Effects of vitamin D and zinc deficiency in acute and long COVID syndrome

OBJECTIVES

Acute inflammatory or neuropsychiatric symptoms, such as headache, fatigue, anosmia, and hyposmia, sometimes persist for more than 30 days or longer than 12 weeks after infection with the Omicron variant of SARS‑CoV‑2 (hereafter referred to as COVID-19). The aim of this study was to determine whether detection of zinc concentration or vitamin D concentration could provide treatment benefits for patients with COVID-19, thus reducing the risk of them experiencing long COVID.

METHODS

The interval between the date of COVID-19 diagnosis and the date of visit to pulmonary department for prolonged symptoms of COVID-19 was recorded for statistical analysis. Inductively coupled plasma mass spectrometry for detecting zinc and chemiluminescence immunoassay for detecting vitamin D were performed in laboratory tests.

RESULTS

Fifty-five patients were included. Of the participants, 29.1 % and 27.3 % had vitamin D and zinc deficiency, respectively. On average, the patients underwent long COVID treatment for 31.7 ± 17.7 days. A positive statistical correlation was observed between vitamin D and zinc concentrations (Pearson's correlation = 0.378). Compared with sufficient zinc levels, zinc deficiency was associated with a higher fibrinogen level (p < 0.05). Within 30 days, the observed vitamin D deficiency rate was only 21.4 %; after 30 days, the vitamin D deficiency rate rose to 37.0 % (McNemar's chi-square test; p < 0.05).

CONCLUSION

Zinc deficiency correlates to acute and persistent inflammation and vitamin D deficiency is associated with delayed recovery in long COVID syndrome.

Role of Changes in Driving Pressure and Mechanical Power in Predicting Mortality in Patients with Acute Respiratory Distress Syndrome

Driving pressure (ΔP) and mechanical power (MP) are associated with increased mortality in patients with acute respiratory distress syndrome (ARDS). We aimed to investigate which was better to predict mortality between changes in ΔP and MP. We reanalyzed data from a prospective observational cohort study of patients with ARDS in our hospital. Serial ΔP and MP values were calculated. The factors associated with survival were analyzed. Binary logistic regression showed that age (odds ratio (OR), 1.012; 95% confidence interval (CI), 1.003-1.022), Sequential Organ Failure assessment (SOFA) score (OR, 1.144; 95% CI, 1.086-1.206), trauma (OR, 0.172; 95% CI, 0.035-0.838), ΔP (OR, 1.077; 95% CI, 1.044-1.111), change in ΔP (OR, 1.087; 95% CI, 1.054-1.120), and change in MP (OR, 1.018; 95% CI, 1.006-1.029) were independently associated with 30-day mortality. Change in MP, change in ΔP, and SOFA scores were superior to ΔP in terms of the accuracy of predicting 30-day mortality. In conclusion, calculating change in ΔP is easy for respiratory therapists in clinical practice and may be used to predict mortality in patients with ARDS.

Efficacy of portable sleep monitoring device in diagnosing central sleep apnea in patients with congestive heart failure

Introduction

Central sleep apnea (CSA) is a common and serious comorbidity mainly occurring in patients with heart failure (HF), which tends to be underdiagnosed and has not been widely studied. Overnight polysomnography (PSG) is the gold standard for diagnosing CSA; however, the time and expense of the procedure limit its applicability. Portable monitoring (PM) devices are convenient and easy to use; however, they have not been widely studied as to their effectiveness in detecting CSA in patients with HF. In the current study, we examined the diagnostic value of PM as a screening tool to identify instances of CSA among patients with HF.

Methods

A total of 22 patients under stable heart failure conditions with an ejection fraction of <50% were enrolled. All patients underwent PM and overnight PSG within a narrow time frame. The measurements of the apnea-hypopnea index (AHI), hypopnea index (HI), central apnea index (CAI), and obstructive apnea index (OAI) obtained from PSG, automatic scoring, and manual scoring of PM were recorded. The results obtained from PSG and those from PM (automatic and manual scoring) were compared to assess the accuracy of PM.

Results

Among the patients, CSA in 11 patients was found by PSG. The AHI measurements performed using manual scoring of PM showed a significant correlation with those performed using PSG (r = 0.69; P = 0.01). Nonetheless, mean AHI measurements showed statistically significant differences between PSG and automatic scoring of PM (40.0 vs. 23.7 events/hour, respectively; P < 0.001), as well as between automatic and manual scoring of PM (23.7 vs. 29.5 events/hour; P < 0.001). Central sleep apnea was detected by PM; however, the results were easily misread as obstructive apnea, particularly in automatic scoring.

Conclusion

PM devices could be used to identify instances of central sleep apnea among patients with HF. The results from PM were well-correlated with standard PSG results, and manual scoring was preferable to automated scoring.

