Obstructive sleep apnea: not just a sleep disorder

Periocular Manifestation of Obstructive Sleep Apnea as a Novel Perioperative Screening Tool

Purpose

Obstructive sleep apnea (OSA) presents perioperative challenges with increased risk for complications. Floppy eyelid syndrome (FES) is associated with OSA yet has not been addressed perioperatively. The current standard for perioperative OSA screening includes assessing patient risk factors or the STOP-BANG tool, which requires an active participant. We aimed to confirm a connection between FES and OSA in presurgical patients and develop a screening method appropriate for patients with perioperative OSA risk.

Materials and Methods

162 presurgical pre-anesthesia clinic patients were enrolled. Screening questions determined eligibility. Those who were pregnant or aged < 19 were excluded. Control group included those with a STOP-BANG score < 3. Experimental group included those with BMI > 35 and OSA diagnosis. Examiners photographed participants’ eyes with vertical and horizontal retraction while two blinded ophthalmologists used a grading scale to review grade of eyelid laxity.

Results

Differences in habitus, ASA score, and hypertension as a comorbidity were significant. Sensitivity of FES screening was 52% (CI 37–66%) and specificity was 56% (CI 46–66%) for reviewer 1. For reviewer 2, sensitivity was 48% (CI 28–69%) and specificity was 72% (CI 60–81%). Negative predictive value was 86% (CI 81–90) for reviewer 1 and 88% (CI 83–92%) for reviewer 2. Inter-rater agreement was moderate.

Conclusion

While specificity and sensitivity were lower than anticipated, negative predictive value was high. Given this strong negative predictive value, our findings indicate using eyelid retraction to screen for FES has perioperative clinical utility. These findings encourage further research addressing the connection of lid laxity/FES to OSA.

Key Points

• Aimed to investigate if a FES screening tool could identify perioperative OSA risk.

• Negative predictive value for FES with OSA was 86%.

• Observing periocular lid laxity has clinical utility; is feasible in any patient.

Graphical abstract

Evaluation of the success of obstructive sleep apnea surgery using criteria based on long-term symptoms and incident hypertension

OBJECTIVE

To identify appropriate success criteria, based on long-term symptoms and incident hypertension, after surgery for obstructive sleep apnea (OSA).

METHODS

This observational cohort study included 97 adult OSA patients (90 men) who underwent surgical treatment at our tertiary medical center. Subjective symptoms [witnessed sleep apnea and snoring, and Epworth sleepiness scale (ESS) scores] were evaluated through a telephone survey, and incident hypertension was assessed from medical records. The subjects were divided into success and failure groups according to seven different criteria, and data were analyzed to identify the criteria that could significantly differentiate the success from failure groups.

RESULTS

The participants had a mean age of 48.8 ± 11.9 years and a mean preoperative body mass index of 26.5 ± 3.5 kg/m². The mean preoperative and postoperative apnea-hypopnea index (AHI) values were 36.1/h and 19.4/h, respectively. The mean follow-up duration was 77.0 ± 31.1 months. Postoperative witnessed apnea, snoring, and the ESS scores decreased significantly compared to preoperative scores in both the success and failure groups based on most of the seven criteria. Among the seven criteria, success and failure groups based on a postoperative AHI cutoff of 15 or 20/h differed significantly in witnessed apnea, snoring, or ESS scores. Kaplan-Meier survival analysis based on incident hypertension revealed that no criterion could significantly distinguish between the two groups.

CONCLUSIONS

Our results suggest that some of the success criteria analyzed may be more useful in differentiating between success and failure groups after surgery, in terms of long-term improvement of subjective OSA-related symptoms.

Treatment success with titratable thermoplastic mandibular advancement devices for obstructive sleep apnea: A comparison of patient characteristics

A titratable thermoplastic mandibular advancement device (MAD) is clearly an effective treatment option in some patients with obstructive sleep apnea (OSA). Determining which patients may be more likely to respond to treatment with thermoplastic MADs and to adhere to treatment would be of obvious clinical relevance. This was an experimental descriptive study (N = 60). Patients with OSA were instructed to wear a titratable thermoplastic MAD for 3 months. Treatment success was defined as a ≥50% reduction from baseline in the apnea-hypopnea index (AHI) or AHI <10 when wearing MAD. Adherence was defined as MAD use ≥5 nights/week. Treatment was successful in 66.7% of patients and 60.0% were adherent. All polysomnographic parameters and visual analogue scale scores (sleep quality, snoring, waking refreshed) were significantly improved after treatment. The patients in whom treatment failed had significantly higher neck circumferences (39.3 cm vs. 37.5 cm, p = 0.014), higher baseline AHI values (26.6 vs. 18.0, p = 0.016), and smaller AHI reduction (-31.8 vs -53.1, p < 0.001) than those in the group in whom treatment succeeded. There were no significant differences in polysomnographic, cephalometric, or visual analogue scale measures between patients for whom treatment was and was not successful, regardless of baseline values or the change rates after the MAD was placed. Titratable thermoplastic MADs can improve indicators of sleep quality, even in patients in whom treatment is considered to have failed.

