"Count on Sleep": an OSA awareness project update

Obstructive sleep apnea (OSA) is a common, chronic sleep-related breathing disorder that affects approximately 12% of the US adult population. Greater public awareness of OSA is necessary to decrease the number of people with undiagnosed or untreated OSA and reduce the negative health consequences of unrecognized OSA. In 2021, the American Academy of Sleep Medicine initiated the "Count on Sleep" project in partnership with key stakeholders with the objective of raising the awareness of OSA among the public, health care providers, and public health officials. Four workgroups implemented strategies and completed tasks focused on increasing OSA awareness in their targeted areas to address the objectives of the project including (1) Public Awareness and Communications, (2) Provider Education, (3) Tool Development and Surveillance, and (4) a Strategic Planning workgroup that coordinated efforts across the project. Over the first 2 years, workgroups made substantial progress toward project goals including holding "listening sessions" with representatives of communities disproportionately affected by OSA and its consequences, developing resources for primary care providers that can be easily accessed and used in practice, and developing a brief survey for use in estimating and tracking OSA risk across the population. Over the first 2 project years, workgroups made significant progress in advancing efforts to increase awareness of OSA in US communities. The third year of the project will focus on dissemination of campaign materials and resources for all targeted groups, including the public, health care professionals, and public health professionals.

CITATION

Martin JL, Rowley J, Goel N, et al. "Count on Sleep": an OSA awareness project update. J Clin Sleep Med. 2024;20(2):303-307.

Enhancing public health and safety by diagnosing and treating obstructive sleep apnea in the transportation industry: an American Academy of Sleep Medicine position statement

Obstructive sleep apnea (OSA) may lead to serious health, safety, and financial implications-including sleepiness-related crashes and incidents-in workers who perform safety-sensitive functions in the transportation industry. Evidence and expert consensus support its identification and treatment in high-risk commercial operators. An Advanced Notice of Proposed Rulemaking regarding the diagnosis and treatment of OSA in commercial truck and rail operators was issued by the Federal Motor Carrier Safety Administration and Federal Railroad Administration, but it was later withdrawn. This reversal has led to questions about whether efforts to identify and treat OSA are warranted. In the absence of clear directives, we urge key stakeholders, including clinicians and patients, to engage in a collaborative approach to address OSA by following, at a minimum, the 2016 guidelines issued by a Medical Review Board of the Federal Motor Carrier Safety Administration, alone or in combination with 2006 guidance by a joint task force. The current standard of care demands action to mitigate the serious health and safety risks of OSA.

CITATION

Das AM, Chang JL, Berneking M, et al. Enhancing public health and safety by diagnosing and treating obstructive sleep apnea in the transportation industry: an American Academy of Sleep Medicine position statement. J Clin Sleep Med. 2022;18(10):2467-2470.

Age and weight considerations for the use of continuous positive airway pressure therapy in pediatric populations: an American Academy of Sleep Medicine position statement

This position statement provides guidance for age and weight considerations for using continuous positive airway pressure (CPAP) therapy in pediatric populations. The American Academy of Sleep Medicine (AASM) commissioned a task force of experts in pediatric sleep medicine to review the medical literature and develop a position statement based on a thorough review of these studies and their clinical expertise. The AASM Board of Directors approved the final position statement. It is the position of the AASM that CPAP can be safe and effective for the treatment of obstructive sleep apnea (OSA) for pediatric patients, even in children of younger ages and lower weights, when managed by a clinician with expertise in evaluating and treating pediatric OSA. The clinician must make the ultimate judgment regarding any specific care in light of the individual circumstances presented by the patient, accessible treatment options, patient/parental preference, and resources.

Sleep is essential to health: an American Academy of Sleep Medicine position statement

CITATION

Sleep is a biological necessity, and insufficient sleep and untreated sleep disorders are detrimental for health, well-being, and public safety. Healthy People 2030 includes several sleep-related objectives with the goal to improve health, productivity, well-being, quality of life, and safety by helping people get enough sleep. In addition to adequate sleep duration, healthy sleep requires good quality, appropriate timing, regularity, and the absence of sleep disorders. It is the position of the American Academy of Sleep Medicine (AASM) that sleep is essential to health. There is a significant need for greater emphasis on sleep health in education, clinical practice, inpatient and long-term care, public health promotion, and the workplace. More sleep and circadian research is needed to further elucidate the importance of sleep for public health and the contributions of insufficient sleep to health disparities.

CITATION

Ramar K, Malhotra RK, Carden KA, et al. Sleep is essential to health: an American Academy of Sleep Medicine position statement. J Clin Sleep Med. 2021;17(10):2115-2119.

Treatment of central disorders of hypersomnolence: an American Academy of Sleep Medicine systematic review, meta-analysis, and GRADE assessment

INTRODUCTION

This systematic review provides supporting evidence for the accompanying clinical practice guideline on the treatment of central disorders of hypersomnolence in adults and children. The review focuses on prescription medications with U.S. Food & Drug Administration approval and nonpharmacologic interventions studied for the treatment of symptoms caused by central disorders of hypersomnolence.

METHODS

The American Academy of Sleep Medicine commissioned a task force of experts in sleep medicine to perform a systematic review. Randomized controlled trials and observational studies addressing pharmacological and nonpharmacological interventions for central disorders of hypersomnolence were identified. Statistical analyses were performed to determine the clinical significance of all outcomes. Finally, the Grading of Recommendations Assessment, Development and Evaluation (GRADE) process was used to assess the evidence for the purpose of making specific treatment recommendations.

RESULTS

The literature search identified 678 studies; 144 met the inclusion criteria and 108 provided data suitable for statistical analyses. Evidence for the following interventions is presented: armodafinil, clarithromycin, clomipramine, dextroamphetamine, flumazenil, intravenous immune globulin (IVIG), light therapy, lithium, l-carnitine, liraglutide, methylphenidate, methylprednisolone, modafinil, naps, pitolisant, selegiline, sodium oxybate, solriamfetol, and triazolam. The task force provided a detailed summary of the evidence along with the quality of evidence, the balance of benefits and harms, patient values and preferences, and resource use considerations.

CITATION

Maski K, Trotti LM, Kotagal S, et al. Treatment of central disorders of hypersomnolence: an American Academy of Sleep Medicine systematic review, meta-analysis, and GRADE assessment. J Clin Sleep Med. 2021;17(9):1895-1945.

Treatment of central disorders of hypersomnolence: an American Academy of Sleep Medicine clinical practice guideline

INTRODUCTION

This guideline establishes clinical practice recommendations for the treatment of central disorders of hypersomnolence in adults and children.

METHODS

The American Academy of Sleep Medicine commissioned a task force of experts in sleep medicine to develop recommendations and assign strengths to each recommendation, based on a systematic review of the literature and an assessment of the evidence using the GRADE process. The task force provided a summary of the relevant literature and the quality of evidence, the balance of benefits and harms, patient values and preferences, and resource use considerations that support the recommendations. The AASM Board of Directors approved the final recommendations.

