Evaluation of Clinical Tools to Screen and Assess for Obstructive Sleep Apnea

A Machine Learning Prediction Model of Adult Obstructive Sleep Apnea Based on Systematically Evaluated Common Clinical Biochemical Indicators

Objective

Obstructive sleep apnea (OSA) is a common and potentially fatal sleep disorder. The purpose of this study was to construct an objective and easy-to-promote model based on common clinical biochemical indicators and demographic data for OSA screening.

Methods

The study collected the clinical data of patients who were referred to the Sleep Medicine Center of the Second Affiliated Hospital of Fujian Medical University from December 1, 2020, to July 31, 2023, including data for demographics, polysomnography (PSG), and 30 biochemical indicators. Univariate and multivariate analyses were performed to compare the differences between groups, and the Boruta method was used to analyze the importance of the predictors. We selected and compared 10 predictors using 4 machine learning algorithms which were "Gaussian Naive Bayes (GNB)", "Support Vector Machine (SVM)", "K Neighbors Classifier (KNN)", and "Logistic Regression (LR)". Finally, the optimal algorithm was selected to construct the final prediction model.

Results

Among all the predictors of OSA, body mass index (BMI) showed the best predictive efficacy with an area under the receiver operating characteristic curve (AUC) = 0.699; among the predictors of biochemical indicators, triglyceride-glucose (TyG) index represented the best predictive performance (AUC = 0.656). The LR algorithm outperformed the 4 established machine learning (ML) algorithms, with an AUC (F1 score) of 0.794 (0.841), 0.777 (0.827), and 0.732 (0.788) in the training, validation, and testing cohorts, respectively.

Conclusion

We have constructed an efficient OSA screening tool. The introduction of biochemical indicators in ML-based prediction models can provide a reference for clinicians in determining whether patients with suspected OSA need PSG.

Diagnostic Accuracy of a Portable Electromyography and Electrocardiography Device to Measure Sleep Bruxism in a Sleep Apnea Population: A Comparative Study

BACKGROUND

The gold standard for diagnosing sleep bruxism (SB) and obstructive sleep apnea (OSA) is polysomnography (PSG). However, a final hypermotor muscle activity often occurs after apnea episodes, which can confuse the diagnosis of SB when using portable electromyography (EMG) devices. This study aimed to compare the number of SB episodes obtained from PSG with manual analysis by a sleep expert, and from a manual and automatic analysis of an EMG and electrocardiography (EKG) device, in a population with suspected OSA.

METHODS

Twenty-two subjects underwent a polysomnographic study with simultaneous recording with the EMG-EKG device. SB episodes and SB index measured with both tools and analyzed manually and automatically were compared. Masticatory muscle activity was scored according to published criteria. Patients were segmented by severity of OSA (mild, moderate, severe) following the American Academy of Sleep Medicine (AASM) criteria. ANOVA and the Bland-Altman plot were used to quantify the agreement between both methods. The concordance was calculated through the intraclass correlation coefficient (ICC).

RESULTS

On average, the total events of SB per night in the PSG study were (8.41 ± 0.85), lower than the one obtained with EMG-EKG manual (14.64 ± 0.76) and automatic (22.68 ± 16.02) analysis. The mean number of SB episodes decreases from the non-OSA group to the OSA group with both PSG (5.93 ± 8.64) and EMG-EKG analyses (automatic = 22.47 ± 18.07, manual = 13.93 ± 11.08). However, this decrease was minor in proportion compared to the automatic EMG-EKG analysis mode (from 23.14 to 22.47). The ICC based on the number of SB episodes in the segmented sample by severity degree of OSA along the three tools shows a moderate correlation in the non-OSA (0.61) and mild OSA (0.53) groups. However, it is poorly correlated in the moderate (0.24) and severe (0.23) OSA groups: the EMG-EKG automatic analysis measures 14.27 units more than PSG. The results of the manual EMG-EKG analysis improved this correlation but are not good enough.

CONCLUSIONS

The results obtained in the PSG manual analysis and those obtained by the EMG-EKG device with automatic and manual analysis for the diagnosis of SB are acceptable but only in patients without OSA or with mild OSA. In patients with moderate or severe OSA, SB diagnosis with portable electromyography devices can be confused due to apneas, and further study is needed to investigate this.

