The differential impact of respiratory event scoring criteria on CPAP eligibility in women and men

Obstructive Sleep Apnea

OBJECTIVE

Obstructive sleep apnea (OSA) is the most common type of sleep-disordered breathing. This article describes advances in the diagnosis, testing, treatment, and monitoring of OSA.

LATEST DEVELOPMENTS

Home sleep apnea testing and in-laboratory polysomnography are the most commonly used diagnostic tools in the identification and monitoring of OSA, but new methods for diagnosis and at-home monitoring of treatment response are being developed and validated. While the apnea-hypopnea index is regularly used to define OSA severity, recognition is increasing of its inability to risk-stratify patients. Other sleep study data including arousal threshold, hypoxic burden, and pulse rate variability as well as clinical characteristics can help with risk stratification. The most effective treatment is continuous positive airway pressure (CPAP), which can be limited by adherence and tolerance in some patients. Newer masks and comfort features including heated tubing and expiratory pressure relief may improve tolerance to positive airway pressure (PAP) therapy. Additional treatment options include other PAP modalities, mandibular advancement devices, tongue stimulation therapy, negative inspiratory pressure, nasal expiratory pressure valves, nasal congestion treatments, upper airway surgeries including hypoglossal nerve stimulation, and medications.

ESSENTIAL POINTS

OSA is a common disorder that causes sleep and daytime symptoms and increases the risk of neurologic and medical complications. Neurologists should be aware of atypical presentations and understand the diagnostic and treatment options.

Continuous positive airway pressure treatment of obstructive sleep apnea and hypertensive complications in high-risk pregnancy

PURPOSE

To evaluate whether or not continuous positive airway pressure (CPAP) treatment in pregnancies complicated by obstructive sleep apnea (OSA) is associated with a decrease in hypertensive disorders of pregnancy.

METHODS

This was a retrospective cohort study of perinatal outcomes in women who underwent objective OSA testing and treatment as part of routine clinical care during pregnancy. Where diagnostic criteria for OSA were reached (respiratory event index (REI) ≥ 5 events per hour), patients were offered CPAP therapy. Obstetrical outcomes were compared between the control group (no OSA), the group with untreated OSA (OSA diagnosed, not CPAP compliant), and the group with treated OSA (OSA diagnosed and CPAP compliant), with CPAP compliance defined as CPAP use ≥ 4 h, 70% of the time or greater. A composite hypertension outcome combined diagnoses of gestational hypertension (gHTN) and preeclampsia (PreE) of any severity.

RESULTS

The study comprised outcomes from 177 completed pregnancies. Our cohort was characterized by obesity, with average body mass indices > 35 kg/m2, and average maternal age > 30 years old. CPAP was initiated at an average gestational age of 23 weeks (12.1-35.3 weeks), and average CPAP use was 5.9 h (4-8.5 h). The composite hypertension outcome occurred in 43% of those without OSA (N = 77), 64% of those with untreated OSA (N = 77), and 57% of those with treated OSA, compliant with CPAP (N = 23) (p = 0.034).

CONCLUSION

Real-world data in this small study suggest that CPAP therapy may modulate the increased risk of hypertensive complications in pregnancies complicated by OSA.

Sex-specific differences in diagnostic approaches of inpatient sleep testing for obstructive sleep apnea

BACKGROUND

Few studies have investigated sex-specific disparities in inpatient sleep testing. We postulate that women are more likely to have a milder degree of obstructive sleep apnea (OSA) and lower extent of hypoxia on Type III sleep studies versus polysomnography (PSG).

PATIENTS AND METHODS

The Cleveland Clinic Sleep laboratory registry was leveraged to identify all adult inpatient sleep studies performed for OSA. Demographics, comorbidities, and sleep study measures were collected and compared by sex and sleep study type. Logistic regression was used to examine sleep study type predictive of OSA (apnea hypopnea index [AHI; ≥5, ≥15 and ≥ 30]) and hypoxia, (median percentage of sleep time spent at <90% SaO2 [TST<90%,≥ 11%,] adjusted for covariates.

RESULTS

The sample 778 patients had a mean age of 56.1 ± 16.1 years; 44.5% were female and 72.2% Caucasian. At an AHI≥5, women showed an increase odds of OSA (adjusted, OR = 2.04,95%; CI:1.24-3.35, p = 0.005) with Type III sleep study vs PSG compared to men. At an AHI≥15, men had less odds of OSA (adjusted OR = 0.60,95%CI:0.39-0.90,p = 0.015) with Type III sleep study vs PSG compared to women (OR = 1.15,95%CI:0.72-1.85,p = 0.56), with an interaction p-value of 0.040. These results were attenuated when the analysis was restricted using the 3% hypopnea scoring rule. Men and women had higher odds of TST <90 ≥ 11% (OR:2.60,95%CI:1.60-4.21,p=<0.001; OR:3.46,95%CI:1.97-6.05,p < 0.001) with Type III sleep study versus PSG, albeit no sex-interaction was observed.

