of California, San Francisco, California, USA
| | | | - Indu Ayappa
- Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | | | | | | | | | - Maurits S. Boon
- Sidney Kimmel Medical Center at Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Pien Bosschieter
- Academic Centre for Dentistry Amsterdam, Amsterdam, The Netherlands
| | - Itzhak Braverman
- Hillel Yaffe Medical Center, Hadera Technion, Faculty of Medicine, Hadera, Israel
| | - Kara Brodie
- University of California, San Francisco, California, USA
| | | | - Ray Caesar
- Stone Oak Orthodontics, San Antonio, Texas, USA
| | | | - Yi Cai
- University of California, San Francisco, California, USA
| | | | | | | | | | | | | | | | | | - Susmita Chowdhuri
- Wayne State University and John D. Dingell VA Medical Center, Detroit, Michigan, USA
| | - Peter A. Cistulli
- Faculty of Medicine and Health, University of Sydney, Sydney, Australia
| | - David Claman
- University of California, San Francisco, California, USA
| | - Jacob Collen
- Uniformed Services University, Bethesda, Maryland, USA
| | | | | | - Eric M. Davis
- University of Virginia, Charlottesville, Virginia, USA
| | | | | | - Mohan Dutt
- University of Michigan, Ann Arbor, Michigan, USA
| | - Mazen El Ali
- University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | | | | | | | | | - Kirat Gill
- Stanford University, Palo Alto, California, USA
| | | | - Lea Golisch
- University Hospital Mannheim, Ruprecht-Karls-University Heidelberg, Heidelberg, Germany
| | | | | | | | - Arushi Gulati
- University of California, San Francisco, California, USA
| | | | | | - Paul T. Hoff
- University of Michigan, Ann Arbor, Michigan, USA
| | - Oliver M.G. Hoffmann
- University Hospital Mannheim, Ruprecht-Karls-University Heidelberg, Heidelberg, Germany
| | | | - Jennifer Hsia
- University of Minnesota, Minneapolis, Minnesota, USA
| | - Colin Huntley
- Sidney Kimmel Medical Center at Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | | | | | - Sanjana Inala
- Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | | | | | | | | | | | | | | | | | | | - Meena Khan
- Ohio State University, Columbus, Ohio, USA
| | | | - Alan Kominsky
- Cleveland Clinic Head and Neck Institute, Cleveland, Ohio, USA
| | - Meir Kryger
- Yale School of Medicine, New Haven, Connecticut, USA
| | | | | | | | - Derek J. Lam
- Oregon Health and Science University, Portland, Oregon, USA
| | | | | | | | | | | | | | - Atul Malhotra
- University of California, San Diego, California, USA
| | | | - Joachim T. Maurer
- University Hospital Mannheim, Ruprecht-Karls-University Heidelberg, Heidelberg, Germany
| | - Anna M. May
- Case Western Reserve University, Cleveland, Ohio, USA
| | - Ron B. Mitchell
- University of Texas, Southwestern and Children’s Medical Center Dallas, Texas, USA
| | | | | | | | | | - Brandon Nokes
- University of California, San Diego, California, USA
| | | | - Allan I. Pack
- University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | | | | | | | | | | | | | | | | | - Mark Quigg
- University of Virginia, Charlottesville, Virginia, USA
| | | | - Susan Redline
- Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | | | - Armand Ryden
- Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, California, USA
| | | | - Firas Sbeih
- Cleveland Clinic Head and Neck Institute, Cleveland, Ohio, USA
| | | | | | | | | | - Jiyeon Seo
- University of California, Los Angeles, California, USA
| | - Neomi Shah
- Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | | | | | - Ryan J. Soose
- University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | | | - Erika Stephens
- University of California, San Francisco, California, USA
| | | | | | | | | | - Erica Thaler
- University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Sritika Thapa
- Yale School of Medicine, New Haven, Connecticut, USA
| | | | - Nico de Vries
- Academic Centre for Dentistry Amsterdam, Amsterdam, The Netherlands
| | | | - Ian D. Weir
- Yale School of Medicine, New Haven, Connecticut, USA
| | | | | | | | - Josie Xu
- University of Toronto, Ontario, Canada
| | | | | | | | | | | | - Ilene M. Rosen
- University of Pennsylvania, Philadelphia, Pennsylvania, USA
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4
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Randerath W, de Lange J, Hedner J, Ho JPT, Marklund M, Schiza S, Steier J, Verbraecken J. Current and Novel Treatment Options for OSA. ERJ Open Res 2022; 8:00126-2022. [PMID: 35769417 PMCID: PMC9234427 DOI: 10.1183/23120541.00126-2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2022] [Accepted: 04/24/2022] [Indexed: 12/03/2022] Open
Abstract
Obstructive sleep apnoea is a challenging medical problem due to its prevalence, its impact on quality of life and performance in school and professionally, the implications for risk of accidents, and comorbidities and mortality. Current research has carved out a broad spectrum of clinical phenotypes and defined major pathophysiological components. These findings point to the concept of personalised therapy, oriented on both the distinct clinical presentation and the most relevant pathophysiology in the individual patient. This leads to questions of whether sufficient therapeutic options other than positive airway pressure (PAP) alone are available, for which patients they may be useful, if there are specific indications for single or combined treatment, and whether there is solid scientific evidence for recommendations. This review describes our knowledge on PAP and non-PAP therapies to address upper airway collapsibility, muscle responsiveness, arousability and respiratory drive. The spectrum is broad and heterogeneous, including technical and pharmaceutical options already in clinical use or at an advanced experimental stage. Although there is an obvious need for more research on single or combined therapies, the available data demonstrate the variety of effective options, which should replace the unidirectional focus on PAP therapy. The analysis of individual pathophysiological composition opens new directions towards personalised treatment of OSA, focusing not only on pharyngeal dilation, but also on technical or pharmaceutical interventions on muscle function or breathing regulationhttps://bit.ly/3sayhkd
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5