Assessment of Leptin Levels and Their Correlation With the Severity of Obstructive Sleep Apnea Syndrome: A Case-Control Study

Background Obstructive sleep apnea (OSA) is characterized by a combination of structural issues in the upper airway and imbalances in the respiratory control system. While numerous studies have linked OSA with obesity, it remains uncertain whether leptin, a hormone associated with fat, plays a role in the functional and anatomical defects that lead to OSA. Therefore, the aim of this study was to investigate whether leptin levels could be used as a predictor of OSA syndrome (OSAS). Methodology A case-control observational study was conducted, enrolling study participants who reported obesity (BMI > 30) within the range of >30 to <35 kg/m2, along with a short neck and a history of snoring, excessive daytime drowsiness, fatigue, or insomnia. Leptin levels and fasting blood sugar (FBS) were measured in all individuals. Additionally, the study evaluated the severity of OSAS using indicators such as the STOP BANG scores, apnea-hypopnea index, uvula grade score, and Epworth Sleepiness Scale scores. Results A total of 80 participants (40 cases and 40 controls) were included in the study. The mean leptin and FBS levels were significantly higher in cases compared to controls. Moreover, leptin levels exhibited a significant correlation with the severity indices of OSAS. Conclusion The study findings indicate that individuals with higher leptin levels tend to exhibit more severe OSAS symptoms. Furthermore, these elevated leptin levels contribute to the worsening of various OSA symptoms. Larger controlled studies have suggested that pharmacologically restoring the altered leptin levels may serve as a beneficial adjunct to treatment for alleviating OSAS symptoms.

Examining the feasibility of adult quality-of-life measurement for obstructive sleep apnea in clinical settings: what is the path forward for sleep centers?

Quality of life (QoL) is one of the outcomes that can be measured as a component of the required standards for sleep facility accreditation by the American Academy of Sleep Medicine. Utilization of a psychometrically robust QoL instrument is recommended; however, clinicians face a challenge balancing psychometric properties with questionnaire completion and scoring characteristics. This article provides an overview of common QoL instruments as a reference for clinicians when selecting a QoL tool for use in the clinical setting for adult patients with obstructive sleep apnea.

CITATION

Colvin L, Collop N, Lorenz R, Morgenthaler T, Weaver TE. Examining the feasibility of adult quality-of-life measurement for obstructive sleep apnea in clinical settings: what is the path forward for sleep centers? J Clin Sleep Med. 2023;19(6):1145-1155.

Combining four screening tools for cost effective screening of OSA in train drivers: A UK experience

Background

Obstructive sleep apnoea (OSA) in drivers/workers has been implicated in railway and road traffic safety incidents; however, there are insufficient data on its prevalence and cost-effective screening methods.

Aim

This pragmatic study examines four OSA screening tools: the Epworth sleepiness scale (ESS), the STOP-Bang (SB), the adjusted neck circumference (ANC) and the body mass index (BMI), exploring their suitability and effectiveness separately and in combination.

Method

Using all four tools, 292 train drivers were opportunistically screened between 2016 and 2017. A polygraph (PG) test was carried out when OSA was suspected. Patients with an apnoea-hypopnea index (AHI) ≥5 were referred to a clinical specialist and reviewed annually. Those who had continuous positive airway pressure (CPAP) treatment were evaluated for compliance and control.

Results

Of the 40 patients who had PG testing, 3 and 23 participants met the ESS >10 and SB >4, criteria, respectively, whereas 25 participants each had an ANC >48 and a BMI >35 with a risk factor or ≥40 with none. OSA was detected in 3, 18 and 16 of them who met the ESS, SB and ANC criteria, respectively, and was positive for OSA in addition to 16 others who met the BMI criteria. A total of 28 (72%) were diagnosed with OSA.

Conclusion

Although when used individually, these screening methods are less effective/inadequate, combining them is easy, feasible and offers the maximum chance of OSA detection in train drivers.

Sleep Disturbances in Neurological Disease: A Target for Intervention

Sleep is a biological function required for neurological and general health, but a significant and under-recognized proportion of the population has disturbed sleep. Here, we briefly overview the biology of sleep, sleep requirements over the lifespan, and common sleep disorders. We then turn our attention to five neurological diseases that significantly contribute to global disease burden and neurology practice makeup: epilepsy, headache, ischemic stroke, Parkinson's disease, and Alzheimer's disease. For each disease, we review evidence that sleep disturbances contribute to disease risk and severity and discuss existing data that addressing sleep disturbances may have disease-modifying effects. We provide recommendations derived from the literature and existing clinical guidelines to facilitate the evaluation and management of sleep disturbances within the context of each neurological disease. Finally, we synthesize identified needs and commonalities into future directions for the field and practical sleep-related recommendations for physicians caring for patients at risk for or currently suffering from neurological disease.