Alterations in Gut Microbiota and Upregulations of VPAC2 and Intestinal Tight Junctions Correlate with Anti-Inflammatory Effects of Electroacupuncture in Colitis Mice with Sleep Fragmentation

Simple Summary

Along with the modernization of society and people getting older, sleep disturbances and gut health have been identified as two key factors influencing aging, with dramatic effects on immunity and metabolism. Sleep is closely related to the gut, reflects the degree of chronic inflammation, and is associated with many degenerative diseases, hence the term “inflammaging”. This article addresses how sleep fragmentation affects the inflammatory state of the gut and elucidates the effects of restorative sleep and acupuncture on inflammatory gut remodeling and gut microbial recovery. In summary, fragmented sleep disrupted intestinal repair in mice with colitis, while electroacupuncture demonstrated likely results in alleviating colon inflammation, including maintaining colon length and daily body weight changes. In addition, the structure of the microbiota changed with decreasing gut inflammatory status. The intestinal tight junction proteins may be the key mechanism of electroacupuncture in treating sleep-fragmented ulcerative colitis mice. Electroacupuncture affects VIP through VPAC2 and further regulates intestinal mucosal immunity. This experiment demonstrates how physical stimulation stabilizes the intestinal epithelium and exerts an important anti-inflammatory effect.

Abstract

The relationship between inflammatory bowel disease and sleep disturbances is complicated and of increasing interest. We investigated the inflammatory and immunological consequences of EA in sleep-deprived colitis and found that dextran sulfate sodium (DSS)-induced colitis in sleep-fragmented (SF) mice was more severe than that in mice with normal sleep. This increase in the severity of colitis was accompanied by reduced body weight, shortened colon length, and deteriorated disease activity index. DSS with SF mice presented obvious diminished intestinal tight junction proteins (claudin-1 and occludin), elevated proinflammatory cytokines (CRP, IFN-γ, IL-6), lowered melatonin and adiponectin levels, downregulated vasoactive intestinal peptide (VIP) type 1 and 2 receptor (VPAC1, VPAC2) expression, and decreased diversity of gut bacteria. EA ameliorated colitis severity and preserved the performance of the epithelial tight junction proteins and VIP receptors, especially VPAC2. Meanwhile, the innate lymphoid cells-derived cytokines in both group 2 (IL-4, IL5, IL-9, IL-13) and group 3 (IL-22, GM-CSF) were elevated in mice colon tissue. Furthermore, dysbiosis was confirmed in the DSS group with and without SF, and EA could maintain the species diversity. Firmicutes could be restored, such as Lachnospiraceae, and Proteobacteria become rebalanced, mainly Enterobacteriaceae, after EA intervention. On the other hand, SF plays different roles in physiological and pathological conditions. In normal mice, interrupted sleep did not affect the expression of claudin-1 and occludin. But VPAC1, VPAC2, and gut microbiota diversity, including Burkholderiaceae and Rhodococcus, were opposite to mice in an inflamed state.

Comparing Clinical Outcomes of Tiotropium/Olodaterol, Umeclidinium/Vilanterol, and Indacaterol/Glycopyrronium Fixed-Dose Combination Therapy in Patients with Chronic Obstructive Pulmonary Disease in Taiwan: A Multicenter Cohort Study

Background

Long-acting beta-agonists (LABA) and long-acting muscarinic antagonists (LAMA) combination therapy improved lung function and health-related quality-of-life and reduced exacerbation rates and dyspnea in symptomatic chronic obstructive pulmonary disease (COPD) patients. We compared the real-world effects of three fixed-dose LABA/LAMA combinations for COPD in Taiwan.

Methods

This multicenter, retrospective study evaluated 1-year outcomes after LABA/LAMA combination therapy in patients with symptomatic COPD. Exacerbations and symptoms of COPD, lung functions, and therapy escalation were compared among patients using tiotropium/olodaterol, umeclidinium/vilanterol and indacaterol/glycopyrronium. Propensity score matching (PSM) was applied to balance the baseline characteristics.

Results

Data of 1,617 patients were collected. After PSM, time to first moderate-to-severe COPD exacerbation was comparable among three groups, while the annualized rates of the exacerbation (episodes/patient/year) in patients receiving tiotropium/olodaterol (0.19) or umeclidinium/vilanterol (0.17) were significantly lower than those receiving indacaterol/glycopyrronium (0.38). COPD-related symptoms were stable over the treatment period, and there was no significant difference in the changes of symptom scores including CAT and mMRC among three groups at the end of the study period.

Conclusion

This study presented valuable real-world outcome in terms of exacerbation and treatment response of COPD patients treated with fixed-dose LABA/LAMA regimens in Taiwan. The annualized rates of moderate-to-severe exacerbation in patients receiving tiotropium/olodaterol or umeclidinium/vilanterol were significantly lower than those receiving indacaterol/glycopyrronium, though the time to first moderate-to-severe exacerbation was similar among different fixed-dose LABA/LAMA combinations.

Association of Sleep, Neuropsychological Performance, and Gray Matter Volume With Glymphatic Function in Community-Dwelling Older Adults

BACKGROUND AND OBJECTIVES

The glymphatic system, which is robustly enabled during some stages of sleep, is a fluid-transport pathway that clears cerebral waste products. Most contemporary knowledge regarding the glymphatic system is inferred from rodent experiments and human research is limited. Our objective is to explore the associations between human glymphatic function, sleep, neuropsychological performance, and cerebral gray matter volumes.