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Rabec C, Fresnel E, Rétory Y, Zhu K, Joly K, Kerfourn A, Dudoignon B, Mendoza A, Cuvelier A, Muir JF, Melloni B, Chabot JF, Gonzalez-Bermejo J, Patout M. Addition of bacterial filter alters positive airway pressure and non-invasive ventilation performances. Eur Respir J 2022; 59:13993003.02636-2021. [PMID: 35086835 PMCID: PMC9030068 DOI: 10.1183/13993003.02636-2021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2021] [Accepted: 01/05/2022] [Indexed: 11/26/2022]
Abstract
Recently, one manufacturer of home ventilators issued an alert regarding the potential risk of serious injury related to the use of some of their positive airway pressure (PAP) and non-invasive ventilation (NIV) devices [1]. The risk is caused by the polyurethane foam used in their ventilators. In some cases, the foam broke into the blower and could have been inhaled by patients. The manufacturer and some healthcare regulatory agencies advocated, as a temporary solution, to modify PAP and NIV circuits by adding an inline bacterial filter in order to reduce the risk of inhalation [2]. However, changing ventilator circuits can alter ventilator performances during PAP and NIV [3]. The recommendation to add a bacterial filter on home positive pressure devices has significant negative impact on their performances and precludes auto-titrating positive airway pressure to function. These data suggest to not follow such recommendation.https://bit.ly/31YrWyo
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Affiliation(s)
- Claudio Rabec
- Pulmonary Department and Respiratory Critical Care Unit, University Hospital Dijon, Dijon, France.,Fédération ANTADIR, Paris, France.,Groupe Assistance Ventilatoire et O2 (GAVO2), Société de Pneumologie de Langue Française, Paris, France
| | | | - Yann Rétory
- Centre EXPLOR, Air Liquide Healthcare, Gentilly, France
| | - Kaixian Zhu
- Centre EXPLOR, Air Liquide Healthcare, Gentilly, France
| | | | | | - Benjamin Dudoignon
- 6AP-HP, Groupe Hospitalier Universitaire APHP-Sorbonne Université, site Pitié-Salpêtrière, Service des Pathologies du Sommeil (Département R3S), Paris, France
| | - Alexis Mendoza
- Groupe Assistance Ventilatoire et O2 (GAVO2), Société de Pneumologie de Langue Française, Paris, France
| | - Antoine Cuvelier
- Normandie Univ, UNIRouen, EA3830-GRHV, Institute for Research and Innovation in Biomedicine (IRIB), Rouen, France.,Groupe Assistance Ventilatoire et O2 (GAVO2), Société de Pneumologie de Langue Française, Paris, France
| | | | - Boris Melloni
- Fédération ANTADIR, Paris, France.,Pulmonary department, University Hospital Limoges, Limoges France
| | - Jean-François Chabot
- Fédération ANTADIR, Paris, France.,Département de Pneumologie, Université de Lorraine, CHU de Nancy, Vandœuvre-lès-Nancy, France
| | - Jésus Gonzalez-Bermejo
- Groupe Assistance Ventilatoire et O2 (GAVO2), Société de Pneumologie de Langue Française, Paris, France.,AP-HP, Groupe Hospitalier Universitaire APHP-Sorbonne Université, site Pitié-Salpêtrière, Service de Pneumologie, Médecine Intensive et Réanimation (Département R3S), Paris, France.,Sorbonne Université, INSERM, UMRS1158 Neurophysiologie Respiratoire Expérimentale et Clinique, Paris, France
| | - Maxime Patout
- Groupe Assistance Ventilatoire et O2 (GAVO2), Société de Pneumologie de Langue Française, Paris, France .,6AP-HP, Groupe Hospitalier Universitaire APHP-Sorbonne Université, site Pitié-Salpêtrière, Service des Pathologies du Sommeil (Département R3S), Paris, France.,Sorbonne Université, INSERM, UMRS1158 Neurophysiologie Respiratoire Expérimentale et Clinique, Paris, France
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6
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Feinsilver SH. Obstructive Sleep Apnea: Treatment with Positive Airway Pressure. Clin Geriatr Med 2021; 37:417-427. [PMID: 34210447 DOI: 10.1016/j.cger.2021.04.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
As in other adults, continuous positive airway pressure treatment for obstructive sleep apnea should be the mainstay of treatment. Benefits include improvements in sleepiness and quality of life, as well as improvements in hypertension control, arrhythmias, cardiovascular risk, and mortality. This article discusses issues in prescribing this treatment, including those related specifically to elderly individuals.
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Affiliation(s)
- Steven H Feinsilver
- Zucker School of Medicine at Hofstra Northwell Health, Lenox Hill Hospital, New York, NY, USA.
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Syed Z, Mehta I, Hella JR, Barber K, Khorfan F. Implementing a sleep technician supervised and personalized APAP interface fitting session prior to initiation of home APAP therapy improves adherence in patients with obstructive sleep apnea. JOURNAL OF CLINICAL SLEEP MEDICINE : JCSM : OFFICIAL PUBLICATION OF THE AMERICAN ACADEMY OF SLEEP MEDICINE 2021; 17:2057-2065. [PMID: 33983111 DOI: 10.5664/jcsm.9368] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
STUDY OBJECTIVES Home Automatic Positive Airway Pressure (APAP) therapy is becoming a mainstay treatment of obstructive sleep apnea (OSA). It is typically prescribed without any prior supervised titration. Initial experience of APAP treatment dictates subsequent use. Discomfort related to the APAP interface contributes to poor APAP adherence. METHODS After obtaining IRB approval, 156 adult patients newly diagnosed with OSA were prospectively randomized into two groups (groups A and B). Group A received a 30-minute personalized interface/mask fitting session supervised by a certified sleep technician during which APAP therapy was simulated and patients were educated on proper use. Patients sampled different interfaces to address any issues with comfort. Group B received usual care where patients obtained an interface through Durable Medical Equipment suppliers. Primary endpoints included percent APAP usage (number of days APAP was used for ≥4 hours divided by 30 days) and APAP usage (number of days APAP was used for any duration) during the initial 30 days of home APAP therapy. Interface associated air leak served as the secondary endpoint. RESULTS Mean percent APAP usage was higher in group A compared to group B (78.4% vs 67.8%; p=0.04). On average, group A utilized the APAP machine on more days compared to group B (27 vs 24 days; p=0.01). APAP interface associated air leak was lower in group A compared to group B (14.9 vs 21.1 l/min; p=0.03). CONCLUSIONS Our findings demonstrate that implementing a personalized interface fitting session supervised by a sleep technician improves APAP adherence.