Management of obstructive sleep apnea in Europe - A 10-year follow-up

OBJECTIVE

In 2010, a questionnaire-based study on obstructive sleep apnea (OSA) management in Europe identified differences regarding reimbursement, sleep specialist qualification, and titration procedures. Now, 10 years later, a follow-up study was conducted as part of the ESADA (European Sleep Apnea Database) network to explore the development of OSA management over time.

METHODS

The 2010 questionnaire including questions on sleep diagnostic, reimbursement, treatment, and certification was updated with questions on telemedicine and distributed to European Sleep Centers to reflect European OSA management practice.

RESULTS

26 countries (36 sleep centers) participated, representing 20 ESADA and 6 non-ESADA countries. All 21 countries from the 2010 survey participated. In 2010, OSA diagnostic procedures were performed mainly by specialized physicians (86%), whereas now mainly by certified sleep specialists and specialized physicians (69%). Treatment and titration procedures are currently quite homogenous, with a strong trend towards more Autotitrating Positive Airway Pressure treatment (in hospital 73%, at home 62%). From 2010 to 2020, home sleep apnea testing use increased (76%-89%) and polysomnography as sole diagnostic procedure decreased (24%-12%). Availability of a sleep specialist qualification increased (52%-65%) as well as the number of certified polysomnography scorers (certified physicians: 36%-79%; certified technicians: 20%-62%). Telemedicine, not surveyed in 2010, is now in 2020 used in diagnostics (8%), treatment (50%), and follow-up (73%).

CONCLUSION

In the past decade, formal qualification of sleep center personnel increased, OSA diagnostic and treatment procedures shifted towards a more automatic approach, and telemedicine became more prominent.

Obstructive Sleep Apnea Is Treatable With Continuous Positive Airway Pressure in People With Schizophrenia and Other Psychotic Disorders

Obstructive sleep apnea (OSA) is a highly prevalent condition in people living with schizophrenia or other psychotic disorder. Its treatment with continuous positive airway pressure therapy (CPAP) can dramatically improve daytime and physical health function. People with a psychotic disorder, however, are rarely diagnosed and treated and there are no large-scale studies showing evidence of successful treatment with CPAP. Using a retrospective case-control study approach (N = 554), we examined adherence to and effectiveness of a CPAP trial in individuals with comorbid psychotic disorder and OSA (psychosis group, n = 165) referred for a CPAP trial at the West Australian Sleep Disorders Research Institute. Given that antipsychotic medication is an important confounder, we included a psychiatric (non-psychosis) comparison group taking antipsychotic medication (antipsychotic group, n = 82), as well as a nonpsychiatric control group (OSA control group, n = 307) also diagnosed with OSA and referred for CPAP. Variables included OSA symptom response, CPAP engagement, and usage at 3 months. The Psychosis group had the most severe OSA at baseline and they attended fewer clinic appointments overall. However, there were no other group differences either in CPAP adherence or treatment response. CPAP was equally effective in normalizing OSA symptoms and daytime sleepiness in all groups. CPAP usage was longer per night in the Psychosis and Antipsychotic groups, perhaps suggesting a role of sedation from antipsychotic medications. In conclusion, OSA is treatable and CPAP feasible in people with severe mental illness and antipsychotic medications are not a barrier to treatment response.

An easy maneuver to screen for moderate-to-severe obstructive sleep spnea: the Simmons Chin Press and Tongue Curl

OBJECTIVES

To demonstrate that the Simmons chin press and tongue curl (SCPTC) correlates with diagnosis of moderate-to-severe obstructive sleep apnea (msOSA) by itself as well as irrespective of the presence of other associated features.

MATERIAL AND METHODS

A consecutive sample of 1,911 sleep studies performed on adult patients from 2/8/2017 to 3/5/2019 was analyzed. The SCPTC exam maneuver was performed on each patient, followed by home sleep apnea testing or in-laboratory polysomnography. The AASM hypopnea 1B 4% desaturation criteria were utilized for scoring to correlate results to existing literature on morbidity and mortality. A chi-squared using low and high SCPTC score was performed for the outcome of msOSA. Known significant predictors of OSA were dichotomized for comparison and a multiple logistic regression was performed.

RESULTS

1,708 patients qualified for inclusion: 902 males (52.8%) and 806 females (47.2%) with a mean age of 49.4 and a mean body mass index (BMI) of 28.6. A high SCPTC score correlated with an odds ratio (OR) of 2.49 (95% CI: 2.03-3.04, p<0.001) for msOSA. A multiple logistic regression analysis including other risk factors for msOSA demonstrated that high SCPTC scores had an odds ratio for msOSA of 1.77 (95% CI: 1.40-2.23; p<0.001).

CONCLUSION

The SCPTC is a reproducible physical exam feature that can be utilized by healthcare providers to screen for patients with msOSA.