Randomized, Prospective Study of the Impact of a Sleep Health Program on Firefighter Injury and Disability

Study Objectives

Firefighters' schedules include extended shifts and long work weeks which cause sleep deficiency and circadian rhythm disruption. Many firefighters also suffer from undiagnosed sleep disorders, exacerbating fatigue. We tested the hypothesis that a workplace-based Sleep Health Program (SHP) incorporating sleep health education and sleep disorders screening would improve firefighter health and safety compared to standard practice.

Design

Prospective station-level randomized, field-based intervention.

Setting

US fire department.

Participants

1189 firefighters.

Interventions

Sleep health education, questionnaire-based sleep disorders screening, and sleep clinic referrals for respondents who screened positive for a sleep disorder.

Measurements and Results

Firefighters were randomized by station. Using departmental records, in an intention-to-treat analysis, firefighters assigned to intervention stations which participated in education sessions and had the opportunity to complete sleep disorders screening reported 46% fewer disability days than those assigned to control stations (1.4 ± 5.9 vs. 2.6 ± 8.5 days/firefighter, respectively; p = .003). There were no significant differences in departmental injury or motor vehicle crash rates between the groups. In post hoc analysis accounting for intervention exposure, firefighters who attended education sessions were 24% less likely to file at least one injury report during the study than those who did not attend, regardless of randomization (OR [95% CI] 0.76 [0.60, 0.98]; χ2 = 4.56; p = .033). There were no significant changes pre- versus post-study in self-reported sleep or sleepiness in those who participated in the intervention.

Conclusions

A firefighter workplace-based SHP providing sleep health education and sleep disorders screening opportunity can reduce injuries and work loss due to disability in firefighters.

Evaluating the benefits of home-based management of atrial fibrillation: current perspectives

Atrial fibrillation (AF) is the most common arrhythmia worldwide, leading to an extensive public health and economic burden. The increasing incidence and prevalence of AF is due to the advancing age of the population, structural heart disease, hypertension, diabetes, and thyroid disease. The majority of costs associated with AF have been attributed to the cost of hospitalization. In order to minimize costs and decrease hospitalizations, counseling on modifiable risk factors contributing to AF has been strongly emphasized. With the release of novel oral anticoagulants bypassing the need for anticoagulant bridging or laboratory monitoring, post-discharge nurse-led home intervention, and novel methods of heart rate monitoring, home-based AF management has reached a new level of ease and sophistication. In this review, we aimed to review modifiable risk factors for AF and various methods of home-based management of AF, along with their benefits.

[Clinical features of obstructive sleep apnea syndrome in patients with acromegaly]

AIM

To investigate the incidence of sleep-related breathing disorders (SRBDs) in patients with active acromegaly (AM), to specify risk factors influencing apnea/hypopnea index (AHI), and to reveal the specific features of obstructive sleep apnea (OSA) in patients with AM versus those with OSA without AM.

SUBJECTS AND METHODS

Fifty patients with active AM were examined and divided into 3 groups: control group 1 did not differ from the study group in body mass index (BMI); control group 2 did not similar in AHI from the AM group. Polysomnography was done in all the patients.

RESULTS

SRBDs were detected in 40 (80%) patients. Obstructive apnea was found in all cases. Correlation analysis revealed the relationships between AHI and gender (AHI was higher in the men), BMI, disease duration, and insulin-like growth factor 1 (GF-1). There were no correlations between AHI and gender, maximum adenoma size, and growth hormone levels. Compared with control group 1, the AM group had a statistically significantly higher median AHI [16 (1-92) and 4.7 (0-31.3) episodes per hour of sleep (p < 0.001)]. In control group 2, the median BMI was considerably higher than in the control group [29.2 (19.9-44.3) and 35 (24-56) kg/m2 (p < 0.001).

CONCLUSION

The detection rate of SRBDs in patients with active AM was 80%, with obstructive disorders being prevalent. There was a positive relationship between SRBD severity and BMI, AM duration, IGF-1 level. Compared to the controls, the patients with AM developed SRBDs similar in severity with lower BMI; severer SRBDs were detected in the patients with active AM with the similar BMI.

