Weight Loss Is Integral to Obstructive Sleep Apnea Management. Ten-Year Follow-up in Sleep AHEAD

Impact of surgical intervention on obstructive sleep apnea (OSA) and body-mass index: a scoping review

BACKGROUND

Upper airway surgery for obstructive sleep apnea (OSA) offers an alternative to CPAP, but its impact on weight changes is poorly studied.

PURPOSE

To systematically review published literature on the relationship between surgical intervention for OSA and changes in body mass index (BMI).

METHODS

A literature search was conducted from 2013-2024 in five databases. Full-text English articles which examined BMI changes in adults with OSA pre- and post-surgery were included. The quality of each study was assessed independently by two researchers using the Newcastle-Ottawa Scale. This study was reported according to the PRISMA-ScR.

RESULTS

Eleven studies, involving 406 patients from six countries were included. Most patients were males (88.4%) with a mean age of 40 years old. The pre-operative BMI were higher [27.8 kg/m2 (SD = 2.6)] compared to a BMI of 27.7 kg/m2 (SD = 1.3) at 21.0 months post-operation. The pre-operative Epworth Sleepiness Score was 13.28 (SD = 6.36), while the apnea-hypopnea index was 41.2 (SD = 16.88), indicating that most patients were diagnosed with severe OSA. The average oxygen desaturation index was 35.63 (SD = 11.17). The meta-analysis showed no significant BMI changes after surgery (mean difference:-0.29; 95% CI:-0.80 to 0.21; I2 = 30%). Findings were consistent with no publication bias found.

CONCLUSIONS

Upper airway surgery for OSA does not significantly affect BMI. The authors propose closer monitoring of weight changes following upper airway surgery, as weight fluctuations can impact the outcomes of surgery. Unchanged weight post-surgery may be attributed to suboptimal OSA treatment.

Early-to-Midlife Body Mass Index Trajectories and Obstructive Sleep Apnoea Risk 10 Years Later

BACKGROUND AND OBJECTIVE

While short-term weight changes are known to influence obstructive sleep apnoea (OSA), the impact of body mass index (BMI) changes over the life course has been poorly documented. We examined the association between BMI trajectories from childhood to middle age and adult OSA, 10 years later.

METHODS

Five BMI trajectories were previously identified in the population-based cohort Tasmanian Longitudinal Health Study (TAHS), using eight time-point BMI from age 5 to 43 years. The primary outcome was probable OSA at 53 years, defined using STOP-Bang questionnaire, with Berlin and OSA-50 questionnaires used to ensure consistency of findings. Clinically significant diagnosed OSA was defined as self-reported medical diagnosis or mild OSA with symptoms or moderate-to-severe OSA, using type-4 sleep studies. Associations were examined using multivariable logistic regression.

RESULTS

Compared with the average BMI trajectory, the child average-increasing (aOR = 5.28, 95% CI 3.38-8.27) and persistently high trajectories (aOR = 3.73, 2.06-6.74) were associated with increased risk of probable OSA. These associations were consistent when using clinically significant diagnosed OSA (child average-increasing trajectory: aOR = 2.95, 1.30-6.72; high trajectory: aOR = 2.23, 0.82-6.09). Individuals belonging to the low trajectory were less likely than the average trajectory to have OSA. Notably, the child high-decreasing trajectory was not associated with OSA.

CONCLUSION

Physicians and the public should be aware of the potential risk of OSA in middle-aged adults when BMI is high or continuously increasing from childhood to mid-40s. Obese children who subsequently lose weight were not at higher risk of OSA in middle age-a novel and key finding.

The Impact of Living in a Low Food Access/Low Income Area on Obstructive Sleep Apnea

OBJECTIVE

To assess differences in obstructive sleep apnea (OSA)-related health parameters between residents of low income/low access (LILA) census tracts-food deserts-and non-LILA residents STUDY DESIGN: Retrospective review.

SETTING

Single institution serving a large region in Southern California from 2017 to 2023.