Using anthropometric measures to screen for obstructive sleep apnea in the Sleep Heart Health Study cohort

STUDY OBJECTIVES

To evaluate predictions of moderate-to-severe-obstructive sleep apnea (MS-OSA) by the neck circumference height ratio (NHR) and waist circumference height ratio (WHR) and compare to the derived STOP-Bang Questionnaire (dSBQ) prediction.

METHODS

Included were 6,167 participants from the Sleep Heart Health Study (SHHS) baseline evaluation who completed polysomnograms, had anthropometric measurements, and data to compute proxy dSBQ item answers. The sample was divided randomly into derivation (n = 2,035) and validation (n = 4,132) subsets. The derivation sample was used to estimate the NHR and WHR cut points to detect MS-OSA; the validation sample was used to evaluate sensitivity (SN) and specificity (SP).

RESULTS

Mean age was 63.1 years, and 47.2% were male for the overall sample. In the derivation sample, a cut point ≥ 0.21 for NHR yielded a SN of 92.0% and SP of 25.0%; a cut point ≥ 0.52 for WHR yielded a SN of 91.2% and SP of 25.0% for MS-OSA. Using the validation sample, the NHR, WHR, and dSBQ areas under the receiver operator curves (AUCs) were 69.8%, 65.2%, and 70.5% respectively for MS-OSA. There was no statistical difference with listwise comparison of the NHR and dSBQ AUCs (p = 0.997); however, there was a significant difference between the WHR and dSBQ AUCs (p = 0.015) for MS-OSA.

CONCLUSIONS

The NHR is a viable OSA screening tool comparable to the dSBQ, independent of witnessed apneas and BMI, that can be used for different body types.

Selection of Screening Tool for Sleep-Disordered Breathing or Obstructive Sleep Apnea in Pediatric Patients in the Perianesthesia Setting

PURPOSE

This study was undertaken to select an appropriate tool to predict risk of obstructive sleep apnea (OSA) among pediatric patients in the preoperative setting.

DESIGN/METHODS

A retrospective chart review and a survey of nursing staff to compare two tools that were determined to be valid in assessing risk of OSA and postanesthesia complications in pediatric patients aged 6 months to 18 years was conducted. About 300 pediatric patients presenting for elective surgery were screened for OSA using STBUR (Snoring, Trouble Breathing during sleep, struggling to Breathe during Sleep, and waking UnRefreshed) and ST(1)OP-BANG (Snoring, Tonsillar hypertrophy, sleep Obstruction, BMI, Age, Neuromuscular disorders, and Genetic/congenital deformities) concurrently. Six preoperative nurses were then surveyed to compare ease of use and time to complete the screening tools.

FINDINGS

The STBUR tool was found to predict complications in 37.5% patients versus 22.7% patients with the pediatric ST(1)OP-BANG. Nursing staff found that although both tools were quick and easy to use, the STBUR tool was easier for parents to answer.

CONCLUSIONS

Use of a screening tool to help predict risk of OSA and postanesthetic complications also helps to dictate anesthesia technique, nursing staffing requirements, and plans of care for postoperative management of pediatric patients.

Evaluation and Management of Adults with Obstructive Sleep Apnea Syndrome

Obstructive sleep apnea syndrome (OSAS) is a common and underdiagnosed medical condition characterized by recurrent sleep-dependent pauses and reductions in airflow. While a narrow, collapsible oropharynx plays a central role in the pathophysiology of OSAS, there are other equally important nonanatomic factors including sleep-stage dependent muscle tone, arousal threshold, and loop gain that drive obstructive apneas and hypopneas. Through mechanisms of intermittent hypoxemia, arousal-related sleep fragmentation, and intrathoracic pressure changes, OSAS impacts multiple organ systems. Risk factors for OSAS include obesity, male sex, age, specific craniofacial features, and ethnicity. The prevalence of OSAS is rising due to increasing obesity rates and improved sensitivity in the tools used for diagnosis. Validated questionnaires have an important but limited role in the identification of patients that would benefit from formal testing for OSA. While an in-laboratory polysomnography remains the gold standard for diagnosis, the widespread availability and accuracy of home sleep apnea testing modalities increase access and ease of OSAS diagnosis for many patients. In adults, the most common treatment involves the application of positive airway pressure (PAP), but compliance continues to be a challenge. Alternative treatments including mandibular advancement device, hypoglossal nerve stimulator, positional therapies, and surgical options coupled with weight loss and exercise offer possibilities of an individualized personal approach to OSAS. Treatment of symptomatic patients with OSAS has been found to be beneficial with regard to sleep-related quality of life, sleepiness, and motor vehicle accidents. The benefit of treating asymptomatic OSA patients, particularly with regard to cardiovascular outcomes, is controversial and more data are needed.