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Affiliation(s)
- Ziauddin Syed
- Department of Internal Medicine, Ascension Genesys Hospital, Grand Blanc, MI
| | - Isha Mehta
- Windsor University, School of Medicine, Cayon, Saint Kitts and Nevis, West Indies
| | - Jennifer R Hella
- Department of Research, Ascension Genesys Hospital, Grand Blanc, MI
| | - Kimberly Barber
- Department of Research, Ascension Genesys Hospital, Grand Blanc, MI
| | - Fahim Khorfan
- Department of Pulmonology and Critical Care, Ascension Genesys Hospital, Grand Blanc, MI.,Michigan State University, East Lansing, MI.,Genesee Lung Associates, Grand Blanc, MI
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8
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Huber FL, Furian M, Kohler M, Latshang TD, Nussbaumer-Ochsner Y, Turk A, Schoch OD, Laube I, Thurnheer R, Bloch KE. Health Preference Measures in Patients with Obstructive Sleep Apnea Syndrome Undergoing Continuous Positive Airway Pressure Therapy: Data from a Randomized Trial. Respiration 2021; 100:328-338. [PMID: 33540413 DOI: 10.1159/000513306] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2020] [Accepted: 11/09/2020] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND In patients with obstructive sleep apnea syndrome (OSAS), the preference-based, health-related quality of life in terms of utility has not been extensively studied. OBJECTIVE To address this point, we compared the performance of different instruments assessing utility in patients with OSAS undergoing continuous positive airway pressure (CPAP) therapy. MATERIALS AND METHODS Data of 208 patients with OSAS (28 women, mean ± SE age 54.4 ± 0.7 years, apnea-hypopnea index (AHI) 51.9 ± 1.8/h, Epworth sleepiness score 13.4 ± 0.2) participating in a randomized trial of different CPAP modalities over 2 years were analyzed. Evaluations included sleep studies, Epworth sleepiness scale, and several utility instruments that measure subjective health preference on a scale ranging from 1 (most preferred and perfect health) to 0 (least preferred and very poor health). RESULTS After 2 years of CPAP therapy, the mean ± SE AHI was 6.7 ± 1.5/h and Epworth score 7.9 ± 0.4, both p < 0.001 versus baseline. Baseline utilities and changes (95% confidence interval) after 2 years of CPAP therapy were EuroQol 5-dimensions 0.79 ± 0.01, 0.02 (0.00-0.05, p = 0.064); short-form 6-dimension medical outcome questionnaire 0.72 ± 0.01, 0.06 (0.04-0.08, p < 0.001); Euro-thermometer visual analog scale 0.70 ± 0.01, 0.09 (0.07-0.12, p < 0.001); time trade-off 0.82 ± 0.01, 0.03 (0.01-0.06, p = 0.002); and standard gamble 0.82 ± 0.01, -0.01 (-0.03 to 0.02, p = 0.712). CONCLUSION The short-form 6-dimensions questionnaire, the Euro-thermometer, and the time trade-off instruments reflected the major clinical improvements in OSAS, while the EuroQoL 5-dimensions and standard gamble tests were not sensitive to CPAP effects. These results indicate that the evaluation of utility of a treatment for OSAS depends critically on the instrument used, which is important from an individual and societal perspective.
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Affiliation(s)
- Fabienne L Huber
- Department of Respiratory Medicine, Sleep Disorders Center, University Hospital Zurich, Zurich, Switzerland
| | - Michael Furian
- Department of Respiratory Medicine, Sleep Disorders Center, University Hospital Zurich, Zurich, Switzerland
| | - Malcolm Kohler
- Department of Respiratory Medicine, Sleep Disorders Center, University Hospital Zurich, Zurich, Switzerland
| | - Tsogyal D Latshang
- Department of Respiratory Medicine, Sleep Disorders Center, Cantonal Hospital Chur, Chur, Switzerland
| | | | - Alexander Turk
- Department of Internal Medicine, See-Spital, Horgen, Switzerland
| | - Otto D Schoch
- Department of Respiratory Medicine, Center for Sleep Medicine, Cantonal Hospital St. Gallen, St. Gallen, Switzerland
| | - Irene Laube
- Department of Respiratory Medicine, Sleep Disorders Center, Triemli Hospital, Zurich, Switzerland
| | - Robert Thurnheer
- Department of Respiratory Medicine, Sleep Disorders Center, Cantonal Hospital Münsterlingen, Münsterlingen, Switzerland
| | - Konrad E Bloch
- Department of Respiratory Medicine, Sleep Disorders Center, University Hospital Zurich, Zurich, Switzerland,
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9
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Tan L, Latshang TD, Aeschbacher SS, Huber F, Flueck D, Lichtblau M, Ulrich S, Hasler ED, Scheiwiller PM, Ulrich S, Bloch KE, Furian M. Effect of Nocturnal Oxygen Therapy on Nocturnal Hypoxemia and Sleep Apnea Among Patients With Chronic Obstructive Pulmonary Disease Traveling to 2048 Meters: A Randomized Clinical Trial. JAMA Netw Open 2020; 3:e207940. [PMID: 32568400 PMCID: PMC7309443 DOI: 10.1001/jamanetworkopen.2020.7940] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
IMPORTANCE There are no established measures to prevent nocturnal breathing disturbances and other altitude-related adverse health effects (ARAHEs) among lowlanders with chronic obstructive pulmonary disease (COPD) traveling to high altitude. OBJECTIVE To evaluate whether nocturnal oxygen therapy (NOT) prevents nocturnal hypoxemia and breathing disturbances during the first night of a stay at 2048 m and reduces the incidence of ARAHEs. DESIGN, SETTING, AND PARTICIPANTS This randomized, placebo-controlled crossover trial was performed from January to October 2014 with 32 patients with COPD living below 800 m with forced expiratory volume in the first second of expiration (FEV1) between 30% and 80% predicted, pulse oximetry of at least 92%, not requiring oxygen therapy, and without history of sleep apnea. Evaluations were performed at the University Hospital Zurich (490 m, baseline) and during 2 stays of 2 days and nights each in a Swiss Alpine hotel at 2048 m while NOT or placebo treatment was administered in a randomized order. Between altitude