METHODS

This cross-sectional study included individuals 60 years or older who had participated in the Integrating Systemic Data of Geriatric Medicine to Explore the Solution for Health Aging study between September 2019 and October 2020. Community-dwelling older adults were enrolled at 2 different sites. Participants with dementia, major depressive disorders, and other major organ system abnormalities were excluded. Sleep profile was accessed using questionnaires and polysomnography. Administered neuropsychological test batteries included Everyday Cognition (ECog) and the Consortium to Establish a Registry for Alzheimer's Disease Neuropsychological Battery (CERAD-NB). Gray matter volumes were estimated based on MRI. Diffusion tensor imaging analysis along the perivascular space (DTI-ALPS) index was used as the MRI marker of glymphatic function.

RESULTS

A total of 84 participants (mean [SD] age 73.3 [7.1] years, 47 [56.0%] women) were analyzed. Multivariate linear regression model determined that age (unstandardized β, -0.0025 [SE 0.0001]; p = 0.02), N2 sleep duration (unstandardized β, 0.0002 [SE 0.0001]; p = 0.04), and the apnea-hypopnea index (unstandardized β, -0.0011 [SE 0.0005]; p = 0.03) were independently associated with DTI-ALPS. Higher DTI-ALPS was associated with better ECog language scores (unstandardized β, -0.59 [SE 0.28]; p = 0.04) and better CERAD-NB word list learning delayed recall subtest scores (unstandardized β, 6.17 [SE 2.31]; p = 0.009) after covarying for age and education. Higher DTI-ALPS was also associated with higher gray matter volume (unstandardized β, 107.00 [SE 43.65]; p = 0.02) after controlling for age, sex, and total intracranial volume.

DISCUSSION

Significant associations were identified between glymphatic function and sleep, stressing the importance of sleep for brain health. This study also revealed associations between DTI-ALPS, neuropsychological performance, and cerebral gray matter volumes, suggesting the potential of DTI-ALPS as a biomarker for cognitive disorders.

Skeletal and upper airway stability following modified maxillomandibular advancement for treatment of obstructive sleep apnea in skeletal class I or II deformity

OBJECTIVES

Maxillomandibular advancement (MMA) is an effective short-term treatment for obstructive sleep apnea (OSA). This study aimed to evaluate the long-term stability of the facial skeleton, upper airway, and its surrounding structures, as well as improvement in OSA following MMA.

MATERIALS AND METHODS

Thirty-one adults with moderate-to-severe OSA underwent surgery-first modified MMA as primary surgery. Polysomnography and cone-beam computed tomography were obtained pre-surgery, early post-surgery, and at follow-up (i.e., ≥ 2 years post-surgery). Image analysis software assessed the facial skeleton, upper airway, and its surrounding structures.

RESULTS

Early post-surgery, apnea-hypopnea index (AHI) had decreased significantly (p < 0.001) and the minimum oxygen saturation (MSAT) increased (p = 0.001), indicating significant improvement in OSA. At follow-up, the AHI and MSAT remained stable. However, the anterior maxilla, soft palate, and tongue moved backward while the hyoid moved downward. There was also a significant decrease in the minimal cross-sectional area of the oropharynx. The reduction in AHI was significantly related to the anterior movement of the anterior maxilla and tongue, inferior movement of the posterior maxilla, and superior movement of the soft palate tip.

CONCLUSIONS

The improvement of OSA after modified MMA remained stable for at least 2 years following treatment, despite the relapse of the facial skeleton, upper airway, and its surrounding structures. The reduction of AHI was not related to changes in the caliber of the upper airway but to the movement of the maxilla, soft palate, and tongue. Clinical relevance Modified MMA is clinically effective for long-term treatment of patients with moderate-to-severe OSA.

Elevated serum matrix metalloproteinase-2 levels in heart failure patients with reduced ejection fraction and Cheyne-Stokes respiration

STUDY OBJECTIVES

Cheyne-Stokes respiration (CSR), a kind of central sleep apnea (CSA), is referred to as a poor prognostic factor in heart failure patients with reduced ejection fraction (HFrEF). Matrix metalloproteinase (MMP) and B-type natriuretic peptide (BNP) play important roles in HFrEF patients and are markers of poor prognosis. However, there is no literature mentioning the changes in MMP and BNP in HFrEF patients with CSR.

METHODS

From June 2018 to June 2019, 41 adult patients with stable heart failure and left ventricular ejection fraction (LVEF) <50% were enrolled from the cardiology clinic. After history taking and medication review to exclude possible central nervous system or medication related CSA, an overnight polysomnography study was performed, and CSR was identified. The morning serum MMP-2, MMP-9 and BNP levels were determined using enzyme-linked immunosorbent assay and fluorescence immunoassay techniques. A positive airway pressure (PAP) device was applied to 7 patients for 3 months.