Age-specific markers of adiposity in patients with obstructive sleep apnea

OBJECTIVES

Adiposity can have varying effects on the individual depending upon its distribution pattern. We assessed age-related distribution of adipose tissue by anthropometric measures and bioelectrical impedance analysis, as well as their association with obstructive sleep apnea (OSA) severity.

METHODS

Participants were 169 elderly (aged ≥ 65 years) and 142 non-elderly (aged < 65 years) referred for overnight polysomnography. The associations between obesity parameters and apnea-hypopnea index (AHI) were determine by univariate and multivariate linear regression analyses. Area under receiver operating characteristic curve (AUC) was used to access the predicting performance of some parameters.

RESULTS

Compared with non-elderly, elderly showed higher conicity index and visceral adiposity (VA)/subcutaneous adiposity (SA), lower body mass index (BMI), neck circumference, waist circumference, hip circumference and SA. Multiple regression analyses revealed that VA and VA/SA were independently associated with AHI in elderly (explained 17.2% of the AHI ^0.5 variability), while BMI and VA/SA were independently associated with AHI in non-elderly (explained 25.9% of the AHI ^0.5 variability), after adjusting for age, sex, cigarette smoking, alcohol drinking and main comorbidities. In elderly, VA over 128 cm² and VA/SA less than 0.41 resulted in sensitivity, specificity and AUC of 0.382, 0.790, 0.580 and 0.176, 0.947, 0.553 in predicting moderate-to-severe OSA, respectively. In non-elderly, BMI over 24.7 kg/m² and VA/SA over 0.54 resulted in sensitivity, specificity and AUC of 0.883, 0.484, 0.704 and 0.550, 0.710, 0.667 in predicting moderate-to-severe OSA, respectively.

CONCLUSIONS

VA is strongly associated with OSA severity in elderly, independently of general obesity as per BMI standards, while general adiposity appears to be more strongly associated with OSA severity in non-elderly. Our study supports age-specific approaches should be developed with respect to prediction and treatment of OSA.

Characteristics of pharyngeal paraesthesia symptoms in patients with obstructive sleep apnoea

PURPOSE

This study aimed to investigate pharyngeal paraesthesia symptoms in patients with obstructive sleep apnoea (OSA).

MATERIAL AND METHODS

Patients with snoring and suspected OSA as well as age-matched controls were recruited. All participants underwent nocturnal polysomnography (PSG) and pharyngeal paraesthesia assessment using the Glasgow-Edinburgh throat scale (GETS). The incidence and severity of pharyngeal paraesthesia symptoms were compared between the groups.

RESULTS

A total of 280 patients who snored or were suspected of having OSA and 35 healthy, age-matched controls were recruited. The total pharyngeal paraesthesia symptom score was significantly higher in the OSA group than in the healthy group (12 [5, 23] vs. 3 [0, 9]; p < 0.001). The most frequent pharyngeal paraesthesia symptoms in the snore patients were Q7 (catarrh down the throat) and Q3 (discomfort/irritation in the throat), which are related to the irritability of the throat. The incidence of Q7 (OSA, 58% vs. controls, 14%; χ² = 23.66; p < 0.001), Q3 (OSA, 46% vs. controls, 3%; χ² = 23.07; p < 0.001), Q1 (feeling of something stuck in the throat; OSA, 33% vs. controls, 6%; χ² = 11.00; p = 0.001), Q6 (swelling in the throat; OSA, 31% vs. controls, 0%; χ² = 14.53; p < 0.001), Q9 (want to swallow all the time; OSA, 20% vs. controls, 6%; χ² = 6.28; p = 0.012), Q5 (throat closing off; OSA, 24% vs. controls, 6%; χ² = 6.16; p = 0.013), and Q2 (pain in the throat; OSA, 23% vs. controls, 6%; χ² = 5.32; p = 0.021) was significantly higher in the OSA group than in the controls CONCLUSIONS: Patients with obstructive sleep apnoea have higher pharyngeal paraesthesia symptoms scores and tend to have irritated throats compared to healthy controls.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT03506178.

Diagnostic accuracy and suitability of instruments that screen for obstructive sleep apnoea, insomnia and sleep quality in cardiac patients: a meta-analysis

BACKGROUND

A number of clinical guidelines recommend that all cardiac rehabilitation patients should be screened for potential sleep disorders with a validated screening instrument. There is currently no consensus on what specific tools should be used.

OBJECTIVE

To identify tools that are practical to use in the clinical environment and have high diagnostic accuracy.