sojourns, patients spent at least 2 weeks below 800 m. Data analysis was performed from January 1, 2015, to December 31, 2018. INTERVENTION During nights at 2048 m, NOT or placebo (room air) was administered at 3 L/min by nasal cannula. MAIN OUTCOMES AND MEASURES Coprimary outcomes were differences between NOT and placebo intervention in altitude-induced change in mean nocturnal oxygen saturation (SpO2) as measured by pulse oximetry and apnea-hypopnea index (AHI) measured by polysomnography during night 1 at 2048 m and analyzed according to the intention-to-treat principle. Further outcomes were the incidence of predefined ARAHE, other variables from polysomnography results and respiratory sleep studies in the 2 nights at 2048 m, clinical findings, and symptoms. RESULTS Of the 32 patients included, 17 (53%) were women, with a mean (SD) age of 65.6 (5.6) years and a mean (SD) FEV1 of 53.1% (13.2%) predicted. At 490 m, mean (SD) SpO2 was 92% (2%) and mean (SD) AHI was 21.6/h (22.2/h). At 2048 m with placebo, mean (SD) SpO2 was 86% (3%) and mean (SD) AHI was 34.9/h (20.7/h) (P < .001 for both comparisons). Compared with placebo, NOT increased SpO2 by a mean of 9 percentage points (95% CI, 8-11 percentage points; P < .001), decreased AHI by 19.7/h (95% CI, 11.4/h-27.9/h; P < .001), and improved subjective sleep quality measured on a visual analog scale by 9 percentage points (95% CI, 0-17 percentage points; P = .04). During visits to 2048 m or within 24 hours after descent, 8 patients (26%) using placebo and 1 (4%) using NOT experienced ARAHEs (P < .001). CONCLUSIONS AND RELEVANCE Lowlanders with COPD experienced hypoxemia, sleep apnea, and impaired well-being when staying at 2048 m. Because NOT significantly mitigated these undesirable effects, patients with moderate to severe COPD may benefit from preventive NOT during high altitude travel. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT02150590.
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Affiliation(s)
- Lu Tan
- Sleep Disorders Center, Department of Respiratory Medicine, University Hospital of Zurich, Zurich, Switzerland
| | - Tsogyal D. Latshang
- Sleep Disorders Center, Department of Respiratory Medicine, University Hospital of Zurich, Zurich, Switzerland
| | - Sayaka S. Aeschbacher
- Sleep Disorders Center, Department of Respiratory Medicine, University Hospital of Zurich, Zurich, Switzerland
| | - Fabienne Huber
- Sleep Disorders Center, Department of Respiratory Medicine, University Hospital of Zurich, Zurich, Switzerland
| | - Deborah Flueck
- Sleep Disorders Center, Department of Respiratory Medicine, University Hospital of Zurich, Zurich, Switzerland
| | - Mona Lichtblau
- Sleep Disorders Center, Department of Respiratory Medicine, University Hospital of Zurich, Zurich, Switzerland
| | - Stefanie Ulrich
- Sleep Disorders Center, Department of Respiratory Medicine, University Hospital of Zurich, Zurich, Switzerland
| | - Elisabeth D. Hasler
- Sleep Disorders Center, Department of Respiratory Medicine, University Hospital of Zurich, Zurich, Switzerland
| | - Philipp M. Scheiwiller
- Sleep Disorders Center, Department of Respiratory Medicine, University Hospital of Zurich, Zurich, Switzerland
| | - Silvia Ulrich
- Sleep Disorders Center, Department of Respiratory Medicine, University Hospital of Zurich, Zurich, Switzerland
| | - Konrad E. Bloch
- Sleep Disorders Center, Department of Respiratory Medicine, University Hospital of Zurich, Zurich, Switzerland
| | - Michael Furian
- Sleep Disorders Center, Department of Respiratory Medicine, University Hospital of Zurich, Zurich, Switzerland
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10
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Patout M, Gagnadoux F, Rabec C, Trzepizur W, Georges M, Perrin C, Tamisier R, Pépin JL, Llontop C, Attali V, Goutorbe F, Pontier-Marchandise S, Cervantes P, Bironneau V, Portmann A, Delrieu J, Cuvelier A, Muir JF. AVAPS-AE versus ST mode: A randomized controlled trial in patients with obesity hypoventilation syndrome. Respirology 2020; 25:1073-1081. [PMID: 32052923 DOI: 10.1111/resp.13784] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2019] [Revised: 01/21/2020] [Accepted: 01/28/2020] [Indexed: 11/28/2022]
Abstract
BACKGROUND AND OBJECTIVE Average volume-assured pressure support-automated expiratory positive airway pressure (AVAPS-AE) combines an automated positive expiratory pressure to maintain upper airway patency to an automated pressure support with a targeted tidal volume. The aim of this study was to compare the effects of 2-month AVAPS-AE ventilation versus pressure support (ST) ventilation on objective sleep quality in stable patients with OHS. Secondary outcomes included arterial blood gases, health-related quality of life, daytime sleepiness, subjective sleep quality and compliance to NIV. METHODS This is a prospective multicentric randomized controlled trial. Consecutive OHS patients included had daytime Pa CO2 > 6 kPa, BMI ≥ 30 kg/m2 , clinical stability for more than 2 weeks and were naive from home NIV. PSG were analysed centrally by two independent experts. Primary endpoint was sleep quality improvement at 2 months. RESULTS Among 69 trial patients, 60 patients had successful NIV setup. Baseline and follow-up PSG were available for 26 patients randomized in the ST group and 30 in the AVAPS-AE group. At baseline, Pa CO2 was 6.94 ± 0.71 kPa in the ST group and 6.61 ± 0.71 in the AVAPS-AE group (P = 0.032). No significant between-group difference was observed for objective sleep quality indices. Improvement in Pa CO2 was similar between groups with a mean reduction of -0.87 kPa (95% CI: -1.12 to -0.46) in the ST group versus -0.87 kPa (95% CI: -1.14 to -0.50) in the AVAPS-AE group (P = 0.984). Mean NIV use was 6.2 h per night in both groups (P = 0.93). NIV setup duration was shorter in the AVAPS-AE group (P = 0.012). CONCLUSION AVAPS-AE and ST ventilation for 2 months had similar impact on sleep quality and gas exchange.