RECOMMENDATIONS

The following recommendations are intended to guide clinicians in choosing a specific treatment for central disorders of hypersomnolence in adults and children. Each recommendation statement is assigned a strength ("strong" or "conditional"). A "strong" recommendation (ie, "We recommend…") is one that clinicians should follow under most circumstances. A "conditional" recommendation (ie, "We suggest…") is one that requires that the clinician use clinical knowledge and experience and strongly consider the individual patient's values and preferences to determine the best course of action. Under each disorder, strong recommendations are listed in alphabetical order followed by the conditional recommendations in alphabetical order. The section on adult patients with hypersomnia because of medical conditions is categorized based on the clinical and pathological subtypes identified in ICSD-3. The interventions in all the recommendation statements were compared to no treatment.

Adult patients with narcolepsy

1

We recommend that clinicians use modafinil for the treatment of narcolepsy in adults. (STRONG).

2

We recommend that clinicians use pitolisant for the treatment of narcolepsy in adults. (STRONG).

3

We recommend that clinicians use sodium oxybate for the treatment of narcolepsy in adults. (STRONG).

4

We recommend that clinicians use solriamfetol for the treatment of narcolepsy in adults. (STRONG).

5

We suggest that clinicians use armodafinil for the treatment of narcolepsy in adults. (CONDITIONAL).

6

We suggest that clinicians use dextroamphetamine for the treatment of narcolepsy in adults. (CONDITIONAL).

7

We suggest that clinicians use methylphenidate for the treatment of narcolepsy in adults. (CONDITIONAL).

Adult patients with idiopathic hypersomnia

8

We recommend that clinicians use modafinil for the treatment of idiopathic hypersomnia in adults. (STRONG).

9

We suggest that clinicians use clarithromycin for the treatment of idiopathic hypersomnia in adults. (CONDITIONAL).

10

We suggest that clinicians use methylphenidate for the treatment of idiopathic hypersomnia in adults. (CONDITIONAL).

11

We suggest that clinicians use pitolisant for the treatment of idiopathic hypersomnia in adults. (CONDITIONAL).

12

We suggest that clinicians use sodium oxybate for the treatment of idiopathic hypersomnia in adults. (CONDITIONAL).

Adult patients with Kleine-Levin syndrome

13

We suggest that clinicians use lithium for the treatment of Kleine-Levin syndrome in adults. (CONDITIONAL).

Adult patients with hypersomnia due to medical conditions

Hypersomnia secondary to alpha-synucleinopathies

14

We suggest that clinicians use armodafinil for the treatment of hypersomnia secondary to dementia with Lewy bodies in adults. (CONDITIONAL).

15

We suggest that clinicians use modafinil for the treatment of hypersomnia secondary to Parkinson's disease in adults. (CONDITIONAL).

16

We suggest that clinicians use sodium oxybate for the treatment of hypersomnia secondary to Parkinson's disease in adults. (CONDITIONAL).

Posttraumatic hypersomnia

17

We suggest that clinicians use armodafinil for the treatment of hypersomnia secondary to traumatic brain injury in adults. (CONDITIONAL).

18

We suggest that clinicians use modafinil for the treatment of hypersomnia secondary to traumatic brain injury in adults. (CONDITIONAL).

Adult patients with genetic disorders associated with primary central nervous system somnolence

19

We suggest that clinicians use modafinil for the treatment of hypersomnia secondary to myotonic dystrophy in adults. (CONDITIONAL).

Adult patients with hypersomnia secondary to brain tumors, infections, or other central nervous system lesions

20

We suggest that clinicians use modafinil for the treatment of hypersomnia secondary to multiple sclerosis in adults. (CONDITIONAL).

Pediatric patients with narcolepsy

21

We suggest that clinicians use modafinil for the treatment of narcolepsy in pediatric patients. (CONDITIONAL).

22

We suggest that clinicians use sodium oxybate for the treatment of narcolepsy in pediatric patients. (CONDITIONAL).

CITATION

Maski K, Trotti LM, Kotagal S, et al. Treatment of central disorders of hypersomnolence: an American Academy of Sleep Medicine clinical practice guideline. J Clin Sleep Med. 2021;17(9):1881-1893.

Daylight saving time: an American Academy of Sleep Medicine position statement

None

The last several years have seen intense debate about the issue of transitioning between standard and daylight saving time. In the United States, the annual advance to daylight saving time in spring, and fall back to standard time in autumn, is required by law (although some exceptions are allowed under the statute). An abundance of accumulated evidence indicates that the acute transition from standard time to daylight saving time incurs significant public health and safety risks, including increased risk of adverse cardiovascular events, mood disorders, and motor vehicle crashes. Although chronic effects of remaining in daylight saving time year-round have not been well studied, daylight saving time is less aligned with human circadian biology-which, due to the impacts of the delayed natural light/dark cycle on human activity, could result in circadian misalignment, which has been associated in some studies with increased cardiovascular disease risk, metabolic syndrome and other health risks. It is, therefore, the position of the American Academy of Sleep Medicine that these seasonal time changes should be abolished in favor of a fixed, national, year-round standard time.

Artificial intelligence in sleep medicine: an American Academy of Sleep Medicine position statement

None

Sleep medicine is well positioned to benefit from advances that use big data to create artificially intelligent computer programs. One obvious initial application in the sleep disorders center is the assisted (or enhanced) scoring of sleep and associated events during polysomnography (PSG). This position statement outlines the potential opportunities and limitations of integrating artificial intelligence (AI) into the practice of sleep medicine. Additionally, although the most apparent and immediate application of AI in our field is the assisted scoring of PSG, we propose potential clinical use cases that transcend the sleep laboratory and are expected to deepen our understanding of sleep disorders, improve patient-centered sleep care, augment day-to-day clinical operations, and increase our knowledge of the role of sleep in health at a population level.

Oxygen Therapy in Sleep-Disordered Breathing

Sleep-disordered breathing (SDB) is highly prevalent in adults and leads to significant cardiovascular and neurologic sequelae. Intermittent hypoxia during sleep is a direct consequence of SDB. Administration of nocturnal supplemental oxygen (NSO) has been used as a therapeutic alternative to positive airway pressure (PAP) in SDB. NSO significantly improves oxygen saturation in OSA but is inferior to PAP in terms of reducing apnea severity and may prolong the duration of obstructive apneas. The effect of NSO on daytime sleepiness remains unclear, but NSO may improve physical function-related quality of life in OSA. Its effects on BP reduction remain inconclusive. The effects of NSO vs PAP in OSA with comorbid COPD (overlap syndrome) are unknown. NSO is effective in reducing central sleep apnea related to congestive heart failure; however, its impact on mortality and cardiovascular clinical outcomes are being investigated in an ongoing clinical trial. In conclusion, studies are inconclusive or limited regarding clinical outcomes with oxygen therapy compared with sham or PAP therapy in patients with OSA and overlap syndrome. Oxygen does mitigate central sleep apnea. This review examines the crucial knowledge gaps and suggests future research priorities to clarify the effects of optimal dose and duration of NSO, alone or in combination with PAP, on cardiovascular, sleep, and cognitive outcomes.

Strategies to improve patient care for obstructive sleep apnea: a report from the American Academy of Sleep Medicine Sleep-Disordered Breathing Collaboration Summit

NONE

In Chicago, Illinois, on Saturday, November 10, 2018, the American Academy of Sleep Medicine hosted 35 representatives from 14 medical societies, nurse practitioner associations and patient advocacy groups for a one-day Sleep-Disordered Breathing Collaboration Summit to discuss strategies to improve the diagnosis and treatment of obstructive sleep apnea. This report provides a brief synopsis of the meeting, identifies current challenges, and highlights potential opportunities for ongoing collaboration.