METHODS

We systematically searched online databases to identify patient reported outcome instruments that have been used in published research studies to assess the likelihood of obstructive sleep apnoea (OSA) in cardiac patients. In studies that provided diagnostic data, these data were extracted and verified via an evidence-based diagnostic calculator. Where sufficient numbers of studies were available, a meta-analysis was conducted to determine pooled estimates of specificity, sensitivity and diagnostic odds ratios. Selected papers were qualitatively assessed using the Standards for Reporting Diagnostic accuracy studies (STARD).

RESULTS

Of the 21 instruments identified, six detected likelihood of OSA, two assessed daytime sleepiness, five assessed insomnia and eight examined sleep quality. A meta-analysis of 14 studies that assessed diagnostic accuracy of moderate OSA, revealed moderate sensitivity for the Berlin Questionnaire, Sens = 0.49 (95% CI 0.45-0.52) and good sensitivity for the Stop-BANG, Sens = 0.93 (95% CI 0.87-0.96) but poor specificity at standard cut-off criteria.

CONCLUSION

There are promising practical tools available to screen patients with OSA and other sleep disorders in cardiac rehabilitation settings, but specificity could be improved. Additional assessment of sleep quality may enhance prognostic ability with both OSA and insomnia screening.

Sleep screening for cystic fibrosis patients: A survey of cystic fibrosis programs

OBJECTIVE

The prevalence of sleep disorders in patients with cystic fibrosis (CF) is unknown, and no standardized screening or treatment guidelines exist to address sleep disorders in CF. The objective of this study is to characterize current sleep screening practices in adult, pediatric, combined, and affiliate CF programs.

METHODS

A survey was developed in Research Electronic Data Capture and distributed to program directors of accredited CF programs in the United States.

RESULTS

Eighty-eight program directors responded (36% adult, 43% pediatric, 16% combined, 3% affiliate, and 1% unidentified). Of the respondents, 68% were part of an academic institution, 24% were associated with an academic institution, and 8% were part of a community or private program. Program sizes ranged from less than 50 to more than 500 patients. Routine or informal sleep screening was not performed in 44% of adults, 29% of pediatricians, and 35% of combined and affiliate programs. Most programs (>80%) have access to otolaryngology and sleep medicine although not all of these programs refer patients for evaluation of sleep disorders. Most program directors (77%) perceive sleep disorders as a problem in CF and would recommend routine sleep screening. Possible barriers to sleep screening included clinic flow, screening fatigue, and lack of recommendations for sleep screening.

CONCLUSIONS

Formal sleep screening is inconsistent among CF care centers although most survey respondents would recommend the inclusion of screening in routine CF care. Future work is needed to further evaluate the impact of sleep disorders in CF and determine best practices for standardization of sleep screening and treatment.

Night-time frequency of urination as a manifestation of sleep-disordered breathing: the Nagahama study

AIMS

Sleep-disordered breathing (SDB) is a well-known risk factor for cardiovascular outcomes. Studies of patients with SDB have identified frequent night-time urination as a manifestation related to SDB. We aimed to clarify whether night-time frequency of urination is independently associated with SDB in a general population. We also investigated whether night-time frequency of urination can help presumptive diagnose SDB.

METHODS

Study participants consisted of 7151 community residents. Oxygen saturation during sleep was measured for four nights using a pulse oximeter. SDB was defined as ≥15 events per hour in which oxygen desaturation exceeded or equal to 3% during an actigraphy-determined sleep period. Night-time frequency of urination was recorded for one week using a sleep diary.

RESULTS

Significant positive correlations were evident between night-time frequency of urination and SDB (none, 5.8%; once/night, 14.1%; twice/night, 20.1%; thrice/night, 28.7%; >thrice/night, 44.1%, P < 0.001). This association was independent of possible covariates, including sleep duration (adjusted odds ratio: once/night = 1.50, twice/night = 2.15, thrice/night = 3.07, >thrice/night = 3.73, P < 0.001). Other factors significantly associated with SDB were age, sex, obesity, observation of sleep apnea, and short sleep duration. The area under the curve of the risk score for SDB consisting of these conventional six items (0.834) significantly improved (0.842, P = 0.001) when night-time frequency of urination was considered as a risk score item.

CONCLUSION

Night-time frequency of urination was associated with SDB. Our findings suggest that the urination frequency should be considered a manifestation of SDB even in a general population.