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Affiliation(s)
- Maxime Patout
- Service de Pneumologie, oncologie thoracique et Soins Intensifs Respiratoires, Rouen University Hospital, Rouen, France.,Normandie Univ, UNIRouen, EA3830-GRHV, Institute for Research and Innovation in Biomedicine (IRIB), Rouen, France
| | - Frédéric Gagnadoux
- Département de Pneumologie, Centre Hospitalier Universitaire d'Angers, Angers, France
| | - Claudio Rabec
- Pulmonary Department and Respiratory Critical Care Unit, University Hospital Dijon, Dijon, France
| | - Wojciech Trzepizur
- Département de Pneumologie, Centre Hospitalier Universitaire d'Angers, Angers, France
| | - Marjolaine Georges
- Pulmonary Department and Respiratory Critical Care Unit, University Hospital Dijon, Dijon, France
| | | | - Renaud Tamisier
- Pôle Thorax and Vaisseaux, Grenoble Alps University Hospital, Grenoble, France
| | | | - Claudia Llontop
- Service d'Explorations Fonctionnelles de la Respiration, de l'Exercice et de la Dyspnée, Hôpitaux Universitaires Pitié Salpêtrière - Charles Foix, Assistance Publique Hôpitaux de Paris (APHP), Paris, France
| | - Valerie Attali
- UMRS_1158 Neurophysiologie Respiratoire Expérimentale et Clinique, Sorbonne Université, INSERM, Paris, France.,Service des Pathologies du Sommeil (Département 'R3S'), Hôpitaux Universitaires Pitié Salpêtrière - Charles Foix, Assistance Publique Hôpitaux de Paris (APHP), Paris, France
| | | | | | - Pierre Cervantes
- Service de Pneumologie Hôpitaux Privés de Metz, Hôpital Robert Schuman, Metz, France
| | - Vanessa Bironneau
- Pneumologie, Centre Hospitalier Universitaire de Poitiers, Poitiers, France.,ANTADIR, Paris, France
| | - Adriana Portmann
- Service de Pneumologie, oncologie thoracique et Soins Intensifs Respiratoires, Rouen University Hospital, Rouen, France.,Normandie Univ, UNIRouen, EA3830-GRHV, Institute for Research and Innovation in Biomedicine (IRIB), Rouen, France
| | | | - Antoine Cuvelier
- Service de Pneumologie, oncologie thoracique et Soins Intensifs Respiratoires, Rouen University Hospital, Rouen, France.,Normandie Univ, UNIRouen, EA3830-GRHV, Institute for Research and Innovation in Biomedicine (IRIB), Rouen, France
| | - Jean-François Muir
- Service de Pneumologie, oncologie thoracique et Soins Intensifs Respiratoires, Rouen University Hospital, Rouen, France.,Normandie Univ, UNIRouen, EA3830-GRHV, Institute for Research and Innovation in Biomedicine (IRIB), Rouen, France.,ANTADIR, Paris, France
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11
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Tietjens JR, Claman D, Kezirian EJ, De Marco T, Mirzayan A, Sadroonri B, Goldberg AN, Long C, Gerstenfeld EP, Yeghiazarians Y. Obstructive Sleep Apnea in Cardiovascular Disease: A Review of the Literature and Proposed Multidisciplinary Clinical Management Strategy. J Am Heart Assoc 2020; 8:e010440. [PMID: 30590966 PMCID: PMC6405725 DOI: 10.1161/jaha.118.010440] [Citation(s) in RCA: 177] [Impact Index Per Article: 44.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Affiliation(s)
| | - David Claman
- 1 Department of Medicine University of California San Francisco CA
| | - Eric J Kezirian
- 4 USC Caruso Department of Otolaryngology - Head & Neck Surgery Keck School of Medicine University of Southern California Los Angeles CA
| | - Teresa De Marco
- 1 Department of Medicine University of California San Francisco CA
| | | | - Bijan Sadroonri
- 6 Division of Pulmonary Diseases and Sleep Medicine Holy Family Hospital Methuen MA
| | - Andrew N Goldberg
- 7 Department of Otolaryngology - Head & Neck Surgery University of California San Francisco CA
| | - Carlin Long
- 1 Department of Medicine University of California San Francisco CA
| | | | - Yerem Yeghiazarians
- 1 Department of Medicine University of California San Francisco CA.,2 Eli and Edythe Broad Center of Regeneration Medicine and Stem Cell Research University of California San Francisco CA.,3 Cardiovascular Research Institute University of California San Francisco CA
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12
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Kennedy B, Lasserson TJ, Wozniak DR, Smith I. Pressure modification or humidification for improving usage of continuous positive airway pressure machines in adults with obstructive sleep apnoea. Cochrane Database Syst Rev 2019; 12:CD003531. [PMID: 31792939 PMCID: PMC6888022 DOI: 10.1002/14651858.cd003531.pub4] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
BACKGROUND Obstructive sleep apnoea (OSA) is the repetitive closure of the upper airway during sleep. This results in disturbed sleep and excessive daytime sleepiness. It is a risk factor for long-term cardiovascular morbidity. Continuous positive airway pressure (CPAP) machines can be applied during sleep. They deliver air pressure by a nasal or oronasal mask to prevent the airway from closing, reducing sleep disturbance and improving sleep quality. Some people find them difficult to tolerate because of high pressure levels and other symptoms such as a dry mouth. Switching to machines that vary the level of air pressure required to reduce sleep disturbance could increase comfort and promote more regular use. Humidification devices humidify the air that is delivered to the upper airway through the CPAP circuit. Humidification may reduce dryness of the throat and mouth and thus improve CPAP tolerability. This updated Cochrane Review looks at modifying the delivery of positive pressure and humidification on machine usage and other