CONCLUSIONS

These results suggest that sex-specific differences in diagnostic performance of sleep testing type in the inpatient setting should be considered according to level of OSA severity, which are influenced by hypopnea-related desaturation extent.

Fifteen Patients Who Can Be Helped by Medicare: Insurance Policy Changes in the Coverage of CPAP Therapy for Obstructive Sleep Apnea

Insurance coverage policies define the diagnostic criteria and adherence requirements for patients to qualify for initial and ongoing therapy with continuous positive airway pressure (CPAP) treatment, the most complete therapy for obstructive sleep apnea. Unfortunately, a number of patients who use CPAP and benefit from treatment fail to meet these requirements. We present 15 patients who fail to meet Centers for Medicare and Medicaid Services' (CMS) criteria, highlighting policies that do not support patient care. Finally, we review expert panel recommendations to improve CMS policies, and we suggest ways that physicians can better support CPAP access within the current regulatory restrictions.

Obstructive Sleep Apnea: Another Condition to Screen for in Women with Infertility

Women with obstructive sleep apnea (OSA) are at increased risk of poor pregnancy outcomes such as fetal growth restriction, hypertensive disorders of pregnancy, and gestational diabetes mellitus. Given this increased risk, we aimed to study the screening prevalence of OSA in women seeking fertility treatment. We performed a cross sectional study of patients presenting to a university-affiliated fertility clinic between March-April 2021. Patients were asked to complete OSA screening (STOP-BANG), anxiety screening (GAD-7), and depression screening (PHQ-2) questionnaires. 107 women completed the surveys. Mean age was 35.1 years and mean body mass index (BMI) was 25.7 kg/m2. Nine (8.4%) women screened positive for OSA using the STOP-BANG screening tool. Women who screened positive for OSA were more likely to be older (37.8 years vs. 34.7 years, p = 0.02) and have a higher BMI (42.6 kg/m2 vs. 27.4 kg/m2, p < 0.001). Women who screened positive for OSA were also more likely to screen positive for mild-severe depressive symptoms (22.2% vs. 3.1%, p = 0.006) and mild-severe anxiety (66.7% vs. 21.4%, p = 0.003) symptoms. 24.3% of the population had polycystic ovary syndrome (PCOS). Women with PCOS were more likely to screen positive for OSA (19.2% vs. 4.9%; p = 0.04). Despite this being a low-risk population of young women seeking fertility evaluation or treatment, 8% screened positive for OSA. Given the association between OSA and adverse pregnancy outcomes, our results underline the need to screen women seeking fertility treatment.

A transition to the AASM recommended hypopnea definition in adults: initiatives of the Hypopnea Scoring Rule Task Force

The American Academy of Sleep Medicine (AASM) recommends that hypopneas be identified using a definition that is based on a ≥30% decrease in airflow associated with a ≥3% reduction in the oxygen saturation or an arousal (H3A) for diagnosis of obstructive sleep apnea (OSA) in adults. This conflicts with the Centers for Medicare and Medicaid Services (CMS) definition, which requires a ≥4% decrease in the oxygen saturation to identify a hypopnea (H4) and does not acknowledge arousals. In 2018, the AASM board of directors constituted a Hypopnea Scoring Rule Task Force (HSRTF) with a mandate to "create a strategy for adoption and implementation of the AASM recommended adult hypopnea scoring criteria among members, payers and device manufacturers." The task force initiated several activities including a survey of AASM accredited laboratories and discussions with polysomnography software vendors. Survey results indicated that most laboratories scored polysomnograms using only the CMS definition. Vendors indicated that they could easily support dual scoring. Informal testing among task force members' laboratories confirmed there would be little additional work if dual scoring was performed. The task force convened several meetings of a working group of OSA content experts and interested parties, with the purpose of creating research recommendations to study the impact on relevant clinical outcomes using the different definitions of hypopnea. Several possible prospective and retrospective approaches were discussed with emphasis on the group of patients diagnosed with OSA based on an apnea-hypopnea index (AHI) using H3A but NOT H4. Based on the deliberations of the working group, the HSRTF submitted recommendations to the AASM Foundation concerning research project strategies for potential grant funding. Further discussions within the HSRTF focused on developing advocacy initiatives among patient stakeholder groups to change payer policy.