Complex sleep apnea syndrome

Investigation of Snoring and Obstructive Sleep Apnea Using Portable Polysomnography in Patients with Temporomandibular Disorder

Objective

To investigate snoring and obstructive sleep apnea (OSA) in patients with temporomandibular disorder (TMD) using portable polysomnography and identify sex-based differences in clinical features and sleep-related results.

Methods

Seventy consecutive patients (44 female; mean age, 46.6918.18 years) with myofascial pain-associated TMD, diagnosed based on the criteria for TMD Axis I, were enrolled. Sleep quality and quantity were measured using portable polysomnography. Clinical characteristics were investigated using well-structured standardized reports on clinical signs and symptoms, questionnaires, and clinical examination by TMD specialists.

Results

Among 70 TMD patients, 50.0% had OSA and 15.7% had snoring, with no sex-based differences. The mean Mallampati scores for OSA prediction (2.69±1.12 vs. 1.70±0.82, p<0.001), mean body mass index (BMI) (24.94±1.78 vs. 22.02±2.24, p<0.001), and ratio of overweight patients (57.7 vs. 11.4%) with BMI ≥25 were significantly higher in males than in females (all p<0.001). Conversely, the mixed sleep apnea index was significantly higher in females than in males (0.81±0.80 vs. 0.44±0.54, p=0.022). Female sex was associated with the absence of snoring (OR=0.146, p=0.022). Based on the area under curve (AUC) value for snoring prediction, Mallampati score was the strongest predictor (AUC>0.932, p<0.001), followed by BMI, overweight, and obstructive sleep apnea index (AUC>0.8, all p<0.001).

Conclusions

Our results support the necessity of investigating sex-based differences when examining sleep problems, including snoring and OSA, in TMD patients. Mallampati scoring could be a useful tool for physical examination prior to polysomnography. Sleep and biopsychosocial factors are important for the diagnosis and treatment of TMD.

Atrial fibrillation is associated with central sleep apnea in clinic patients undergoing diagnostic polysomnography

INTRODUCTION

Sleep apnea is highly prevalent in patients with atrial fibrillation (AF). Obstructive sleep apnea (OSA) is the most common type, and best studied in the context of AF. However, recent investigations have indicated that central sleep apnea (CSA) may be a risk factor for incident AF. We evaluated the burden of CSA events in patients referred for diagnostic polysomnography (PSG) and whether AF is associated with CSA.

METHODS

We identified patients with and without a history of AF who underwent clinically indicated PSG in a matched manner. OSA was defined as obstructive apnea-hypopnea index (AHI) ≥15/h, and CSA was defined as central apnea index (CAI) ≥5/h. The association between AF and CSA was evaluated using multivariable logistic regression.

RESULTS

Among 465 patients included, mean AHI was 25.5/h, and mean CAI was 1.7/h. OSA prevalence was 53.3%, while CSA prevalence was 8.4%. The prevalence of OSA in the AF and non-AF groups (54.7% vs 52.0%, P = .56) was similar. CSA was more common in the AF group (12.3% vs 4.4%, P = .002). In multivariable analysis, AF (OR: 2.19 [1.02, 5.03], P = .05), male gender (OR: 2.5 [1.17, 5.84], P = .02), and older age (OR: 2.44, [1.16, 5.46], P = .02) were associated with CSA.

CONCLUSION

Though CSA is much less common than OSA in patients with AF, the presence of AF is independently associated with CSA.

Central sleep apnea and atrial fibrillation: A review on pathophysiological mechanisms and therapeutic implications

Precipitating factors and chronic diseases associated with atrial fibrillation (AF) are detailed in the literature. Emerging evidence over the last several decades suggests a potential causal relationship between central sleep apnea (CSA) and AF. Mechanisms including apnea-induced hypoxia with intermittent arousal, fluctuating levels of carbon dioxide, enhanced sympathetic/neurohormonal activation and oxidative stress causing inflammation have been implicated as etiologic causes of AF within this subpopulation. CSA affects the efficacy of pharmacologic and catheter-based antiarrhythmic treatments, which is why treating CSA prior to these interventions may lead to lower rates of AF. Subsequently, a reduction in the AF burden with transvenous phrenic nerve stimulation (TPNS) has become a topic of interest. The present review describes the relationship between these conditions, pathophysiologic mechanisms implicating the role of CSA in development of AF, and emerging therapeutic interventions.