Sleep, fatigue and burnout among physicians: an American Academy of Sleep Medicine position statement

None

Physician burnout is a serious and growing threat to the medical profession and may undermine efforts to maintain a sufficient physician workforce to care for the growing and aging patient population in the United States. Burnout involves a host of complex underlying associations and potential for risk. While prevalence is unknown, recent estimates of physician burnout are quite high, approaching 50% or more, with midcareer physicians at highest risk. Sleep deprivation due to shift-work schedules, high workload, long hours, sleep interruptions, and insufficient recovery sleep have been implicated in the genesis and perpetuation of burnout. Maladaptive attitudes regarding sleep and endurance also may increase the risk for sleep deprivation among attending physicians. While duty-hour restrictions have been instituted to protect sleep opportunity among trainees, virtually no such effort has been made for attending physicians who have completed their training or practicing physicians in nonacademic settings. It is the position of the American Academy of Sleep Medicine that a critical need exists to evaluate the roles of sleep disruption, sleep deprivation, and circadian misalignment in physician well-being and burnout. Such evaluation may pave the way for the development of effective countermeasures that promote healthy sleep, with the goal of reducing burnout and its negative impacts such as a shrinking physician workforce, poor physician health and functional outcomes, lower quality of care, and compromised patient safety.

Chronic Opioid Therapy and Sleep: An American Academy of Sleep Medicine Position Statement

None

There is a complex relationship among opioids, sleep and daytime function. Patients and medical providers should be aware that chronic opioid therapy can alter sleep architecture and sleep quality as well as contribute to daytime sleepiness. It is also important for medical providers to be cognizant of other adverse effects of chronic opioid use including the impact on respiratory function during sleep. Opioids are associated with several types of sleep-disordered breathing, including sleep-related hypoventilation, central sleep apnea (CSA), and obstructive sleep apnea (OSA). Appropriate screening, diagnostic testing, and treatment of opioid-associated sleep-disordered breathing can improve patients' health and quality of life. Collaboration among medical providers is encouraged to provide high quality, patient-centered care for people who are treated with chronic opioid therapy.

Clinical Use of a Home Sleep Apnea Test: An Updated American Academy of Sleep Medicine Position Statement

ABSTRACT

The diagnosis and effective treatment of obstructive sleep apnea (OSA) in adults is an urgent health priority. It is the position of the American Academy of Sleep Medicine (AASM) that only a medical provider can diagnose medical conditions such as OSA and primary snoring. Throughout this statement, the term "medical provider" refers to a licensed physician and any other health care professional who is licensed to practice medicine in accordance with state licensing laws and regulations. A home sleep apnea test (HSAT) is an alternative to polysomnography for the diagnosis of OSA in uncomplicated adults presenting with signs and symptoms that indicate an increased risk of moderate to severe OSA. It is also the position of the AASM that: the need for, and appropriateness of, an HSAT must be based on the patient's medical history and a face-to-face examination by a medical provider, either in person or via telemedicine; an HSAT is a medical assessment that must be ordered by a medical provider to diagnose OSA or evaluate treatment efficacy; an HSAT should not be used for general screening of asymptomatic populations; diagnosis, assessment of treatment efficacy, and treatment decisions must not be based solely on automatically scored HSAT data, which could lead to sub-optimal care that jeopardizes patient health and safety; and the raw data from the HSAT device must be reviewed and interpreted by a physician who is either board-certified in sleep medicine or overseen by a board-certified sleep medicine physician.

Polysomnography for Obstructive Sleep Apnea Should Include Arousal-Based Scoring: An American Academy of Sleep Medicine Position Statement

ABSTRACT

The diagnostic criteria for obstructive sleep apnea (OSA) in adults, as defined in the International Classification of Sleep Disorders, Third Edition, requires an increased frequency of obstructive respiratory events demonstrated by in-laboratory, attended polysomnography (PSG) or a home sleep apnea test (HSAT). However, there are currently two hypopnea scoring criteria in The AASM Manual for the Scoring of Sleep and Associated Events: Rules, Terminology and Technical Specifications (AASM Scoring Manual). This dichotomy results in differences among laboratory reports, patient treatments and payer policies. Confusion occurs regarding recognizing and scoring "arousal-based respiratory events" during OSA testing. "Arousal-based scoring" recognizes hypopneas associated with electroencephalography-based arousals, with or without significant oxygen desaturation, when calculating an apnea-hypopnea index (AHI), or it includes respiratory effort-related arousals (RERAs), in addition to hypopneas and apneas, when calculating a respiratory disturbance index (RDI). Respiratory events associated with arousals, even without oxygen desaturation, cause significant, and potentially dangerous, sleep apnea symptoms. During PSG, arousal-based respiratory scoring should be performed in the clinical evaluation of patients with suspected OSA, especially in those patients with symptoms of excessive daytime sleepiness, fatigue, insomnia, or other neurocognitive symptoms. Therefore, it is the position of the AASM that the RECOMMENDED AASM Scoring Manual scoring criteria for hypopneas, which includes diminished airflow accompanied by either an arousal or ≥ 3% oxygen desaturation, should be used to calculate the AHI. If the ACCEPTABLE AASM Scoring Manual criteria for scoring hypopneas, which includes only diminished airflow plus ≥ 4% oxygen desaturation (and does not allow for arousal-based scoring alone), must be utilized due to payer policy requirements, then hypopneas as defined by the RECOMMENDED AASM Scoring Manual criteria should also be scored. Alternatively, the AASM Scoring Manual includes an option to report an RDI which also provides an assessment of the sleep-disordered breathing that results in arousal from sleep. Furthermore, given the inability of most HSAT devices to capture arousals, a PSG should be performed in any patient with an increased risk for OSA whose HSAT is negative. If the PSG yields an AHI of 5 or more events/h, or if the RDI is greater than or equal to 5 events/h, then treatment of symptomatic patients is recommended to improve quality of life, limit neurocognitive symptoms, and reduce accident risk.

Consumer Sleep Technology: An American Academy of Sleep Medicine Position Statement

ABSTRACT

Consumer sleep technologies (CSTs) are widespread applications and devices that purport to measure and even improve sleep. Sleep clinicians may frequently encounter CST in practice and, despite lack of validation against gold standard polysomnography, familiarity with these devices has become a patient expectation. This American Academy of Sleep Medicine position statement details the disadvantages and potential benefits of CSTs and provides guidance when approaching patient-generated health data from CSTs in a clinical setting. Given the lack of validation and United States Food and Drug Administration (FDA) clearance, CSTs cannot be utilized for the diagnosis and/or treatment of sleep disorders at this time. However, CSTs may be utilized to enhance the patient-clinician interaction when presented in the context of an appropriate clinical evaluation. The ubiquitous nature of CSTs may further sleep research and practice. However, future validation, access to raw data and algorithms, and FDA oversight are needed.