Telehealth, Telemedicine, and Obstructive Sleep Apnea

Obstructive sleep apnea (OSA) telehealth management may improve initial and chronic care access, time to diagnosis and treatment, between-visit care, e-communications and e-education, workflows, costs, and therapy outcomes. OSA telehealth options may be used to replace or supplement none, some, or all steps in the evaluation, testing, treatments, and management of OSA. All telehealth steps must adhere to OSA guidelines. OSA telehealth may be adapted for continuous positive airway pressure (CPAP) and non-CPAP treatments. E-data collection enhances uses for individual and group analytics, phenotyping, testing and treatment selections, high-risk identification and targeted support, and comparative and multispecialty therapy studies.

Comparison of Diagnostic Sleep Studies in Hospitalized Neurorehabilitation Patients With Moderate to Severe Traumatic Brain Injury

BACKGROUND

OSA is prevalent during a time of critical neural repair after traumatic brain injury (TBI). The diagnostic utility of existing sleep studies is needed to inform clinical management during acute recovery from TBI.

RESEARCH QUESTION

This study aimed to evaluate the non-inferiority and diagnostic accuracy of a portable level 3 sleep study relative to level 1 polysomnography in hospitalized neurorehabilitation patients with TBI.

STUDY DESIGN AND METHODS

This is a prospective clinical trial conducted at six TBI Model System study sites between May 2017 and February 2019. Of 896 admissions, 449 were screened and eligible for the trial, with 345 consented. Additional screening left 263 eligible for and completing simultaneous administration of both level 1 and level 3 sleep studies, with final analyses completed on 214 (median age = 42 years; ED Glasgow Coma Scale = 6; time to polysomnography [PSG] = 52 days).

RESULTS

Agreement was moderate to strong (weighted kappa = 0.78, 95% CI, 0.72-0.83) with the misclassification commonly occurring with mild sleep apnea due to underestimation of apnea hypopnea index (AHI). Most of those with moderate to severe sleep apnea were correctly classified (n = 54/72). Non-inferiority was not demonstrated: the minimum tolerable specificity of 0.5 was achieved across all AHI cutoff scores (lower confidence limits [LCL] range, 0.807-0.943), but the minimum tolerable sensitivity of 0.8 was not (LCL range, 0.665-0.764).

INTERPRETATION

Although the non-inferiority of level 3 portable diagnostic testing relative to level 1 was not established, strong agreement was seen across sleep apnea indexes. Most of those with moderate to severe sleep apnea were correctly identified; however, there was risk of misclassification with level 3 sleep studies underestimating disease severity for those with moderate to severe AHI and disease presence for those with mild AHI during early TBI neurorehabilitation.

The use of visceral adiposity variables in the prediction of obstructive sleep apnea: evidence from a large cross-sectional study

PURPOSE

The purposes of this study were to evaluate the ability of visceral adiposity variables [the lipid accumulation product (LAP), the visceral adiposity index (VAI), and the triglyceride-glucose index (TyG)] in predicting obstructive sleep apnea hypopnea syndrome (OSAHS) and to determine the effect of sex on the prediction.

METHODS

A total of 5539 subjects admitted to the sleep center for suspected OSAHS were consecutively recruited from 2007 to 2016. Anthropometric measurements, biological indicators, Epworth sleepiness scale score, and polysomnographic variables were collected. Prediction models for diagnosing OSAHS were established in the test group by logistic regression and verified in the validation group by receiver operating characteristic (ROC) curves.

RESULTS

A total of 4703 patients were included in total. LAP and TyG were of moderate diagnostic accuracy for OSAHS, with the diagnostic efficiency differing between men and women. A prediction model was developed that combined visceral adiposity indicators with waist circumstance and the lowest SpO₂. The sensitivity of those indicators were both 84% in men and women, respectively, and their specificity were both 90%. In addition, the model was confirmed in the validation group with a sensitivity and specificity of 83% and 85% in men and 85% and 84% in women.

CONCLUSIONS

LAP and TyG were of moderate efficiency in screening for OSAHS. The prediction model provides a simple and practical screening tool for OSAHS.

Sleep disordered breathing in Marfan syndrome: Value of standard screening questionnaires

Background

A high prevalence of sleep disordered breathing (SDB) has been reported in persons with Marfan syndrome (MFS), a single gene disorder of connective tissue resulting in premature death from aortic rupture. The burden of SDB and accompanying hemodynamic stress could warrant broad screening in this population. Our goal was to assess the utility of traditional SDB screening tools in our sample of persons with MFS.

Methods

Participants were recruited during an annual Marfan Foundation meeting and Marfan status confirmed using the Ghent criteria. Screening questionnaires were administered and SDB assessed by home sleep testing. We assessed accuracy of screening tools using receiver‐operating characteristic curve analyses.