METHODS

Census tracts are defined as LILA if a significant proportion of residents live below the poverty threshold and far from healthy food vendors. Adults newly diagnosed with OSA on polysomnography were included. Food access status was determined by searching patient addresses in the US Department of Agriculture Food Access Research Atlas. Baseline and 1-year follow-up body mass index (BMI) and vitals were collected and compared based on food access and other demographic variables.

RESULTS

A total of 379 patients in the LILA+ group and 2281 patients in the LILA- group met inclusion criteria. BMI was higher in the LILA group (36.6 ± 9.4 vs 35.2 ± 8.9; P = .006). The effect of food access was most significant in certain demographic groups: patients aged < 65, males, Asian/Pacific Islanders, Hispanics, and patients with Medicaid coverage all had a higher BMI when in the LILA+ group compared to the LILA- group. When considering insurance, LILA+ patients with Medicaid coverage had a significantly higher BMI than LILA- patients with non-Medicaid coverage (40.4 ± 10.3 vs 34.2 ± 8.4, P < .001. Blood pressure, heart rate, and apnea-hypopnea index were also significantly higher in LILA+/Medicaid group. BMI change across all demographic groups was minimal at 1-year follow-up.

CONCLUSION

Living in a LILA census tract may result in worse OSA-related health parameters. When accounting for insurance status, the effects are even more profound. Intensive counseling on the importance of weight management should begin at the diagnosis of OSA.

Obstructive Sleep Apnea and Serotoninergic Signalling Pathway: Pathomechanism and Therapeutic Potential

Obstructive Sleep Apnea (OSA) is a disorder characterized by repeated upper airway collapse during sleep, leading to apneas and/or hypopneas, with associated symptoms like intermittent hypoxia and sleep fragmentation. One of the agents contributing to OSA occurrence and development seems to be serotonin (5-HT). Currently, the research focuses on establishing and interlinking OSA pathogenesis and the severity of the disease on the molecular neurotransmitter omnipresent in the human body-serotonin, its pathway, products, receptors, drugs affecting the levels of serotonin, or genetic predisposition. The 5-HT system is associated with numerous physiological processes such as digestion, circulation, sleep, respiration, and muscle tone-all of which are considered factors promoting and influencing the course of OSA because of correlations with comorbid conditions. Comorbidities include obesity, physiological and behavioral disorders as well as cardiovascular diseases. Additionally, both serotonin imbalance and OSA are connected with psychiatric comorbidities, such as depression, anxiety, or cognitive dysfunction. Pharmacological agents that target 5-HT receptors have shown varying degrees of efficacy in reducing the Apnea-Hypopnea Index and improving OSA symptoms. The potential role of the 5-HT signaling pathway in modulating OSA provides a promising avenue for new therapeutic interventions that could accompany the primary treatment of OSA-continuous positive airway pressure. Thus, this review aims to elucidate the complex role of 5-HT and its regulatory mechanisms in OSA pathophysiology, evaluating its potential as a therapeutic target. We also summarize the relationship between 5-HT signaling and various physiological functions, as well as its correlations with comorbid conditions.

Non-sleep related outcomes of maxillomandibular advancement, a systematic review

Maxillomandibular advancement has been shown to be an effective treatment for obstructive sleep apnea; however, the literature focuses mainly on sleep-related parameters such as apnea-hypopnea index, respiratory disturbance index and Epworth sleepiness scale. Other factors that may be important to patients, such as esthetics, patient satisfaction, nasality, swallowing problems and so forth have been reported in the literature but have not been systematically studied. Together with an information specialist, an extensive search in Medline, Embase and Scopus yielded 1592 unique articles. Titles and abstracts were screened by two blinded reviewers. In total, 75 articles were deemed eligible for full-text screening and 38 articles were included for qualitative synthesis. The most common categories of non-sleep related outcomes found were surgical accuracy, facial esthetics, functional outcomes, quality of life, patient satisfaction, and emotional health. All categories were reported using heterogenous methods, such that meta-analysis could not be performed. There was lack of consistent methods to assess these outcomes. This work is the first to systematically review non-sleep related outcomes of maxillomandibular advancement. Despite growing interest in evaluating surgical outcomes through patient subjective experiences, this review points to the need of standardized, validated methods to report these outcomes.