Influence of chronic intermittent hypoxia on growth associated protein 43 expression in the hippocampus of young rats

This study aimed to explore the pathological change to hippocampal neurons and the expression of growth associated protein 43 in 21-day-old young rats following chronic intermittent hypoxia. Hematoxylin-eosin staining results showed varying degrees of degeneration and necrosis in hippocampal neurons depending on the modeling time. Immunohistochemistry revealed that growth associated protein 43 expression in young rats following chronic intermittent hypoxia decreased, but that levels were still higher than those of normal rats at each time point, especially 4 weeks after modeling. During 1–5 weeks after modeling, a slow growth in rat weight was observed. Experimental findings indicate that chronic intermittent hypoxia may induce growth dysfunction and necrosis of hippocampal neurons, as well as increase the expression of growth associated protein 43 in young rats.

White coat hypertension and obstructive sleep apnea

PURPOSE

This study aimed to determine blood pressure characteristics and long-term progress in patients with white coat hypertension (WCH) and obstructive sleep apnea (OSA).

METHODS

Systolic blood pressure (SBP) and diastolic blood pressure (DBP) and sleep test results over a period of 26 months were analyzed from WCH patients with OSA (n = 28), WCH patients (n = 23), and healthy control subjects (n = 27).

RESULTS

At the end of observation, WCH patients with OSA presented significantly increased daytime and nighttime BP and lower diurnal difference of SBP (all Ps < 0.05) and the increased rate of "non-dipper" status (SBP 28.6 %, DBP 32.1 %) was significantly higher when compared with WCH and control groups (all Ps < 0.01). Sustained hypertension was observed in 42.8 % of the WCH patients with OSA, which was significantly higher than that in the WCH and control groups (Ps < 0.01) and was predicted by non-dipper status via 24-h ambulatory SBP/DBP monitoring (Ps < 0.05).

CONCLUSION

WCH may represent a prehypertension status, which could develop into sustained hypertension with OSA.

Efficacy of radiofrequency treatment of the soft palate for patients with mild to moderate obstructive sleep apnea hypopnea syndrome: treatment protocol with nine lesions to the soft palate

PURPOSE

The study aimed at assessing the efficacy and safety of a radiofrequency treatment (RFT) protocol with nine lesions to the soft palate in the treatment of mild to moderate obstructive sleep apnea hypopnea syndrome (OSAHS).

METHODS

Twenty-eight mild to moderate OSAHS patients underwent two sessions of RFT (CelonLab ENT system) at the palatal level within the interval from 6 to 8 weeks. Nine lesions (power setting of 10 W) were made per session. The baseline and posttreatment polysomnography and clinical tests battery consisting of visual analogue scales (VAS), Sleep Apnea Quality of Life Index (SAQLI), Beck Depression Inventory--second edition (BDI-II), and Epworth sleepiness scale (ESS) were applied to assess the RFT outcomes.

RESULTS

Mild to moderate OSAHS patients demonstrated statistically significantly reduced posttreatment mean VAS values for most of the OSAHS-related complaints. A significant improvement in sleepiness (ESS score 6.7 ± 3.7 vs 8.5 ± 4.1, p < 0.01), depressivity (BDI-II score 7.5 ± 6.5 vs 13.1 ± 11.7, p < 0.01), and health-related quality of life (SAQLI score 5.3 ± 0.8 vs 4.7 ± 0.9, p < 0.01) was observed after the RFT. The mean AHI decreased from 13.7 ± 5.9 to 8.3 ± 4.9 points (p < 0.01) in the entire group of patients. According to Sher's criteria of success, 17 out of 28 (60.7 %) patients improved after RFT. No major complications were noted with RFT.

CONCLUSIONS

RFT protocol with nine lesions to the soft palate seems to be an effective and safe treatment modality associated with low morbidity in selected mild to moderate OSAHS patients.

Obstructive sleep apnea and atrial fibrillation: understanding the connection

There is a high incidence of atrial fibrillation (AF) in patients with obstructive sleep apnea (OSA). Whether this represents a causative relationship or is merely an association remains to be determined. This review describes the current understanding of pathophysiologic links supporting a causative relationship between OSA and AF. The management of AF with antiarrhythmics, cardioversion and ablation success depends on compliance with OSA treatment. OSA worsens every risk factor resulting in a higher stroke risk in AF patients. Strategies for early screening and compliance with OSA treatment are the need of the hour.