RESULTS

The serum MMP-2 and BNP levels were significantly higher in HFrEF patients with CSR than in patients without CSR. In addition, elevated serum MMP-2 levels correlated well with the severity of sleep apnea and intermittent hypoxia, which were represented as the apnea-hypopnea index and the oxygen-desaturation index. No positive correlation was found between those markers and LVEF. Finally, the treatment of sleep apnea with CPAP for 3 months tended to reduce the elevated serum MMP-2 levels.

CONCLUSIONS

Higher serum MMP-2 and BNP levels were found in HFrEF patients with CSR. Elevated MMP-2 levels were correlated with the severity of sleep apnea and intermittent hypoxia.

Severe OSA associated with higher risk of mortality in stage III and IV lung cancer

STUDY OBJECTIVES

OSA has been associated with increased cancer incidence and mortality. The aim of this study was to investigate cancer-related mortality, overall survival, and progression-free survival in patients with suspected OSA and lung cancer.

METHODS

This was a case series analysis of lung cancer from a sleep cohort with suspected OSA between 2009 and 2014. The AHI, hypoxia index, and survival outcome were recorded. Immunohistochemistry was used to analyze hypoxia-inducible factor-1α (HIF-1α) and vascular endothelial growth factor expression in tumor pathology.

RESULTS

In the sleep cohort comprising 8,261 patients, a total of 23 patients had lung cancer. The incidence of lung cancer was significantly higher in the sleep cohort than in the entire adult population in Taiwan (crude incidence rate: 242.1 vs 51.5 per 10⁵ persons, P < .01). The 3-year cancer-related mortality was 25% in AHI < 15 events/h, 50% in AHI 15-29 events/h, and 80% in AHI ≥ 30 events/h (χ² test for trend, P = .03). In Kaplan-Meier survival analysis, patients with stage III-IV lung cancer and AHI < 30 events/h exhibited significantly better overall survival (P = .02) and progression-free survival (P = .02) than patients with severe OSA. Overexpression of HIF-1α and vascular endothelial growth factor was shown in 63% and 45% of lung tumor samples. Overexpression of HIF-1α was positively associated with AHI (P = .04).

CONCLUSIONS

In this preliminary case series, severe OSA is associated with an increased risk of cancer mortality in patients with stage III-IV lung cancer. AHI was significantly associated with HIF-1α overexpression.

Association Between Obstructive Sleep Apnea and Diabetic Macular Edema in Patients with Type 2 Diabetes

PURPOSE

To evaluate the relationship between obstructive sleep apnea (OSA) and diabetic macular edema (DME) and the effect of OSA on refractory DME in patients with type 2 diabetes (T2DM).

DESIGN

Retrospective clinical cohort study.

METHODS

A population-based study was conducted at Chang Gung Memorial Hospital from March 1, 2009, to March 1, 2020. Among 14,152 patients who had undergone polysomnography (PSG) and whose data were registered on the sleep center's PSG database, 121 patients (242 eyes) with T2DM were enrolled according to the International Classification of Diseases, Ninth Revision (ICD-9) code 3620 for diabetic retinopathy (DR). Patients with a secondary cause of macular edema and those lacking medical records were excluded. All patients with T2DM enrolled in our study received both optical coherence tomography (OCT) and PSG. The prevalence of severe (apnea-hypopnea index [AHI] ≥30) and nonsevere (AHI <30) OSA was compared between patients with and without DME and refractory DME.

RESULTS

In total, 102 eyes (54 patients) were divided into groups of 40 eyes with DME or 62 eyes without DME. Severe OSA (odds ratio, 7.36; 95% confidence interval [CI]: 1.32-40.96; P = .023) was significantly associated with DME. Refractory DME was significantly more frequent in patients with severe OSA (27%) than in those with nonsevere OSA (0%; P = .009). Cox proportional hazards regression analysis revealed that OSA (hazard ratio, 2.97; CI, 1.08-8.16; P = .034) independently increased the DME risk after adjustment for age, sex, glycohemoglobin level, hypertension, and hypercholesterolemia.

CONCLUSIONS

Severe OSA is a risk factor for DME and is associated with having refractory DME.

Different Associations between Tonsil Microbiome, Chronic Tonsillitis, and Intermittent Hypoxemia among Obstructive Sleep Apnea Children of Different Weight Status: A Pilot Case-Control Study

The tonsil microbiome is associated with chronic tonsillitis and obstructive sleep apnea (OSA) in children, and the gut microbiome is associated with host weight status. In this study, we hypothesized that weight status may be associated with clinical profiles and the tonsil microbiome in children with OSA. We prospectively enrolled 33 non-healthy-weight (cases) and 33 healthy-weight (controls) pediatric OSA patients matched by the proportion of chronic tonsillitis. Differences in the tonsil microbiome between the non-healthy-weight and healthy-weight subgroups and relationships between the tonsil microbiome and clinical variables were investigated. Non-healthy weight was associated with significant intermittent hypoxemia (oxygen desaturation index, mean blood saturation (SpO₂), and minimal SpO₂) and higher systolic blood pressure percentile, but was not related to the tonsil microbiome. However, chronic tonsillitis was related to Acidobacteria in the non-healthy-weight subgroup, and oxygen desaturation index was associated with Bacteroidetes in the healthy-weight subgroup. In post hoc analysis, the children with mean SpO₂ ≤ 97% had reduced α and β diversities and a higher abundance of Bacteroidetes than those with mean SpO₂ > 97%. These preliminary findings are novel and provide insights into future research to understand the pathogenesis of the disease and develop personalized treatments for pediatric OSA.