Medical Cannabis and the Treatment of Obstructive Sleep Apnea: An American Academy of Sleep Medicine Position Statement

ABSTRACT

The diagnosis and effective treatment of obstructive sleep apnea (OSA) in adults is an urgent health priority. Positive airway pressure (PAP) therapy remains the most effective treatment for OSA, although other treatment options continue to be explored. Limited evidence citing small pilot or proof of concept studies suggest that the synthetic medical cannabis extract dronabinol may improve respiratory stability and provide benefit to treat OSA. However, side effects such as somnolence related to treatment were reported in most patients, and the long-term effects on other sleep quality measures, tolerability, and safety are still unknown. Dronabinol is not approved by the United States Food and Drug Administration (FDA) for treatment of OSA, and medical cannabis and synthetic extracts other than dronabinol have not been studied in patients with OSA. The composition of cannabinoids within medical cannabis varies significantly and is not regulated. Synthetic medical cannabis may have differential effects, with variable efficacy and side effects in the treatment of OSA. Therefore, it is the position of the American Academy of Sleep Medicine (AASM) that medical cannabis and/or its synthetic extracts should not be used for the treatment of OSA due to unreliable delivery methods and insufficient evidence of effectiveness, tolerability, and safety. OSA should be excluded from the list of chronic medical conditions for state medical cannabis programs, and patients with OSA should discuss their treatment options with a licensed medical provider at an accredited sleep facility. Further research is needed to understand the functionality of medical cannabis extracts before recommending them as a treatment for OSA.

The Risk of Fatigue and Sleepiness in the Ridesharing Industry: An American Academy of Sleep Medicine Position Statement

ABSTRACT

The ridesharing-or ride-hailing-industry has grown exponentially in recent years, transforming quickly into a fee-for-service, unregulated taxi industry. While riders are experiencing the benefits of convenience and affordability, two key regulatory and safety issues deserve consideration. First, individuals who work as drivers in the ridesharing industry are often employed in a primary job, and they work as drivers during their "off" time. Such a schedule may lead to driving after extended periods of wakefulness or during nights, both of which are factors that increase the risk of drowsy driving accidents. Second, these drivers are often employed as "independent contractors," and therefore they are not screened for medical problems that can reduce alertness, such as obstructive sleep apnea. Some ridesharing companies now require a rest period after an extended driving shift. This measure is encouraging, but it is insufficient to impact driving safety appreciably, particularly since many of these drivers are already working extended hours and tend to drive at non-traditional times when sleepiness may peak. Therefore, it is the position of the American Academy of Sleep Medicine (AASM) that fatigue and sleepiness are inherent safety risks in the ridesharing industry. The AASM calls on ridesharing companies, government officials, medical professionals, and law enforcement officers to work together to address this public safety risk. A collaborative effort is necessary to understand and track the scope of the problem, provide relevant education, and mitigate the risk through thoughtful regulation and effective fatigue risk management systems.

Clinical Use of a Home Sleep Apnea Test: An American Academy of Sleep Medicine Position Statement

ABSTRACT

The diagnosis and effective treatment of obstructive sleep apnea (OSA) in adults is an urgent health priority. It is the position of the American Academy of Sleep Medicine (AASM) that only a physician can diagnose medical conditions such as OSA and primary snoring. Throughout this statement, the term "physician" refers to a medical provider who is licensed to practice medicine. A home sleep apnea test (HSAT) is an alternative to polysomnography for the diagnosis of OSA in uncomplicated adults presenting with signs and symptoms that indicate an increased risk of moderate to severe OSA. It is also the position of the AASM that: the need for, and appropriateness of, an HSAT must be based on the patient's medical history and a face-to-face examination by a physician, either in person or via telemedicine; an HSAT is a medical assessment that must be ordered by a physician to diagnose OSA or evaluate treatment efficacy; an HSAT should not be used for general screening of asymptomatic populations; diagnosis, assessment of treatment efficacy, and treatment decisions must not be based solely on automatically scored HSAT data, which could lead to sub-optimal care that jeopardizes patient health and safety; and the raw data from the HSAT device must be reviewed and interpreted by a physician who is either board-certified in sleep medicine or overseen by a board-certified sleep medicine physician.

An Official American Thoracic Society Research Statement: Impact of Mild Obstructive Sleep Apnea in Adults

BACKGROUND

Mild obstructive sleep apnea (OSA) is a highly prevalent disorder in adults; however, whether mild OSA has significant neurocognitive and cardiovascular complications is uncertain.

OBJECTIVES

The specific goals of this Research Statement are to appraise the evidence regarding whether long-term adverse neurocognitive and cardiovascular outcomes are attributable to mild OSA in adults, evaluate whether or not treatment of mild OSA is effective at preventing or reducing these adverse neurocognitive and cardiovascular outcomes, delineate the key research gaps, and provide direction for future research agendas.

METHODS

Literature searches from multiple reference databases were performed using medical subject headings and text words for OSA in adults as well as by hand searches. Pragmatic systematic reviews of the relevant body of evidence were performed.

RESULTS

Studies were incongruent in their definitions of "mild" OSA. Data were inconsistent regarding the relationship between mild OSA and daytime sleepiness. However, treatment of mild OSA may improve sleepiness in patients who are sleepy at baseline and improve quality of life. There is limited or inconsistent evidence pertaining to the impact of therapy of mild OSA on neurocognition, mood, vehicle accidents, cardiovascular events, stroke, and arrhythmias.

CONCLUSIONS

There is evidence that treatment of mild OSA in individuals who demonstrate subjective sleepiness may be beneficial. Treatment may also improve quality of life. Future research agendas should focus on clarifying the effect of mild OSA and impact of effective treatment on other neurocognitive and cardiovascular endpoints as detailed in the document.

Delaying Middle School and High School Start Times Promotes Student Health and Performance: An American Academy of Sleep Medicine Position Statement

ABSTRACT

During adolescence, internal circadian rhythms and biological sleep drive change to result in later sleep and wake times. As a result of these changes, early middle school and high school start times curtail sleep, hamper a student's preparedness to learn, negatively impact physical and mental health, and impair driving safety. Furthermore, a growing body of evidence shows that delaying school start times positively impacts student achievement, health, and safety. Public awareness of the hazards of early school start times and the benefits of later start times are largely unappreciated. As a result, the American Academy of Sleep Medicine is calling on communities, school boards, and educational institutions to implement start times of 8:30 AM or later for middle schools and high schools to ensure that every student arrives at school healthy, awake, alert, and ready to learn.

Treatment compliance in patients lost to follow-up after polysomnography

Objectives

Studies on positive airway pressure (PAP) compliance typically focus only on patients who returned for follow-up. In this study, we examined patients who failed to follow-up after their initial polysomnogram (PSG) and PAP titration to determine their treatment status in terms of PAP usage.

Study Design

On retrospective chart review, we identified 57 patients who, based on PSG findings and symptoms, required the use of PAP but failed to follow-up after titration. Twenty-five of these patients were successfully contacted and agreed to an interview.

Results

Only 7 (28%) patients were using PAP on a regular basis. The remaining 18 (72%) patients were noncompliant.

Conclusions

A significant proportion (24%) of OSA patients who required treatment with PAP were lost to follow-up after polysomnography. This group of patients has previously been ignored in the literature. We showed in this study that majority (72%) of these patients were not being treated adequately for OSA.