clinical outcomes in OSA. OBJECTIVES To determine the effects of positive pressure modification or humidification on increasing CPAP machine usage in adults with OSA. SEARCH METHODS We searched Cochrane Airways Specialised Register and clinical trials registries on 15 October 2018. SELECTION CRITERIA Randomised parallel group or cross-over trials in adults with OSA. We included studies that compared automatically adjusting CPAP (auto-CPAP), bilevel positive airway pressure (bi-PAP), CPAP with expiratory pressure relief (CPAPexp), heated humidification plus fixed CPAP, automatically adjusting CPAP with expiratory pressure relief, Bi-PAP with expiratory pressure relief, auto bi-PAP and CPAPexp with wakefulness detection with fixed pressure setting. DATA COLLECTION AND ANALYSIS We used standard methods expected by Cochrane. We assessed the certainty of evidence using GRADE for the outcomes of machine usage, symptoms (measured by the Epworth Sleepiness Scale (ESS)), Apnoea Hypopnoea Index (AHI), quality of life measured by Functional Outcomes of Sleep Questionnaire (FOSQ), blood pressure, withdrawals and adverse events (e.g. nasal blockage or mask intolerance). The main comparison of interest in the review is auto-CPAP versus fixed CPAP. MAIN RESULTS We included 64 studies (3922 participants, 75% male). The main comparison of auto-CPAP with fixed CPAP is based on 36 studies with 2135 participants from Europe, USA, Hong Kong and Australia. The majority of studies recruited participants who were recently diagnosed with OSA and had not used CPAP previously. They had excessive sleepiness (ESS: 13), severe sleep disturbance (AHI ranged from 22 to 59), and average body mass index (BMI) of 35 kg/m2. Interventions were delivered at home and the duration of most studies was 12 weeks or less. We judged that studies at high or unclear risk of bias likely influenced the effect of auto-CPAP on machine usage, symptoms, quality of life and tolerability, but not for other outcomes. Primary outcome Compared with average usage of about five hours per night with fixed CPAP, people probably use auto-CPAP for 13 minutes longer per night at about six weeks (mean difference (MD) 0.21 hours/night, 95% confidence interval (CI) 0.11 to 0.31; 31 studies, 1452 participants; moderate-certainty evidence). We do not have enough data to determine whether auto-CPAP increases the number of people who use machines for more than four hours per night compared with fixed CPAP (odds ratio (OR) 1.16, 95% CI 0.75 to 1.81; 2 studies, 346 participants; low-certainty evidence). Secondary outcomes Auto-CPAP probably reduces daytime sleepiness compared with fixed CPAP at about six weeks by a small amount (MD -0.44 ESS units, 95% CI -0.72 to -0.16; 25 studies, 1285 participants; moderate-certainty evidence). AHI is slightly higher with auto-CPAP than with fixed CPAP (MD 0.48 events per hour, 95% CI 0.16 to 0.80; 26 studies, 1256 participants; high-certainty evidence), although it fell with both machine types from baseline values in the studies. Ten per cent of people in auto-CPAP and 11% in the fixed CPAP arms withdrew from the studies (OR 0.90, 95% CI 0.64 to 1.27; moderate-certainty evidence). Auto-CPAP and fixed CPAP may have similar effects on quality of life, as measured by the FOSQ but more evidence is needed to be confident in this result (MD 0.12, 95% CI -0.21 to 0.46; 3 studies, 352 participants; low-certainty evidence). Two studies (353 participants) provided data on clinic-measured blood pressure. Auto-CPAP may be slightly less effective at reducing diastolic blood pressure compared to fixed CPAP (MD 2.92 mmHg, 95% CI 1.06 to 4.77 mmHg; low-certainty evidence). The two modalities of CPAP probably do not differ in their effects on systolic blood pressure (MD 1.87 mmHg, 95% CI -1.08 to 4.82; moderate-certainty evidence). Nine studies (574 participants) provided information on adverse events such as nasal blockage, dry mouth, tolerance of treatment pressure and mask leak. They used different scales to capture these outcomes and due to variation in the direction and size of effect between the studies, the comparative effects on tolerability outcomes are uncertain (very low-certainty evidence). The evidence base for other interventions is smaller, and does not provide sufficient information to determine whether there are important differences between pressure modification strategies and fixed CPAP on machine usage outcomes, symptoms and quality of life. As with the evidence for the auto-CPAP, adverse events are measured disparately. AUTHORS' CONCLUSIONS In adults with moderate to severe sleep apnoea starting positive airway pressure therapy, auto-CPAP probably increases machine usage by about 13 minutes per night. The effects on daytime sleepiness scores with auto-CPAP are not clinically meaningful. AHI values are slightly lower with fixed CPAP. Use of validated quality of life instruments in the studies to date has been limited, although where they have been used the effect sizes have not exceeded proposed clinically important differences. The adoption of a standardised approach to measuring tolerability would help decision-makers to balance benefits with harms from the different treatment options available. The evidence available for other pressure modification strategies does not provide a reliable basis on which to draw firm conclusions. Future studies should look at the effects of pressure modification devices and humidification in people who have already used CPAP but are unable to persist with treatment.