Results

The prevalence of moderate‐severe SDB was 32% in our sample of 31 MFS participants. The Stop‐Bang questionnaire had the highest positive predictive value (PPV) of 60% and the highest negative predictive value (NPV) of 100% using the high‐ and moderate‐risk cut‐offs, respectively, and the Berlin questionnaire had a PPV of 50% and an NPV of 92.3% at the high‐risk cut‐off. When those with mild SDB were included, the Stop‐Bang and the Sleep Apnea Clinical Score (SACS) questionnaires demonstrated useful screening accuracies with PPVs of 94.7% and 92.9%, and NPVs of 63.6% and 47.1%, respectively, at the moderate‐risk cut‐offs.

Conclusion

A survey of SDB in a sample of persons with MFS reveals not only a high burden of SDB but also that conventional screening instruments have utility if adapted appropriately. Future studies should validate the utility of these screening tools given concerns that SDB may contribute to progression of aortic pathology in MFS.

Comparative Effectiveness of Sleep Apnea Screening Instruments During Inpatient Rehabilitation Following Moderate to Severe TBI

OBJECTIVE

To determine the diagnostic sensitivity and specificity and comparative effectiveness of traditional sleep apnea screening tools in traumatic brain injury (TBI) neurorehabilitation admissions.

DESIGN

Prospective diagnostic comparative effectiveness trial of sleep apnea screening tools relative to the criterion standard, attended level 1 polysomnography including encephalography.

SETTING

Six TBI Model System Inpatient Rehabilitation Centers.

PARTICIPANTS

Between May 2017 and February 2019, 449 of 896 screened were eligible for the trial with 345 consented (77% consented). Additional screening left 263 eligible for and completing polysomnography with final analyses completed on 248.

INTERVENTION

Not applicable.

MAIN OUTCOME MEASURES

Area under the curve (AUC) of screening tools relative to total apnea hypopnea index≥15 (AHI, moderate to severe apnea) measured at a median of 47 days post-TBI (interquartile range, 29-47).

RESULTS

The Berlin high-risk score (receiving operating curve [ROC] AUC=0.634) was inferior to the Multivariable Apnea Prediction Index (MAPI) (ROC AUC=0.780) (P=.0211; CI, 0.018-0.223) and Snoring, Tired, Observed, Blood Pressure, Body Mass Index, Age, Neck Circumference, and Gender (STOPBANG) score (ROC AUC=0.785) (P=.001; CI, 0.063-0.230), both of which had comparable AUC (P=.7245; CI, -0.047 to 0.068). Findings were similar for AHI≥30 (severe apnea); however, no differences across scales was observed at AHI≥5. The pattern was similar across TBI severity subgroups except for posttraumatic amnesia (PTA) status wherein the MAPI outperformed the Berlin. Youden's index to determine risk yielded lower sensitivities but higher specificities relative to non-TBI samples.

CONCLUSION

This study is the first to provide clinicians with data to support a choice for which sleep apnea screening tools are more effective during inpatient rehabilitation for TBI (STOPBANG, MAPI vs Berlin) to help reduce comorbidity and possibly improve neurologic outcome.

Real-world STOPBANG: how useful is STOPBANG for sleep clinics?

PURPOSE

The STOPBANG questionnaire has been widely used for screening obstructive sleep apnea (OSA) due to its time friendly, economic advantages over overnight polysomnography (PSG). The aim of this study was to analyze the usefulness of the items constituting the utility of STOPBANG in a sleep clinic and to establish the best assembly for OSA-screening methods in the Korean population.

METHODS

We retrospectively analyzed all patients who completed PSG as well as STOPBANG at a sleep center in a tertiary hospital from January 2016 to December 2017. The sensitivity and specificity of STOPBANG and its smaller counterparts (i.e., SOPBAG) were compared.

RESULTS

A total of 541 subjects completed PSG and STOPBANG. Two hundred thirty-five patients were diagnosed with OSA (OSA+) and were compared to those who were not (OSA-). The respective scores of STOPBANG in OSA+ versus OSA- were 4.29 ± 1.46 and 2.53 ± 1.48 (p < 0.001). There were significant differences in all factors except tiredness and age (SOPBNG). STOPBANG showed sensitivity of 89.1% and specificity of 57.4%. The AUC was 0.809. Excluding tiredness as well as neck circumference (SOPBAG), the AUC was 0.811. The sensitivity and specificity were 71.8% and 77.9%, respectively. The AUC of SOPBAG was neither superior nor inferior to that of STOPBANG.

CONCLUSION

The screening value of STOPBANG for OSA did not perform as expected when compared to PSG for accuracy in Koreans. STOPBANG can be simplified to SOPBAG while maintaining comparable screening performance. It may be practical to consider performing PSGs without the use of the STOPBANG in Korea.