Updated Adaptive Servo-Ventilation Recommendations for the 2012 AASM Guideline: "The Treatment of Central Sleep Apnea Syndromes in Adults: Practice Parameters with an Evidence-Based Literature Review and Meta-Analyses"

ABSTRACT

An update of the 2012 systematic review and meta-analyses were performed and a modified-GRADE approach was used to update the recommendation for the use of adaptive servo-ventilation (ASV) for the treatment of central sleep apnea syndrome (CSAS) related to congestive heart failure (CHF). Meta-analyses demonstrated an improvement in LVEF and a normalization of AHI in all patients. Analyses also demonstrated an increased risk of cardiac mortality in patients with an LVEF of ≤ 45% and moderate or severe CSA predominant sleep-disordered breathing. These data support a Standard level recommendation against the use of ASV to treat CHF-associated CSAS in patients with an LVEF of ≤ 45% and moderate or severe CSAS, and an Option level recommendation for the use of ASV in the treatment CHF-associated CSAS in patients with an LVEF > 45% or mild CHF-related CSAS. The application of these recommendations is limited to the target patient populations; the ultimate judgment regarding propriety of any specific care must be made by the clinician.

A 38-Year-Old Man With Obesity, Intermittent Tachycardia, and One Episode of Syncope

A 38-year-old man with history of diabetes, hypertension, hyperlipidemia, and obesity was referred to the electrophysiology clinic for evaluation of infrequent palpitations and remote history of syncope. The patient described a sensation of racing of the heart, which lasted about 30 min to 1 h and occurred several times over the past year. This was associated with a sense of anxiety and shortness of breath and appeared to resolve spontaneously. The patient also experienced one episode of syncope in the past while enjoying a barbecue on a hot summer day. He did not recall if this episode was accompanied by palpitations, however, the previously mentioned symptoms prompted the consultation. Upon further questioning the patient also reported experiencing fatigue. He stated that he noted decreased energy and frequent daytime sleepiness.

Entrustable professional activities and curricular milestones for fellowship training in pulmonary and critical care medicine: report of a multisociety working group

This article describes the curricular milestones and entrustable professional activities for trainees in pulmonary, critical care, or combined fellowship programs. Under the Next Accreditation System of the Accreditation Council for Graduate Medical Education (ACGME), curricular milestones compose the curriculum or learning objectives for training in these fields. Entrustable professional activities represent the outcomes of training, the activities that society and professional peers can expect fellowship graduates to be able to perform unsupervised. These curricular milestones and entrustable professional activities are the products of a consensus process from a multidisciplinary committee of medical educators representing the American College of Chest Physicians (CHEST), the American Thoracic Society, the Society of Critical Care Medicine, and the Association of Pulmonary and Critical Care Medicine Program Directors. After consensus was achieved using the Delphi process, the document was revised with input from the sponsoring societies and program directors. The resulting lists can serve as a roadmap and destination for trainees, program directors, and educators. Together with the reporting milestones, they will help mark trainees' progress in the mastery of the six ACGME core competencies of graduate medical education.

Transoral robotic surgery for treatment of obstructive sleep apnea: factors predicting surgical response

OBJECTIVES/HYPOTHESIS

We reviewed our experience with the use of transoral robotic surgery (TORS) for base of tongue (BOT) reduction either alone or as part of multilevel strategy in the treatment of obstructive sleep apnea/hypopnea syndrome (OSAHS) in order to identify clinical characteristics that may be associated with surgical response.

STUDY DESIGN

Case series.

METHODS

Between June 2010 and May 2014, BOT reduction via TORS ± partial epiglottectomy ± uvulopalatopharyngoplasty were performed on 72 patients with OSAHS. Thirty-nine patients (15 females and 24 males) with complete preoperative and postoperative clinical information including polysomnograms were included in this study.

RESULTS

Mean apnea-hypopnea index (AHI) was 43.9 ± 32.3 preoperatively and 21.9 ± 23.5 postoperatively and reflected a statistically significant (P < 0.001) AHI reduction of 50.9% ± 38.1%. Statistical significant reduction in daytime somnolence, as measured by Epworth Sleepiness Scale (15.6 ± 5.4 preoperatively vs. 5.7 ± 4.3 postoperatively; P < 0.001), was also achieved. No statistical significant difference was found between preoperative and postoperative body mass index (BMI) (32.9 ± 7.0 vs. 32.4 ± 7.3; P = 0.270). Surgical response, as defined by > 50% reduction in AHI and final AHI < 15 with resolution of daytime somnolence, was achieved in 21 patients (53.8%). Clinical characteristics found to be significantly different between the responders and nonresponders were BMI, AHI, and lateral velopharyngeal collapse. Patients with BMI < 30, AHI < 60, or absence of lateral velopharyngeal collapse have excellent surgical response rate of 88.2%, 67.9%, or 66.7%, respectively.

CONCLUSIONS

We identified three clinical characteristics associated with increased surgical response rate. This finding may be useful for patient selection and counseling prior to surgery.

Effect of addition of chin strap on PAP compliance, nightly duration of use, and other factors

STUDY OBJECTIVES

A chinstrap is potentially useful to reduce unintentional air leak by preventing mouth opening during PAP treatment. This study examines whether the addition of a chinstrap to PAP therapy has any effect on adherence, nightly duration of use, air leak, and residual AHI.

METHODS

This was a retrospective study performed at an AASM-accredited VAMC sleep center. Clinical sleep data of veterans (n = 124) prescribed PAP therapy for sleep apnea was evaluated, and the effect of chinstrap use vs non-use on the above parameters was assessed.

RESULTS

Chinstrap users had significantly greater PAP adherence, longer nightly duration of PAP use, lower residual AHI and lower leak compared to chinstrap non-users at first follow up visit.

CONCLUSIONS

The addition of a chin strap to PAP therapy is a simple and inexpensive method of increasing PAP adherence.

The influence of race on the severity of sleep disordered breathing

BACKGROUND

Studies have indicated that the prevalence of obstructive sleep apnea-hypopnea syndrome (OSAHS) is similar between white and African American patients, but it is unclear if there are differences in the severity of OSAHS. We hypothesized that in patients with diagnosed OSAHS, African Americans would have higher apnea-hypopnea index (AHI) and higher mortality than white individuals.

METHODS

We analyzed a prospectively collected database of 512 patients studied between July 1996 through February 1999. Inclusion criteria included age ≥ 18 y, AHI ≥ 5/h, and full-night PSG. Statistical analysis was performed to determine the association between race and AHI while controlling for the effect of confounders and effect modifiers, which included gender, age, body mass index, and comorbidities.

RESULTS

The database included 340 African American and 172 white patients. AHI was higher in African American patients (median 32.7/h IQR 3.3-69.2) than white patients (22.4/h IQR 12.8-40.6, p = 0.01). Age, sex, and BMI were found to be effect modifiers and were included in final models. In the final model, African American men younger than 39 years and between 50 and 59 years were found to have a higher AHI than white men in the same age ranges.

CONCLUSIONS

African American men younger than 39 years and between 50 and 59 years have a higher AHI compared to white men of the same ages after correcting for confounders and effect modifiers. There was no difference in mortality between African Americans and whites with OSAHS in this cohort.