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Affiliation(s)
- Barry Kennedy
- St. James's HospitalDepartment of Sleep MedicineDublinIreland
| | - Toby J Lasserson
- Cochrane Central ExecutiveEditorial & Methods DepartmentSt Albans House57‐59 HaymarketLondonUKSW1Y 4QX
| | - Dariusz R Wozniak
- Royal Papworth HospitalRespiratory Support and Sleep CentrePapworth EverardCambridgeUKCB23 3RE
| | - Ian Smith
- Royal Papworth HospitalRespiratory Support and Sleep CentrePapworth EverardCambridgeUKCB23 3RE
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13
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Marrone O, Cibella F, Pépin JL, Grote L, Verbraecken J, Saaresranta T, Kvamme JA, Basoglu OK, Lombardi C, McNicholas WT, Hedner J, Bonsignore MR. Comment to the Editorial by KS Park and EW Kang "Is only fixed positive airway pressure a robust tool for kidney protection in patients with obstructive sleep apnea?". J Thorac Dis 2019; 11:S480-S482. [PMID: 30997253 DOI: 10.21037/jtd.2019.01.93] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Oreste Marrone
- CNR, Institute of Biomedicine and Molecular Immunology, Palermo, Italy
| | - Fabio Cibella
- CNR, Institute of Biomedicine and Molecular Immunology, Palermo, Italy
| | - Jean-Louis Pépin
- INSERM Unit 1042, Université Grenoble Alpes, CHU de Grenoble, Laboratoire EFCR, Pôle Thorax et Vaisseaux, Grenoble, France
| | - Ludger Grote
- Sleep Medicine, Sahlgrenska University Hospital and Sahlgrenska Academy, Gothenburg, Sweden
| | - Johan Verbraecken
- Multidisciplinary Sleep Disorders Centre, Antwerp University Hospital and University of Antwerp, Edegem-Antwerp, Belgium
| | - Tarja Saaresranta
- Division of Medicine, Department of Pulmonary Diseases, Turku University Hospital, Sleep Research Center, Department of Pulmonary Diseases and Clinical Allergology, University of Turku, Turku, Finland
| | - John A Kvamme
- ENT Department, Førde Central hospital, Førde, Norway
| | - Ozen K Basoglu
- Department of Chest Diseases, Ege University School of Medicine, Izmir, Turkey
| | - Carolina Lombardi
- Sleep Disorders Center, Department of Cardiovascular Neural and Metabolic Sciences, IRCCS Istituto Auxologico Italiano, Milano-Bicocca University, Milan, Italy
| | - Walter T McNicholas
- Department of Respiratory and Sleep Medicine, St. Vincent's Hospital Group, School of Medicine, University College Dublin, Dublin, Ireland
| | - Jan Hedner
- Sleep Medicine, Sahlgrenska University Hospital and Sahlgrenska Academy, Gothenburg, Sweden
| | - Maria R Bonsignore
- CNR, Institute of Biomedicine and Molecular Immunology, Palermo, Italy.,DiBiMIS, University of Palermo, Palermo, Italy
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14
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Treptow E, Pepin JL, Bailly S, Levy P, Bosc C, Destors M, Woehrle H, Tamisier R. Reduction in sympathetic tone in patients with obstructive sleep apnoea: is fixed CPAP more effective than APAP? A randomised, parallel trial protocol. BMJ Open 2019; 9:e024253. [PMID: 30948567 PMCID: PMC6500296 DOI: 10.1136/bmjopen-2018-024253] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2018] [Revised: 10/09/2018] [Accepted: 11/23/2018] [Indexed: 12/20/2022] Open
Abstract
INTRODUCTION Obstructive sleep apnoea (OSA) is a prevalent disease associated with cardiovascular events. Hypertension is one of the major intermediary mechanisms leading to long-term cardiovascular adverse events. Intermittent hypoxia and hypercapnia associated with nocturnal respiratory events stimulate chemoreflexes, resulting in sympathetic overactivity and blood pressure (BP) elevation. Continuous positive airway pressure (CPAP) is the primary treatment for OSA and induces a small but significant reduction in BP. The use of auto-adjusting positive airway pressure (APAP) has increased in the last years and studies showed different ranges of BP reduction when comparing both modalities. However, the pathophysiological mechanisms implicated are not fully elucidated. Variations in pressure through the night inherent to APAP may induce persistent respiratory efforts and sleep fragmentation that might impair sympathovagal balance during sleep and result in smaller decreases in BP. Therefore, this double-blind randomised controlled trial aims to compare muscle sympathetic nerve activity (MSNA) assessed by microneurography (reference method for measuring sympathetic activity) after 1 month of APAP versus fixed CPAP in treatment-naive OSA patients. This present manuscript describes the design of our study, no results are presented herein. and is registered under the below reference number. METHODS AND ANALYSIS Adult subjects with newly diagnosed OSA (Apnoea-Hypopnoea Index >20/hour) will be randomised for treatment with APAP or fixed CPAP. Measurements of sympathetic activity by MSNA, heart rate variability and catecholamines will be obtained at baseline and after 30 days. The primary composite outcome will be the change in sympathetic tone measured by MSNA in bursts/min and bursts/100 heartbeats. Sample size calculation was performed with bilateral assumption. We will use the Student's t-test to compare changes in sympathetic tone between groups. ETHICS AND DISSEMINATION The protocol was approved by The French Regional Ethics Committee. The study started in March 2018 with primary completion expected to March 2019. Dissemination plans of the results include presentations at conferences and publication in peer-reviewed journals. TRIAL REGISTRATION NUMBER NCT03428516; Pre-results.