Heart rate variability during wakefulness as a marker of obstructive sleep apnea severity

STUDY OBJECTIVES

Patients with obstructive sleep apnea (OSA) exhibit heterogeneous heart rate variability (HRV) during wakefulness and sleep. We investigated the influence of OSA severity on HRV parameters during wakefulness in a large international clinical sample.

METHODS

1247 subjects (426 without OSA and 821 patients with OSA) were enrolled from the Sleep Apnea Global Interdisciplinary Consortium. HRV parameters were calculated during a 5-minute wakefulness period with spontaneous breathing prior to the sleep study, using time-domain, frequency-domain and nonlinear methods. Differences in HRV were evaluated among groups using analysis of covariance, controlling for relevant covariates.

RESULTS

Patients with OSA showed significantly lower time-domain variations and less complexity of heartbeats compared to individuals without OSA. Those with severe OSA had remarkably reduced HRV compared to all other groups. Compared to non-OSA patients, those with severe OSA had lower HRV based on SDNN (adjusted mean: 37.4 vs. 46.2 ms; p < 0.0001), RMSSD (21.5 vs. 27.9 ms; p < 0.0001), ShanEn (1.83 vs. 2.01; p < 0.0001), and Forbword (36.7 vs. 33.0; p = 0.0001). While no differences were found in frequency-domain measures overall, among obese patients there was a shift to sympathetic dominance in severe OSA, with a higher LF/HF ratio compared to obese non-OSA patients (4.2 vs. 2.7; p = 0.009).

CONCLUSIONS

Time-domain and nonlinear HRV measures during wakefulness are associated with OSA severity, with severe patients having remarkably reduced and less complex HRV. Frequency-domain measures show a shift to sympathetic dominance only in obese OSA patients. Thus, HRV during wakefulness could provide additional information about cardiovascular physiology in OSA patients.

CLINICAL TRIAL INFORMATION

A Prospective Observational Cohort to Study the Genetics of Obstructive Sleep Apnea and Associated Co-Morbidities (German Clinical Trials Register - DKRS, DRKS00003966) https://www.drks.de/drks_web/navigate.do?navigationId=trial.HTML&TRIAL_ID=DRKS00003966.

Clinical outcomes and prognostic factors for prolonged mechanical ventilation in patients with acute stroke and brain trauma

BACKGROUND/PURPOSE

Neurological dysfunction is a common condition necessitating prolonged mechanical ventilation (PMV). We investigated the clinical features and outcomes of patients with acute neurological diseases requiring PMV.

METHODS

This retrospective observational study was conducted at the Respiratory Care Center (RCC) of Chang Gung Memorial Hospital, Taiwan, between January 2011 and January 2014. The main outcome was weaning success, defined as successful withdrawal from mechanical ventilator support for more than 5 days.

RESULTS

The study included 103 patients with acute stroke and brain trauma receiving PMV. Weaning success was reported in 63 (61%) patients and weaning failure was reported in 40 (39%) patients. Patients in the weaning failure group were older and had a lower RCC Glasgow Coma Scale (GCS) score (6.0 vs 7.9, p = 0.005), lower albumin level (2.8 vs 3.1, p = 0.015), longer RCC stay (28.7 vs 21.3 days, p = 0.017), and higher in-hospital mortality rate (47% vs 9%, p < 0.01). Multivariate analysis revealed that reduced RCC GCS score is an independent prognostic factor for weaning failure (odds ratio [OR] = 1.22, 95% confidence interval [CI] = 1.05-1.46, p = 0.016) and that per unit increase of RCC GCS score is associated with a lower risk of in-hospital mortality (OR = 0.83, 95% CI = 0.70-0.96, p = 0.019).

CONCLUSION

Reduced RCC GCS score is an independent prognostic factor for weaning failure, and is associated with increased in-hospital mortality rates in patients with acute stroke and brain trauma requiring PMV.

Simple and Unbiased OSA Prescreening: Introduction of a New Morphologic OSA Prediction Score

PURPOSE

An early prescreening in suspected obstructive sleep apnea (OSA) patients is desirable to expedite diagnosis and treatment. However, the accuracy and applicability of current prescreening tools is insufficient. We developed and tested an unbiased scoring system based solely on objective variables, which focuses on the diagnosis of severe OSA and exclusion of OSA.

PATIENTS AND METHODS

The OSA prediction score was developed (n = 150) and validated (n = 50) within German sleep center patients that were recruited as part of the Sleep Apnea Global Interdisciplinary Consortium (SAGIC). Six objective variables that were easy to assess and highly correlated with the apnea-hypopnea index were chosen for the score, including some known OSA risk factors: body-mass index, neck circumference, waist circumference, tongue position, male gender, and age (for women only). To test the predictive ability of the score and identify score thresholds, the receiver-operating characteristics (ROC) and curve were calculated.