Traumatic brain injury and sleep in military and veteran populations: A literature review

BACKGROUND

Traumatic brain injury (TBI) is a hallmark of wartime injury and is related to numerous sleep wake disorders (SWD), which persist long term in veterans. Current knowledge gaps in pathophysiology have hindered advances in diagnosis and treatment.

OBJECTIVE

We reviewed TBI SWD pathophysiology, comorbidities, diagnosis and treatment that have emerged over the past two decades.

METHODS

We conducted a literature review of English language publications evaluating sleep disorders (obstructive sleep apnea, insomnia, hypersomnia, parasomnias, restless legs syndrome and periodic limb movement disorder) and TBI published since 2000. We excluded studies that were not specifically evaluating TBI populations.

RESULTS

Highlighted areas of interest and knowledge gaps were identified in TBI pathophysiology and mechanisms of sleep disruption, a comparison of TBI SWD and post-traumatic stress disorder SWD. The role of TBI and glymphatic biomarkers and management strategies for TBI SWD will also be discussed.

CONCLUSION

Our understanding of the pathophysiologic underpinnings of TBI and sleep health, particularly at the basic science level, is limited. Developing an understanding of biomarkers, neuroimaging, and mixed-methods research in comorbid TBI SWD holds the greatest promise to advance our ability to diagnose and monitor response to therapy in this vulnerable population.

Controversies in Sleep Apnea

This chapter discusses controversies in diagnosis and management of obstructive sleep apnea (OSA), with particular focus on surgical management to improve quality of life. Though OSA is a complex disorder that affects millions of people worldwide, its management remains controversial among clinicians. Gaps in understanding its pathophysiology, long-term health consequences, diagnostic methods, and treatment strategies exist. While continuous positive airway pressure (CPAP) therapy is considered the gold standard for moderate to severe obstructive sleep apnea (OSA), its adherence rate is often low, and its efficacy in improving outcomes beyond symptom reduction and quality of life improvement is uncertain. As such, surgical intervention may be an alternative for specific patient populations. Additionally, the type of surgical intervention may depend on individual patient needs, anatomic features, as well as preferences.

Pharmacological management of co-morbid obstructive sleep apnoea and insomnia

INTRODUCTION

Clinical presentation of both insomnia and obstructive sleep apnea (COMISA) is common. Approximately 30% of clinical cohorts with OSA have insomnia symptoms and vice versa. The underlying pathophysiology of COMISA is multifactorial. This poses a complex clinical challenge. Currently, there are no clinical guidelines or recommendations outside of continuous positive airway pressure (CPAP) therapy and cognitive behavioral therapy for insomnia (CBTi). Clinically translatable precision medicine approaches to characterize individual causes or endotypes may help optimize future pharmacological management of COMISA.

AREAS COVERED

This review article provides an up-to-date account of COMISA and its consequences, the underlying pathophysiology of sleep apnea, insomnia and COMISA, current treatment approaches and limitations, pharmacotherapy targets and future priorities.

EXPERT OPINION

There are multiple promising emerging therapies, but clinical trial data specifically in COMISA populations are lacking. This is a priority for future investigation to inform development of evidence-based guidelines. Pharmacotherapies, particularly for insomnia, do not target the underlying causes of the disorder thus, are indicated for short-term use only and should remain second line. Future multidisciplinary research should be directed toward the multifactorial nature of COMISA and the challenges of adapting COMISA treatment in clinical practice and overcoming the practical barriers that health-care providers and consumers encounter.