[Complex sleep apnea syndrome]

Complex sleep apnea syndrome (Comp-SAS) is the term used to describe a specific form of sleep disordered breathing characterized by the arise of central sleep apnea in patient with previous obstructive sleep apnea syndrome (OSAS) treated with continuous positive airway pressure devices (CPAP). The mechanisms of its occurrence are not well understood, but partly it seems to be a consequence of increased carbon dioxide elimination under positive airway pressure treatment and related improvement of pulmonary ventilation. The prevalence of Comp-SAS ranges from 5% to 20% of OSAS patient getting CPAP therapy with no significant predictors in comparison with simple obstructive sleep apnea, but more likely to happened in older males with more severe OSAS and accompanying cardiovascular pathology such as ischemic heart disease, atrial fibrillation and heart failure. In most cases of Comp-SAS, central apnea events are transient and disappear after continuous CPAP therapy use for 1 to 2 months. Novel treatment options like adaptive servo-ventilation or BiPAP-ST are available for such non-responders to CPAP but contra-indicated to patients with systolic heart failure. From the other hand, still not clear is it mandatory to treat all affected individuals with Comp-SAS if the disease is uncomplicated and patient is asymptomatic.

Predictors of Sleep Apnea in the Canadian Population

Older age, obesity, hypertension, snoring, and excessive daytime sleepiness have been associated with sleep apnea. The objective of this study was to determine the prevalence (crude and adjusted), as well as the risk factors, of sleep apnea in the adult Canadian population. Data from the 2009 Sleep Apnea Rapid Response (SARR) questionnaire were used to identify the risk factors, and all sleep-related questions in the SARR questionnaire were used. The outcome variable of interest was health professional-diagnosed sleep apnea. Covariates of interest were demographic variables, population characteristics, respiratory and cardiovascular diseases, and enabling resources. The multiple logistic regression model adjusted for the clustering effect was used to analyze the data. Sleep apnea was diagnosed in 858,913 adults (3.4% of the population), and more men (65.4%) than women (34.6%) were diagnosed with sleep apnea. Multivariable logistic regression analysis indicated that age (45 and older), loud snoring, sudden awakening with gasping/choking (rare/sometimes and once or more a week), and nodding off/falling asleep in driving in the past 12 months were significantly associated with diagnosed sleep apnea. Predictive probability demonstrated that in overweight and obese persons, ≥15 minutes of daily exercise significantly decreased the risk of diagnosed sleep apnea. The conclusion of this study is that in the Canadian population, sleep apnea is associated with older age, loud snoring, and sleeping problems. The protective effect of exercise warrants further investigation.

The Bidirectional Relationship Between Obstructive Sleep Apnea and Metabolic Disease

Obstructive sleep apnea (OSA) is a common sleep disorder, effecting 17% of the total population and 40-70% of the obese population (1, 2). Multiple studies have identified OSA as a critical risk factor for the development of obesity, diabetes, and cardiovascular diseases (3-5). Moreover, emerging evidence indicates that metabolic disorders can exacerbate OSA, creating a bidirectional relationship between OSA and metabolic physiology. In this review, we explore the relationship between glycemic control, insulin, and leptin as both contributing factors and products of OSA. We conclude that while insulin and leptin action may contribute to the development of OSA, further research is required to determine the mechanistic actions and relative contributions independent of body weight. In addition to increasing our understanding of the etiology, further research into the physiological mechanisms underlying OSA can lead to the development of improved treatment options for individuals with OSA.