Practice parameters for the non-respiratory indications for polysomnography and multiple sleep latency testing for children

BACKGROUND

Although a level 1 nocturnal polysomnogram (PSG) is often used to evaluate children with non-respiratory sleep disorders, there are no published evidence-based practice parameters focused on the pediatric age group. In this report, we present practice parameters for the indications of polysomnography and the multiple sleep latency test (MSLT) in the assessment of non-respiratory sleep disorders in children. These practice parameters were reviewed and approved by the Board of Directors of the American Academy of Sleep Medicine (AASM).

METHODS

A task force of content experts was appointed by the AASM to review the literature and grade the evidence according to the American Academy of Neurology grading system.

RECOMMENDATIONS FOR PSG AND MSLT USE

PSG is indicated for children suspected of having periodic limb movement disorder (PLMD) for diagnosing PLMD. (STANDARD)The MSLT, preceded by nocturnal PSG, is indicated in children as part of the evaluation for suspected narcolepsy. (STANDARD)Children with frequent NREM parasomnias, epilepsy, or nocturnal enuresis should be clinically screened for the presence of comorbid sleep disorders and polysomnography should be performed if there is a suspicion for sleep-disordered breathing or periodic limb movement disorder. (GUIDELINE)The MSLT, preceded by nocturnal PSG, is indicated in children suspected of having hypersomnia from causes other than narcolepsy to assess excessive sleepiness and to aid in differentiation from narcolepsy. (OPTION)The polysomnogram using an expanded EEG montage is indicated in children to confirm the diagnosis of an atypical or potentially injurious parasomnia or differentiate a parasomnia from sleep-related epilepsy (OPTION)Polysomnography is indicated in children suspected of having restless legs syndrome (RLS) who require supportive data for diagnosing RLS. (OPTION) RECOMMENDATIONS AGAINST PSG USE: Polysomnography is not routinely indicated for evaluation of children with sleep-related bruxism. (STANDARD) CONCLUSIONS: The nocturnal polysomnogram and MSLT are useful clinical tools for evaluating pediatric non-respiratory sleep disorders when integrated with the clinical evaluation.

Drug-induced sleep endoscopy vs awake Müller's maneuver in the diagnosis of severe upper airway obstruction

OBJECTIVE

To compare fiber-optic nasal endoscopy with Müller's maneuver (FNMM) against drug-induced sleep endoscopy (DISE) in diagnosing the presence of severe level-specific upper airway collapse in patients with obstructive sleep apnea/hypopnea syndrome (OSAHS).

STUDY DESIGN

Case series with chart review.

SETTING

Tertiary care academic center.

SUBJECTS AND METHODS

Medical records of all adult patients undergoing diagnostic DISE as part of their surgical evaluation were reviewed. Patients were included if they had undergone FNMM and had documented Friedman tongue position and tonsillar grade prior to DISE. Airway obstruction on both endoscopic procedures was described according to airway level and severity. Severe airway obstruction was defined as >75% collapse on endoscopy.

RESULTS

Fifty-three patients were included in this study. Fiber-optic nasal endoscopy with Müller's maneuver and DISE did not differ significantly regarding the presence of severe retropalatal airway collapse. There was a statistically significant difference in the incidence of severe retrolingual collapse identified via DISE (84.9% [45/53]) compared with FNMM (35.8% [19/53]; P < .0001). This discrepancy between FNMM and DISE findings was statistically significant in individuals with Friedman I and II tongue positions (FNMM = 16.7%, DISE = 88.9%, P < .0001) and individuals with Friedman III tongue position (FNMM = 31.8%, DISE = 81.8%, P = .002). Patients with Friedman IV showed no significant difference (P = .65) between FNMM (69.2%) and DISE (84.6%).

CONCLUSION

This study shows a significant difference between FNMM and DISE in the identification of severe retrolingual collapse. Since the effectiveness of surgical interventions depends largely on the accurate preoperative identification of the site of obstruction, further scrutiny of each diagnostic endoscopic technique is warranted.

The treatment of restless legs syndrome and periodic limb movement disorder in adults--an update for 2012: practice parameters with an evidence-based systematic review and meta-analyses: an American Academy of Sleep Medicine Clinical Practice Guideline

A systematic literature review and meta-analyses (where appropriate) were performed to update the previous AASM practice parameters on the treatments, both dopaminergic and other, of RLS and PLMD. A considerable amount of literature has been published since these previous reviews were performed, necessitating an update of the corresponding practice parameters. Therapies with a STANDARD level of recommendation include pramipexole and ropinirole. Therapies with a GUIDELINE level of recommendation include levodopa with dopa decarboxylase inhibitor, opioids, gabapentin enacarbil, and cabergoline (which has additional caveats for use). Therapies with an OPTION level of recommendation include carbamazepine, gabapentin, pregabalin, clonidine, and for patients with low ferritin levels, iron supplementation. The committee recommends a STANDARD AGAINST the use of pergolide because of the risks of heart valve damage. Therapies for RLS secondary to ESRD, neuropathy, and superficial venous insufficiency are discussed. Lastly, therapies for PLMD are reviewed. However, it should be mentioned that because PLMD therapy typically mimics RLS therapy, the primary focus of this review is therapy for idiopathic RLS.

Development and growth of a large multispecialty certification examination: sleep medicine certification--results of the first three examinations

This paper summarizes the results of the first three examinations (2007, 2009, and 2011) of the Sleep Medicine Certification Examination, administered by its six sponsoring American Board of Medical Specialty Boards. There were 2,913 candidates who took the 2011 examination through one of three pathways-self-attested practice experience, previous certification by the American Board of Sleep Medicine, or formal Sleep Medicine fellowship training. The 2011 exam was the last administration in which candidates who had not previously been admitted could take it without completion of formal Sleep Medicine fellowship training. As expected, the number of candidates admitted to the 2011 examination through the practice experience pathway increased, and the overall scores of these candidates were on average lower than the other candidates. Consequently, the pass rate for all first takers of the 2011 examination (65%) was lower than that observed from the 2009 examination (78%) and the 2007 examination (73%). For each administration, candidates admitted through the fellowship training pathway scored the highest; over 90% of them passed the 2011 and 2009 examinations.

Lateral oropharyngeal wall and supraglottic airway collapse associated with failure in sleep apnea surgery

OBJECTIVES/HYPOTHESIS

To identify patterns of airway collapse during preoperative drug-induced sleep endoscopy (DISE) as predictors of surgical failure following multilevel airway surgery for patients with obstructive sleep apnea-hypopnea syndrome (OSAHS).

STUDY DESIGN

Retrospective clinical chart review.

METHODS

Medical records of patients who underwent site-specific surgical modification of the upper airway for treatment of OSHAS were reviewed. Patients were included in this study if they had a preoperative airway evaluation with DISE as well as preoperative and postoperative polysomnography. Airway obstruction on DISE was described according to airway level, severity, and axis of collapse. Severe airway obstruction was defined as >75% collapse on endoscopy. Surgical success was described as a postoperative apnea-hypopnea index (AHI) of <20 and a >50% decrease in preoperative AHI.