RESULTS

A score ≥8 for predicting severe OSA resulted in an area under the ROC curve (ROC-AUC) of 90% (95% confidence interval: 84%, 95%), test accuracy of 82% (75%, 88%), sensitivity of 82% (65%, 93%), specificity of 82% (74%, 88%), and positive likelihood ratio of 4.55 (3.00, 6.90). A score ≤5 for predicting the absence of OSA resulted in a ROC-AUC of 89% (83%, 94%), test accuracy of 80% (73%, 86%), sensitivity of 72% (55%, 85%), specificity of 83% (75%, 89%), and positive likelihood ratio of 4.20 (2.66, 6.61). Performance characteristics were comparable in the small validation sample.

CONCLUSION

We introduced a novel prescreening tool combining easily obtainable objective measures with predictive power and high general applicability. The proposed tool successfully predicted severe OSA (important due to its high risk of cardiovascular disease) and the exclusion of OSA (rarely a feature of previous screening instruments, but important for better differential diagnosis and treatment).

Idiopathic Sudden Sensorineural Hearing Loss in Patients with Obstructive Sleep Apnea

PURPOSE

Obstructive sleep apnea (OSA) is characterized by recurring hypoxic-apneic events during sleep, and labyrinthine vascular compromise is a pathophysiologic hallmark of idiopathic sudden sensorineural hearing loss (ISSNHL). Some reports have discussed the relationship between OSA and hearing impairment; however, few have examined hearing prognosis in OSA and patients without OSA with ISSNHL. We aimed to investigate clinical manifestations of ISSNHL in patients with OSA, including severity of hearing loss and response to treatment.

PATIENTS AND METHODS

A case-control study was conducted by extracting data from the sleep center and cochlea center databases of the Chang Gung Memorial Hospital. A retrospective chart review was performed to include confirmed adult OSA patients diagnosed with unilateral ISSNHL. Age and sex-matched patients without OSA with ISSNHL were enrolled as controls. Pure-tone average (PTA) thresholds were measured at specific frequencies. Changes in PTA before and after standard treatment with oral prednisolone (1mg/kg/day for 5 days, then tapered) and between participants with OSA and without OSA were compared. Standard treatment was given to all ISSNHL patients.

RESULTS

Twenty-eight out of 8500 (0.33%) OSA patients experienced subsequent ISSNHL in 9 years. Patients with OSA (n=28) had poorer high-frequency perception in the unaffected ear than the patients without OSA (n=120), although the difference was not significant. Hearing in the affected ear among patients with OSA was comparable to that patients without OSA at individual frequencies and average, suggesting no difference in hearing loss in the affected ear between the two groups. In terms of high-frequencies (4000 and 8000 Hz) perception, patients with OSA had significantly poorer responses to steroid treatment than patients without OSA.

CONCLUSION

ISSNHL may be one of the auditory complications associated with OSA. Patients with OSA had poorer prednisolone related hearing improvement in high frequencies than patients without OSA. Despite study limitations, OSA-related hypoxia and snoring noise is hazardous to hearing and standard treatments with CPAP is suggested in OSA patients for both holistic and auditory health.

Diagnostic meta-analysis of the Pediatric Sleep Questionnaire, OSA-18, and pulse oximetry in detecting pediatric obstructive sleep apnea syndrome

The aim of this meta-analysis was to compare the pooled sensitivity and specificity of the Pediatric Sleep Questionnaire (PSQ), Obstructive Sleep Apnea Questionnaire (OSA-18), and pulse oximetry (PO) according to OSAS severity. Three electronic databases were searched for studies evaluating sensitivity and specificity of the three tools against the apnea-hypopnea index measured using overnight in-laboratory or in-home polysomnography in children and adolescents from inception until January 11, 2020. A random-effects bivariate model was used to estimate the summary sensitivity and specificity of the tools. We identified 39 studies involving 6131 clinical and community children (aged 2.9-16.7 y). The PSQ exhibited the highest sensitivity (74%) for detecting symptoms of mild pediatric OSAS. The PSQ and PO had comparable sensitivity in screening moderate and severe pediatric OSAS (0.82 and 0.89 vs 0.83 and 0.83, respectively). PO yielded superior specificity in detecting mild, moderate, and severe pediatric OSAS (86%, 75%, and 83%, respectively) than did the PSQ and OSA-18 (all p < 0.05). Age, percentage of girls, index test criteria, methodology quality, and sample size significantly moderated sensitivity and specificity. For early detection of pediatric OSAS, the combined use of PSQ and PO is recommended when polysomnography is not available. PROSPERO REGISTRATION NUMBER: CRD42018090571.