Positive airway pressure adherence and subthreshold adherence in posttraumatic stress disorder patients with comorbid sleep apnea

STUDY OBJECTIVES

Patients with comorbid posttraumatic stress disorder (PTSD) and obstructive sleep apnea (OSA) manifest low adherence to continuous positive airway pressure (CPAP) due to fixed, pressure-induced expiratory pressure intolerance (EPI), a subjective symptom and objective sign aggravated by anxiety sensitivity and somatosensory amplification. As advanced PAP therapy modes (ie, auto-bilevel PAP [ABPAP] or adaptive servo-ventilation [ASV]) may address these side effects, we hypothesized such treatment would be associated with decreased expiratory intolerance and increased adherence in posttraumatic stress patients with co-occurring OSA.

METHODS

We reviewed charts of 147 consecutive adult patients with moderately severe posttraumatic stress symptoms and objectively diagnosed OSA. All patients failed or rejected CPAP and were manually titrated on auto-adjusting, dual-pressure ABPAP or ASV modes in the sleep laboratory, a technique to eliminate flow limitation breathing events while resolving EPI. Patients were then prescribed either mode of therapy. Follow-up encounters assessed patient use, and objective data downloads (ODDs) measured adherence.

RESULTS

Of 147 charts reviewed, 130 patients were deemed current PAP users, and 102 provided ODDs: 64 used ASV and 38 used ABPAP. ODDs yielded three groups: 59 adherent per insurance conventions, 19 subthreshold compliant partial users, and 24 noncompliant. Compliance based on available downloads was 58%, notably higher than recently reported rates in PTSD patients with OSA. Among the 19 partial users, 17 patients were minutes of PAP use or small percentages of nights removed from meeting insurance compliance criteria for PAP devices.

CONCLUSION

Research is warranted on advanced PAP modes in managing CPAP failure in PTSD patients with comorbid OSA. Subthreshold adherence constructs may inform clinical care in a patient-centric model distinct from insurance conventions. Speculatively, clinical application of this transitional zone ("subthreshold" number of hours) may increase PAP use and eventual adherence.

Clinical predictors of central sleep apnea evoked by positive airway pressure titration

PURPOSE

Treatment-emergent central sleep apnea (TECSA), also called complex apnea, occurs in 5%-15% of sleep apnea patients during positive airway pressure (PAP) therapy, but the clinical predictors are not well understood. The goal of this study was to explore possible predictors in a clinical sleep laboratory cohort, which may highlight those at risk during clinical management.

METHODS

We retrospectively analyzed 728 patients who underwent PAP titration (n=422 split-night; n=306 two-night). Demographics and self-reported medical comorbidities, medications, and behaviors as well as standard physiological parameters from the polysomnography (PSG) data were analyzed. We used regression analysis to assess predictors of binary presence or absence of central apnea index (CAI) ≥5 during split-night PSG (SN-PSG) versus full-night PSG (FN-PSG) titrations.

RESULTS

CAI ≥5 was present in 24.2% of SN-PSG and 11.4% of FN-PSG patients during titration. Male sex, maximum continuous positive airway pressure, and use of bilevel positive airway pressure were predictors of TECSA, and rapid eye movement dominance was a negative predictor, for both SN-PSG and FN-PSG patients. Self-reported narcotics were a positive predictor of TECSA, and the time spent in stage N2 sleep was a negative predictor only for SN-PSG patients. Self-reported history of stroke and the CAI during the diagnostic recording predicted TECSA only for FN-PSG patients.

CONCLUSION

Clinical predictors of treatment-evoked central apnea spanned demographic, medical history, sleep physiology, and titration factors. Improved predictive models may be increasingly important as diagnostic and therapeutic modalities move away from the laboratory setting, even as PSG remains the gold standard for characterizing primary central apnea and TECSA.

The association of sleep disordered breathing with heart failure and other cardiovascular conditions

An abundance of evidence exists in support of primary and secondary prevention for tackling the scourge of cardiovascular disease. Despite our wealth of knowledge, certain deficiencies still remain. One such example is the association between sleep disordered breathing (SDB) and cardiovascular disease. A clear body of evidence exists to link these two disease entities (independent of other factors such as obesity and smoking), yet our awareness of this association and its clinical implication does not match that of other established cardiovascular risk factors. Here, we outline the available evidence linking SDB and cardiovascular disease as well as discussing the potential consequences and management in the cardiovascular disease population.