Atrial fibrillation in the 21st century: a current understanding of risk factors and primary prevention strategies

Atrial fibrillation (AF) is the most common arrhythmia worldwide, and it has a significant effect on morbidity and mortality. It is a significant risk factor for stroke and peripheral embolization, and it has an effect on cardiac function. Despite widespread interest and extensive research on this topic, our understanding of the etiology and pathogenesis of this disease process is still incomplete. As a result, there are no set primary preventive strategies in place apart from general cardiology risk factor prevention goals. It seems intuitive that a better understanding of the risk factors for AF would better prepare medical professionals to initially prevent or subsequently treat these patients. In this article, we discuss widely established risk factors for AF and explore newer risk factors currently being investigated that may have implications in the primary prevention of AF. For this review, we conducted a search of PubMed and used the following search terms (or a combination of terms): atrial fibrillation, metabolic syndrome, obesity, dyslipidemia, hypertension, type 2 diabetes mellitus, omega-3 fatty acids, vitamin D, exercise toxicity, alcohol abuse, and treatment. We also used additional articles that were identified from the bibliographies of the retrieved articles to examine the published evidence for the risk factors of AF.

Ambulatory office visits and medical comorbidities associated with obstructive sleep apnea

OBJECTIVE

(1) Understand the epidemiology of obstructive sleep apnea (OSA) ambulatory office visits in the United States. (2) Quantify the prevalence of comorbid illnesses that are likely to occur in the setting of OSA.

METHODS

From the 2008-2009 National Ambulatory Medical Care Surveys and National Hospital Ambulatory Medical Care Surveys, adult cases with a diagnosis of OSA were extracted. The epidemiology of OSA was determined. The prevalences of comorbid priority illnesses (obesity, asthma, cerebrovascular disease, depression, hypertension, and ischemic heart disease) were also determined.

STUDY DESIGN

Cross-sectional analysis of a national survey database.

SETTING

Ambulatory care settings in the United States.

RESULTS

There were an estimated 4.1 ± 1.2 million annual visits with a diagnosis of OSA (60% ± 3.2% men; mean age, 56.4 ± 0.9 years). There were 419,000 ± 28,000 visits annually to otolaryngologists for OSA. Comorbid illnesses were obesity (23.8% ± 5.2%), asthma (14.3% ± 3.0%), cerebrovascular disease (2.5% ± 1.5%), depression (23.2% ± 2.6%), hypertension 53.8% ± 3.9%), and ischemic heart disease (10.3% ± 3.0%). Adjusting for age, sex, ethnicity, obesity, and race, statistically significant increased odds for the presence of obesity (3.6, P < .001), asthma (2.7, P < .001), depression (2.5, P < .001), and hypertension (2.0, P < .001) with OSA were noted. Increased odds for cerebrovascular disease and ischemic heart disease were not identified (P = .725 and P = .083, respectively).

CONCLUSION

Obstructive sleep apnea is a relatively common diagnosis in ambulatory and otolaryngologic care. It is associated with a significantly increased prevalence of several key priority health care conditions in the United States. Otolaryngologists and health care providers should be aware of these associations, understanding the potentially broad impact of OSA on general health.

Pulmonary hypertension due to obstructive sleep apnea in a child with Rubinstein-Taybi syndrome

Rubinstein-Taybi syndrome (RTS) is characterized by peculiar facies, mental retardation, broad thumbs, and great toes. Approximately one-third of the affected individuals have a variety of congenital heart diseases. They can also have upper airway obstruction during sleep, due to hypotonia and the anatomy of the oropharynx and airway, which make these patients susceptible to obstructive sleep apnea (OSA). In our case, pulmonary hypertension was caused, successively, by congenital heart defects (a large patent ductus arteriosus and arch hypoplasia) and obstructive sleep apnea during early infancy. The congenital heart defects were surgically corrected, but persistent pulmonary hypertension was identified 2 months after the operation. This pulmonary hypertension was due to OSA, and it was relieved by nasal continuous positive airway pressure. This case is the first report of pulmonary hypertension from OSA in a young infant with RTS.

The world epidemic of sleep disorders is linked to vitamin D deficiency

An observation of sleep improvement with vitamin D supplementation led to a 2 year uncontrolled trial of vitamin D supplementation in 1500 patients with neurologic complaints who also had evidence of abnormal sleep. Most patients had improvement in neurologic symptoms and sleep but only through maintaining a narrow range of 25(OH) vitamin D3 blood levels of 60-80 ng/ml. Comparisons of brain regions associated with sleep-wake regulation and vitamin D target neurons in the diencephalon and several brainstem nuclei suggest direct central effects of vitamin D on sleep. We propose the hypothesis that sleep disorders have become epidemic because of widespread vitamin D deficiency. The therapeutic effects together with the anatomic-functional correspondence warrant further investigation and consideration of vitamin D in the etiology and therapy of sleep disorders.