Differences in Anthropometric and Clinical Features among Preschoolers, School-Age Children, and Adolescents with Obstructive Sleep Apnea-A Hospital-Based Study in Taiwan

Pediatric obstructive sleep apnea (OSA) is associated with adverse health outcomes; however, little is known about the diversity of this population. This retrospective study aims to investigate age-related differences in the anthropometric and clinical features of this population. A total of 253 Taiwanese children (70 (27.7%) girls and 183 (72.3%) boys) with OSA were reviewed. Their median age, body mass index (BMI) z-score, and apnea-hypopnea index were 6.9 years, 0.87, and 9.5 events/h, respectively. The cohort was divided into three subgroups: ‘preschoolers’ (≥2 and <6 years), ‘school-age children’ (≥6 and <10 years), and ‘adolescents (≥10 and <18 years)’. The percentage of the male sex, BMI z-score, neck circumference, systolic blood pressure z-score, neutrophil-to-lymphocyte ratio, and platelet-to-lymphocyte ratio tended to increase with age. Adenoid grades tended to decrease with age. Overall, disease severity was independently correlated with neck circumference, tonsil size, and adenoid grade. Increased neck circumference and tonsillar hypertrophy were the most influential factors for younger children, whereas adenoidal hypertrophy became more important at an older age. In conclusion, gender prevalence ratio, anthropometric measures, and clinical features varied with age, and the pathogenic drivers were not necessarily the same as the aggravating ones.

Defining Extreme Phenotypes of OSA Across International Sleep Centers

BACKGROUND

Extreme phenotypes of OSA have not been systematically defined.

RESEARCH QUESTION

This study developed objective definitions of extreme phenotypes of OSA by using a multivariate approach. The utility of these definitions for identifying characteristics that confer predisposition toward or protection against OSA is shown in a new prospective sample.

STUDY DESIGN AND METHODS

In a large international sample, race-specific liability scores were calculated from a weighted logistic regression that included age, sex, and BMI. Extreme cases were defined as individuals with an apnea-hypopnea index (AHI) ≥ 30 events/hour but low likelihood of OSA based on age, sex, and BMI (liability scores > 90th percentile). Similarly, extreme controls were individuals with an AHI < 5 events/hour but high likelihood of OSA (liability scores < 10th percentile). Definitions were applied to a prospective sample from the Sleep Apnea Global Interdisciplinary Consortium, and differences in photography-based craniofacial and intraoral phenotypes were evaluated.

RESULTS

This study included retrospective data from 81,338 individuals. A total of 4,168 extreme cases and 1,432 extreme controls were identified by using liability scores. Extreme cases were younger (43.1 ± 14.7 years), overweight (28.6 ± 6.8 kg/m²), and predominantly female (71.1%). Extreme controls were older (53.8 ± 14.1 years), obese (34.0 ± 8.1 kg/m²), and predominantly male (65.8%). These objective definitions identified 29 extreme cases and 87 extreme controls among 1,424 Sleep Apnea Global Interdisciplinary Consortium participants with photography-based phenotyping. Comparisons suggest that a greater cervicomental angle increases risk for OSA in the absence of clinical risk factors, and smaller facial widths are protective in the presence of clinical risk factors.

INTERPRETATION

This objective definition can be applied in sleep centers throughout the world to consistently define OSA extreme phenotypes for future studies on genetic, anatomic, and physiologic pathways to OSA.

Severe Obstructive Sleep Apnea Associated With Higher Risk of Mortality in Stage III and IV Lung Cancer

STUDY OBJECTIVES

Obstructive sleep apnea (OSA) has been associated with increased cancer incidence and mortality. The aim of this study was to investigate cancer-related mortality, overall survival and progression free survival in patients with suspected OSA and lung cancer.

METHODS

This was a case series analysis of lung cancer from a sleep cohort with suspected OSA between 2009 and 2014. The apnea- hypopnea index (AHI), Tsat90% (hypoxia index) and survival outcome were recorded. Immunohistochemistry was used to analyze HIF-1α and VEGF expression in tumor pathology.

RESULTS

In the sleep cohort comprising 8261 patients, a total of 23 patients had lung cancer. The incidence of lung cancer was significantly higher in the sleep cohort than in the entire adult population in Taiwan (242.1 vs 51.5 per 10⁵ persons, P< 0.01). The 3-year cancer-related mortality was 25% in AHI < 15, 50% in AHI 15 to 29 and 80% in AHI ≥ 30 (chi-squared test for trend P =0.03). In Kaplan-Meier survival analysis, patients with stage III-IV lung cancer and AHI< 30 exhibited significantly better overall survival (P = 0.02) and progression free survival (P = 0.02) than patients with severe OSA. Overexpression of HIF-1α and VEGF was shown in 63 % and 45 % of lung tumor samples. Overexpression of HIF-1α was positively associated with AHI (P = 0.04).

CONCLUSIONS

In this preliminary case series, severe OSA is associated with an increased risk of cancer mortality in patients with stage III-IV lung cancer. AHI was significantly associated with HIF-1α overexpression.

Risk of Alzheimer's Disease in Obstructive Sleep Apnea Patients With or Without Treatment: Real-World Evidence

OBJECTIVE

To assess the risk of Alzheimer's disease (AD) in patients with obstructive sleep apnea (OSA) with or without treatment based on real-world evidence.

STUDY DESIGN

Retrospective cohort study.