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Affiliation(s)
- Erika Treptow
- HP2, Inserm 1042, Université Grenoble Alpes, Grenoble, France
| | - Jean Louis Pepin
- HP2, Inserm 1042, Université Grenoble Alpes, Grenoble, France
- Laboratoire sommeil, Hôpital Universitaire de Grenoble, Grenoble, France
| | | | - Patrick Levy
- HP2, Inserm 1042, Université Grenoble Alpes, Grenoble, France
| | | | - Marie Destors
- HP2, Inserm 1042, Université Grenoble Alpes, Grenoble, France
- Laboratoire sommeil, Hôpital Universitaire de Grenoble, Grenoble, France
| | | | - Renaud Tamisier
- HP2, Inserm 1042, Université Grenoble Alpes, Grenoble, France
- Laboratoire sommeil, Hôpital Universitaire de Grenoble, Grenoble, France
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15
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Park KS, Kang EW. Is only fixed positive airway pressure a robust tool for kidney protection in patients with obstructive sleep apnea? J Thorac Dis 2019; 10:S3819-S3823. [PMID: 30631487 DOI: 10.21037/jtd.2018.10.91] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Kyoung Sook Park
- Division of nephrology, Department of Internal Medicine; NHIS Ilsan Hospital, Goyang, Korea
| | - Ea Wha Kang
- Division of nephrology, Department of Internal Medicine; NHIS Ilsan Hospital, Goyang, Korea
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16
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Crook S, Sievi NA, Bloch KE, Stradling JR, Frei A, Puhan MA, Kohler M. Minimum important difference of the Epworth Sleepiness Scale in obstructive sleep apnoea: estimation from three randomised controlled trials. Thorax 2018; 74:390-396. [PMID: 30100576 DOI: 10.1136/thoraxjnl-2018-211959] [Citation(s) in RCA: 47] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2018] [Revised: 06/21/2018] [Accepted: 07/23/2018] [Indexed: 11/04/2022]
Abstract
BACKGROUND The Epworth Sleepiness Scale (ESS) is a widely used tool for assessing sleepiness in patients with obstructive sleep apnoea (OSA). We aimed to estimate the minimal important difference (MID) in patients with OSA. METHODS We used individual data from three randomised controlled trials (RCTs) in patients with OSA where the preintervention to postintervention change in ESS was used as a primary outcome. We used anchor-based linear regression and responder analysis approaches to estimate the MID. For anchors, we used the change in domains of the Functional Outcomes of Sleep Questionnaire and 36-Item Short Form Health Survey. We also used the distribution-based approaches Cohen's effect size, SE of measurement and empirical rule effect size to support the anchor-based estimates. The final MID was determined by triangulating all estimates to a single MID. FINDINGS A total of 639 patients with OSA were included in our analyses across the three RCTs with a median (IQR) baseline ESS score of 10 (6-13). The median (IQR) ESS change score overall was -2 (-5 to 1). The anchor-based estimates of the MID were between -1.74 and -4.21 points and estimates from the responder analysis were between -1 and -3 points. Distribution-based estimates were smaller, ranging from -1.46 to -2.36. INTERPRETATION We propose an MID for the ESS of 2 points in patients with OSA with a disease severity from mild to severe. This estimate provides the means to plan trials and interpret the clinical relevance of changes in ESS. TRIAL REGISTRATION NUMBER Provent, NCT01332175; autoCPAP trial, NCT00280800; MOSAIC,ISRCTN (3416388).
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Affiliation(s)
- Sarah Crook
- Epidemiology, Biostatistics and Prevention Institute, University of Zurich, Zurich, Switzerland
| | - Noriane A Sievi
- Department of Pneumology, University Hospital of Zurich, Zurich, Switzerland
| | - Konrad E Bloch
- Department of Pneumology, University Hospital of Zurich, Zurich, Switzerland.,Center of Interdisciplinary Sleep Research, University of Zurich, Zurich, Switzerland
| | - John R Stradling
- Oxford Centre for Respiratory Medicine and Oxford NIHR Biomedical Research Centre, Churchill Campus, Oxford University, Oxford, UK
| | - Anja Frei
- Epidemiology, Biostatistics and Prevention Institute, University of Zurich, Zurich, Switzerland
| | - Milo A Puhan
- Epidemiology, Biostatistics and Prevention Institute, University of Zurich, Zurich, Switzerland
| | - Malcolm Kohler
- Department of Pneumology, University Hospital of Zurich, Zurich, Switzerland.,Center of Interdisciplinary Sleep Research, University of Zurich, Zurich, Switzerland
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17
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Randerath W, Bassetti CL, Bonsignore MR, Farre R, Ferini-Strambi L, Grote L, Hedner J, Kohler M, Martinez-Garcia MA, Mihaicuta S, Montserrat J, Pepin JL, Pevernagie D, Pizza F, Polo O, Riha R, Ryan S, Verbraecken J, McNicholas WT. Challenges and perspectives in obstructive sleep apnoea. Eur Respir J 2018; 52:13993003.02616-2017. [DOI: 10.1183/13993003.02616-2017] [Citation(s) in RCA: 108] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2017] [Accepted: 04/25/2018] [Indexed: 12/21/2022]
Abstract
Obstructive sleep apnoea (OSA) is a major challenge for physicians and healthcare systems throughout the world. The high prevalence and the impact on daily life of OSA oblige clinicians to offer effective and acceptable treatment options. However, recent evidence has raised questions about the benefits of positive airway pressure therapy in ameliorating comorbidities.An international expert group considered the current state of knowledge based on the most relevant publications in the previous 5 years, discussed the current challenges in the field, and proposed topics for future research on epidemiology, phenotyping, underlying mechanisms, prognostic implications and optimal treatment of patients with OSA.The group concluded that a revision to the diagnostic criteria for OSA is required to include factors that reflect different clinical and pathophysiological phenotypes and relevant comorbidities (e.g.nondipping nocturnal blood pressure). Furthermore, current severity thresholds require revision to reflect factors such as the disparity in the apnoea–hypopnoea index (AHI) between polysomnography and sleep studies that do not include sleep stage measurements, in addition to the poor correlation between AHI and daytime symptoms such as sleepiness. Management decisions should be linked to the underlying phenotype and consider outcomes beyond AHI.
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