Pathophysiological mechanisms and therapeutic approaches in obstructive sleep apnea syndrome

Obstructive sleep apnea syndrome (OSAS) is a common breathing disorder in sleep in which the airways narrow or collapse during sleep, causing obstructive sleep apnea. The prevalence of OSAS continues to rise worldwide, particularly in middle-aged and elderly individuals. The mechanism of upper airway collapse is incompletely understood but is associated with several factors, including obesity, craniofacial changes, altered muscle function in the upper airway, pharyngeal neuropathy, and fluid shifts to the neck. The main characteristics of OSAS are recurrent pauses in respiration, which lead to intermittent hypoxia (IH) and hypercapnia, accompanied by blood oxygen desaturation and arousal during sleep, which sharply increases the risk of several diseases. This paper first briefly describes the epidemiology, incidence, and pathophysiological mechanisms of OSAS. Next, the alterations in relevant signaling pathways induced by IH are systematically reviewed and discussed. For example, IH can induce gut microbiota (GM) dysbiosis, impair the intestinal barrier, and alter intestinal metabolites. These mechanisms ultimately lead to secondary oxidative stress, systemic inflammation, and sympathetic activation. We then summarize the effects of IH on disease pathogenesis, including cardiocerebrovascular disorders, neurological disorders, metabolic diseases, cancer, reproductive disorders, and COVID-19. Finally, different therapeutic strategies for OSAS caused by different causes are proposed. Multidisciplinary approaches and shared decision-making are necessary for the successful treatment of OSAS in the future, but more randomized controlled trials are needed for further evaluation to define what treatments are best for specific OSAS patients.

A Scoping Review of Sleep Apnea: Where Do We Stand?

Obstructive sleep apnea (OSA), a condition in which there is a recurrent collapse of the upper airway while sleeping, is a widespread disease affecting 5% to 10% people worldwide. Despite several advances in the treatment modalities for OSA, morbidity and mortality remain a concern. Common symptoms include loud snoring, gasping for air during sleep, morning headache, insomnia, hypersomnia, attention deficits, and irritability. Obese individuals, male gender, older age (65+), family history, smoking, and alcohol consumption are well recognized risk factors of OSA. This condition holds the ability to increase inflammatory cytokines, cause metabolic dysfunction, and increase the sympathetic output, all of which exacerbate OSA due to their effect on the cardiovascular system. In this review, we discuss its brief history, risk factors, complications, treatment modalities, and the role of clinicians in curbing its risk.

Impact of the COVID-19 pandemic on obstructive sleep apnea: recommendations for symptom management

STUDY OBJECTIVES

In the context of the current COVID-19 pandemic situation, we address the following important questions: (1) How can patients be identified for possible OSA while sleep clinic testing is temporarily unavailable or limited? and (2) What measures can be suggested to improve sleep health until proper diagnosis and treatment become safe and available again?

METHODS

As a proxy for home or in-laboratory testing, validation of a symptom-based measure of OSA risk is presented, based on an ongoing larger prospective study of 156 family medicine patients with OSA (88 women, 68 men; mean age, 57 years) and 60 control participants (36 women, 24 men; mean age, 54 years) recruited from the community. Participants completed the Sleep Symptom Checklist (SSC) and a range of other self-report measures; primary care patients also underwent a polysomnographic sleep study.

RESULTS

Results showed that (1) individuals with OSA reported more symptoms on the SSC related to insomnia, daytime symptoms, sleep disorders, and psychological maladjustment than did the control group (all P < .001), and (2) their sleep-related symptoms were significantly more severe than those of the control patients. In addition, several polysomnographic indices in recently diagnosed untreated individuals with OSA were significantly correlated with SSC measured sleep disorder symptoms, and SSC scores significantly distinguished participants with OSA from control participants.

CONCLUSIONS

Our findings suggest that family practitioners can effectively prescreen patients for possible OSA by inquiring about 5 items that form the SSC sleep disorders subscale. If OSA is suspected, then we can recommend a range of behavioral techniques to improve symptoms. The current pandemic causes us to reflect that the provisional targeting of symptoms and guidance regarding mitigation strategies while waiting for specialist care could serve patients well at any time.