RESULTS

A total of 34 patients were included in this study. The overall surgical success rate was 56%. Surgical success (n = 19) and surgical failure (n = 15) patients were similar with regard to age, gender, body mass index, preoperative AHI, Friedman stage, adenotonsillar grades, and surgical management. DISE findings in the surgical failure group demonstrated greater incidence of severe lateral oropharyngeal wall collapse (73.3% vs. 36.8%, P = .037) and severe supraglottic collapse (93.3% vs. 63.2%, P = .046) as compared to the surgical success group.

CONCLUSIONS

The presence of severe lateral pharyngeal wall and/or supraglottic collapse on preoperative DISE is associated with OSAHS surgical failure. The identification of this failure-prone collapse pattern may be useful in preoperative patient counseling as well as in directing an individualized and customized approach to the treatment of OSHAS.

The treatment of central sleep apnea syndromes in adults: practice parameters with an evidence-based literature review and meta-analyses

The International Classification of Sleep Disorders, Second Edition (ICSD-2) distinguishes 5 subtypes of central sleep apnea syndromes (CSAS) in adults. Review of the literature suggests that there are two basic mechanisms that trigger central respiratory events: (1) post-hyperventilation central apnea, which may be triggered by a variety of clinical conditions, and (2) central apnea secondary to hypoventilation, which has been described with opioid use. The preponderance of evidence on the treatment of CSAS supports the use of continuous positive airway pressure (CPAP). Much of the evidence comes from investigations on CSAS related to congestive heart failure (CHF), but other subtypes of CSAS appear to respond to CPAP as well. Limited evidence is available to support alternative therapies in CSAS subtypes. The recommendations for treatment of CSAS are summarized as follows: CPAP therapy targeted to normalize the apnea-hypopnea index (AHI) is indicated for the initial treatment of CSAS related to CHF. (STANDARD)Nocturnal oxygen therapy is indicated for the treatment of CSAS related to CHF. (STANDARD)Adaptive Servo-Ventilation (ASV) targeted to normalize the apnea-hypopnea index (AHI) is indicated for the treatment of CSAS related to CHF. (STANDARD)BPAP therapy in a spontaneous timed (ST) mode targeted to normalize the apnea-hypopnea index (AHI) may be considered for the treatment of CSAS related to CHF only if there is no response to adequate trials of CPAP, ASV, and oxygen therapies. (OPTION)The following therapies have limited supporting evidence but may be considered for the treatment of CSAS related to CHF after optimization of standard medical therapy, if PAP therapy is not tolerated, and if accompanied by close clinical follow-up: acetazolamide and theophylline. (OPTION)Positive airway pressure therapy may be considered for the treatment of primary CSAS. (OPTION)Acetazolamide has limited supporting evidence but may be considered for the treatment of primary CSAS. (OPTION)The use of zolpidem and triazolam may be considered for the treatment of primary CSAS only if the patient does not have underlying risk factors for respiratory depression. (OPTION)The following possible treatment options for CSAS related to end-stage renal disease may be considered: CPAP, supplemental oxygen, bicarbonate buffer use during dialysis, and nocturnal dialysis. (OPTION) .

Hypocapnia is associated with increased upper airway expiratory resistance during sleep

We hypothesized that hypocapnia is responsible for increased expiratory resistance during NREM sleep. Hypocapnia was induced by hypoxic hyperventilation in 21 subjects (aged 29.4 ± 7.8 yrs, 10 women, BMI 24.4 ± 4.3 kg/m(2)). Isocapnic hypoxia was induced in 12 subjects of whom, 6 underwent hypocapnic hypoxia in the same night. Upper airway resistance (R(UA)) was measured at the linear pressure-flow relationship during inspiration and expiration. Inspiratory flow limitation (IFL) was defined as the dissociation in pressure-flow relationship. (1) Expiratory R(UA) increased during hypocapnic but not isocapnic hypoxia relative to control (11.0 ± 5.6 vs. 8.2 ± 3.6 cm H(2)O/L/s; p < 0.05, and 11.45.0 vs. 10.94.4 cm H(2)O/L/s; p = NS, respectively). (2) No gender difference was found in R(UA) (p = NS). (3) Increased expiratory R(UA) correlated with the IFL change during hypocapnic but not isocapnic hypoxia. (4) No changes were noted in inspiratory R(UA) or IFL. Expiratory R(UA) increased during hypocapnia and was associated with IFL, indicating upper airway narrowing. Gender does not influence the upper airway response to hypocapnic hypoxia.

Inhibition of ventilatory motor output increases expiratory retro palatal compliance during sleep

We hypothesized that inhibition of ventilatory motor output leads to increased pharyngeal compliance during NREM sleep, independent of lung volume.

METHODS

Eighteen subjects were studied using noninvasive positive pressure ventilation (NPPV) to inhibit ventilatory motor output during stable NREM sleep. Nasopharyngoscopy was used to measure the retro palatal cross-sectional area/pressure relationship (CSA/Pph) in 8 subjects. The effect of NPPV on neck circumference (NC) and end-expiratory lung volumes (EELV) was studied in 10 additional subjects using strain gauge plethysmography and respitrace, respectively.

RESULTS

(1) The CSA/Pph was increased during expiration under passive compared to active breathing (11.7 ± 7.1 vs. 8.5 ± 5.6mm(2)/cmH(2)O, respectively; p < 0.05) but not during inspiration. (2) NC correlated with the CSA/Pph during passive expiration (R(2) = 0.77, p < 0.05). (3) NC and EELV did not change between active and passive breaths (p = NS).

CONCLUSIONS

(1) Inhibiting the ventilatory motor output increases the pharyngeal compliance. (2) Increased passive expiratory pharyngeal compliance was not associated with changes in NC or EELV.

Best clinical practices for the sleep center adjustment of noninvasive positive pressure ventilation (NPPV) in stable chronic alveolar hypoventilation syndromes

Noninvasive positive pressure ventilation (NPPV) devices are used during sleep to treat patients with diurnal chronic alveolar hypoventilation (CAH). Bilevel positive airway pressure (BPAP) using a mask interface is the most commonly used method to provide ventilatory support in these patients. BPAP devices deliver separately adjustable inspiratory positive airway pressure (IPAP) and expiratory positive airway pressure (EPAP). The IPAP and EPAP levels are adjusted to maintain upper airway patency, and the pressure support (PS = IPAP-EPAP) augments ventilation. NPPV devices can be used in the spontaneous mode (the patient cycles the device from EPAP to IPAP), the spontaneous timed (ST) mode (a backup rate is available to deliver IPAP for the set inspiratory time if the patient does not trigger an IPAP/EPAP cycle within a set time window), and the timed (T) mode (inspiratory time and respiratory rate are fxed). During NPPV titration with polysomnography (PSG), the pressure settings, backup rate, and inspiratory time (if applicable) are adjusted to maintain upper airway patency and support ventilation. However, there are no widely available guidelines for the titration of NPPV in the sleep center. A NPPV Titration Task Force of the American Academy of Sleep Medicine reviewed the available literature and developed recommendations based on consensus and published evidence when available. The major recommendations derived by this consensus process are as follows: General Recommendations: 1. The indications, goals of treatment, and side effects of NPPV treatment should be discussed in detail with the patient prior to the NPPV titration study. 2. Careful mask fitting and a period of acclimatization to low pressure prior to the titration should be included as part of the NPPV protocol. 3. NPPV titration with PSG is the recommended method to determine an effective level of nocturnal ventilatory support in patients with CAH. In circumstances in which NPPV treatment is initiated and adjusted empirically in the outpatient setting based on clinical judgment, a PSG should be utilized if possible to confirm that the final NPPV settings are effective or to make adjustments as necessary. 4. NPPV treatment goals should be individualized but typically include prevention of worsening of hypoventilation during sleep, improvement in sleep quality, relief of nocturnal dyspnea, and providing respiratory muscle rest. 5. When OSA coexists with CAH, pressure settings for treatment of OSA may be determined during attended NPPV titration PSG following AASM Clinical Guidelines for the Manual Titration of Positive Airway Pressure in Patients with Obstructive Sleep Apnea. 6. Attended NPPV titration with PSG is the recommended method to identify optimal treatment pressure settings for patients with the obesity hypoventilation syndrome (OHS), CAH due to restrictive chest wall disease (RTCD), and acquired or central CAH syndromes in whom NPPV treatment is indicated. 7. Attended NPPV titration with PSG allows definitive identification of an adequate level of ventilatory support for patients with neuromuscular disease (NMD) in whom NPPV treatment is planned. Recommendations for NPPV Titration Equipment: 1. The NPPV device used for titration should have the capability of operating in the spontaneous, spontaneous timed, and timed mode. 2. The airflow, tidal volume, leak, and delivered pressure signals from the NPPV device should be monitored and recorded if possible. The airflow signal should be used to detect apnea and hypopnea, while the tidal volume signal and respiratory rate are used to assess ventilation. 3. Transcutaneous or end-tidal PCO2 may be used to adjust NPPV settings if adequately calibrated and ideally validated with arterial blood gas testing. 4. An adequate assortment of masks (nasal, oral, and oronasal) in both adult and pediatric sizes (if children are being titrated), a source of supplemental oxygen, and heated humidification should be available. Recommendations for Limits of IPAP, EPAP, and PS Settings: 1. The recommended minimum starting IPAP and EPAP should be 8 cm H2O and 4 cm H2O, respectively. 2. The recommended maximum IPAP should be 30 cm H2O for patients > or = 12 years and 20 cm H2O for patients < 12 years. 3. The recommended minimum and maximum levels of PS are 4 cm H2O and 20 cm H2O, respectively. 4. The minimum and maximum incremental changes in PS should be 1 and 2 cm H2O, respectively. Recommendations for Adjustment of IPAP, EPAP, and PS: 1. IPAP and/or EPAP should be increased as described in AASM Clinical Guidelines for the Manual Titration of Positive Airway Pressure in Patients with Obstructive Sleep Apnea until the following obstructive respiratory events are eliminated (no specific order): apneas, hypopneas, respiratory effort-related arousals, and snoring. 2. The pressure support (PS) should be increased every 5 minutes if the tidal volume is low (< 6 to 8 mL/kg) 3. The PS should be increased if the arterial PCO2 remains 10 mm Hg or more above the PCO, goal at the current settings for 10 minutes or more. An acceptable goal for PCO, is a value less than or equal to the awake PCO2. 4. The PS may be increased if respiratory muscle rest has not been achieved by NPPV treatment at the current settings for 10 minutes of more. 5. The PS may be increased if the SpO, remains below 90% for 5 minutes or more and tidal volume is low (< 6 to 8 mL/kg). Recommendations for Use and Adjustment of the Backup Rate/ Respiratory Rate: 1. A backup rate (i.e., ST mode) should be used in all patients with central hypoventilation, those with a significant number of central apneas or an inappropriately low respiratory rate, and those who unreliably trigger IPAP/EPAP cycles due to muscle weakness. 2. The ST mode may be used if adequate ventilation or adequate respiratory muscle rest is not achieved with the maximum (or maximum tolerated) PS in the spontaneous mode. 3. The starting backup rate should be equal to or slightly less than the spontaneous sleeping respiratory rate (minimum of 10 bpm). 4. The backup rate should be increased in 1 to 2 bpm increments every 10 minutes if the desired goal of the backup rate has not been attained. 5. The IPAP time (inspiratory time) should be set based on the respiratory rate to provide an inspiratory time (IPAP time) between 30% and 40% of the cycle time (60/respiratory rate in breaths per minute). 6. If the spontaneous timed mode is not successful at meeting titration goals then the timed mode can be tried. Recommendations Concerning Supplemental Oxygen: 1. Supplemental oxygen may be added in patients with an awake SpO2 < 88% or when the PS and respiratory rate have been optimized but the SpO2 remains < 90% for 5 minutes or more. 2. The minimum starting supplemental oxygen rate should be 1 L/minute and increased in increments of 1 L/minute about every 5 minutes until an adequate SpO2 is attained (> 90%). Recommendations to Improve Patient Comfort and Patient-NPPV Device Synchrony: 1. If the patient awakens and complains that the IPAP and/or EPAP is too high, pressure should be lowered to a level comfortable enough to allow return to sleep. 2. NPPV device parameters (when available) such as pressure relief, rise time, maximum and minimum IPAP durations should be adjusted for patient comfort and to optimize synchrony between the patient and the NPPV device. 3. During the NPPV titration mask refit, adjustment, or change in mask type should be performed whenever any significant unintentional leak is observed or the patient complains of mask discomfort. If mouth leak is present and is causing significant symptoms (e.g., arousals) use of an oronasal mask or chin strap may be tried. Heated humidification should be added if the patient complains of dryness or significant nasal congestion. Recommendations for Follow-Up: 1. Close follow-up after initiation of NPPV by appropriately trained health care providers is indicated to establish effective utilization patterns, remediate side effects, and assess measures of ventilation and oxygenation to determine if adjustment to NPPV is indicated.

Surgical modifications of the upper airway for obstructive sleep apnea in adults: a systematic review and meta-analysis

A substantial portion of patients with obstructive sleep apnea (OSA) seek alternatives to positive airway pressure (PAP), the usual first-line treatment for the disorder. One option is upper airway surgery. As an adjunct to the American Academy of Sleep Medicine (AASM) Standards of Practice paper, we conducted a systematic review and meta-analysis of literature reporting outcomes following various upper airway surgeries for the treatment of OSA in adults, including maxillomandibular advancement (MMA), pharyngeal surgeries such as uvulopharyngopalatoplasty (UPPP), laser assisted uvulopalatoplasty (LAUP), and radiofrequency ablation (RFA), as well as multi-level and multi-phased procedures. We found that the published literature is comprised primarily of case series, with few controlled trials and varying approaches to pre-operative evaluation and post-operative follow-up. We include surgical morbidity and adverse events where reported but these were not systematically analyzed. Utilizing the ratio of means method, we used the change in the apnea-hypopnea index (AHI) as the primary measure of efficacy. Substantial and consistent reductions in the AHI were observed following MMA; adverse events were uncommonly reported. Outcomes following pharyngeal surgeries were less consistent; adverse events were reported more commonly. Papers describing positive outcomes associated with newer pharyngeal techniques and multi-level procedures performed in small samples of patients appear promising. Further research is needed to better clarify patient selection, as well as efficacy and safety of upper airway surgery in those with OSA.