METHODS

Patients newly diagnosed with OSA during 1997-2012 were identified using the National Health Insurance Research Database of Taiwan. Patients without OSA were randomly selected and matched in a 1:4 ratio by age, sex, urbanization level, and income. All patients were followed up until death or the end of 2013. The primary outcome was AD occurrence.

RESULTS

This study included 3,978 OSA patients and 15,912 non-OSA patients. OSA was independently and significantly associated with a higher incidence of AD in an adjusted Cox proportional hazard model (adjusted hazard ratio: 2.12; 95% confidence interval [CI], 1.27-3.56). The average period of AD detection from the time of OSA occurrence was 5.44 years (standard deviation: 2.96). Subgroup analyses revealed that the effect of OSA remained significant in patients aged ≥60 years, male subgroups, patients without CPAP or surgical treatment, and patients without pharmacological therapies. Patients with OSA who received treatment (continuous positive airway pressure or surgery) exhibited a significantly reduced risk of AD compared with those without treatment (incidence rate ratio 0.23, 95% CI, 0.06-0.98).

CONCLUSION

OSA is independently associated with an increased risk of AD. Treatment for OSA reduces the AD risk in OSA patients. AD irreversibility renders OSA as a potential modifiable target for slowing or preventing the process of AD development.

LEVEL OF EVIDENCE

IV Laryngoscope, 130:2292-2298, 2020.

Alterations in Alzheimer's Disease-Associated Gene Expression in Severe Obstructive Sleep Apnea Patients

Background: Obstructive sleep apnea (OSA) increases the risk of Alzheimer’s disease (AD), and inflammation may be involved in the early pathogenesis of AD in patients with OSA. However, the potential pathways between OSA and AD have yet to be established. In this study, we aimed to investigate differential expressions of AD-associated genes in OSA patients without evident AD or dementia. Methods: This prospective case-control study included five patients with severe OSA and five age and sex-matched patients with non-severe OSA without evident dementia who underwent uvulopalatopharyngoplasty between 1 January 2013 and 31 December 2015. The expressions of genes associated with AD were analyzed using whole-exome sequencing. Unsupervised two-dimensional hierarchical clustering was performed on these genes. Pearson’s correlation was used as the distance metric to simultaneously cluster subjects and genes. Results: The expressions of CCL2, IL6, CXCL8, HLA-A, and IL1RN in the patients with severe OSA were significantly different from those in the patients with non-severe OSA and contributed to changes in the immune response, cytokine–cytokine receptor interactions, and nucleotide-binding oligomerization domain-like receptor signaling pathways. Conclusions: Inflammation may contribute to the onset of AD and physicians need to be aware of the potential occurrence of AD in patients with severe OSA.

A Global Comparison of Anatomic Risk Factors and Their Relationship to Obstructive Sleep Apnea Severity in Clinical Samples

STUDY OBJECTIVES

Obstructive sleep apnea (OSA) is a global health issue and is associated with obesity and oropharyngeal crowding. Global data are limited on the effect of ethnicity and sex on these relationships. We compare associations between the apnea-hypopnea index (AHI) and these risk factors across ethnicities and sexes within sleep clinics.

METHODS

This is a cross-sectional, multicenter study of patients with OSA from eight sleep centers representing the Sleep Apnea Global Interdisciplinary Consortium (SAGIC). Four distinct ethnic groups were analyzed, using a structured questionnaire: Caucasians (Australia, Iceland, Germany, United States), African Americans (United States), Asians (Taiwan), and South Americans (Brazil). Regression analyses and interaction tests were used to assess ethnic and sex differences in relationships between AHI and anthropometric measures (body mass index [BMI], neck circumference, waist circumference) or Mallampati score.

RESULTS

Analyses included 1,585 individuals from four ethnic groups: Caucasian (60.6%), African American (17.5%), Asian (13.1%), and South American (8.9%). BMI was most strongly associated with AHI in South Americans (7.8% increase in AHI per 1 kg/m² increase in BMI; P < .0001) and most weakly in African Americans (1.9% increase in AHI per 1 kg/m² increase in BMI; P = .002). In Caucasians and South Americans, associations were stronger in males than females. Mallampati score differed between ethnicities but did not influence AHI differently across groups.

CONCLUSIONS

We demonstrate ethnic and sex variations in associations between obesity and OSA. For similar BMI increases, South American patients show greatest AHI increases compared to African Americans. Findings highlight the importance of considering ethnicity and sex in clinical assessments of OSA risk.

Monocytic C-C chemokine receptor 5 expression increases in in vitro intermittent hypoxia condition and in severe obstructive sleep apnea patients

Purpose

Obstructive sleep apnea (OSA) patients have higher risk of cardiovascular disease. C-C chemokine receptor 5 (CCR5), as an important receptor for monocyte recruitment and the initiation of atherosclerosis, was studied under intermittent hypoxia and in OSA patients.

Methods

The expression and function of CCR5 regulated by intermittent hypoxia in monocytic THP-1 cells were investigated in an in vitro intermittent hypoxia culture system. The expression levels of protein and mRNA were analyzed by western blot and RT/real-time PCR analysis. Cell adhesion assay and transwell filter migration assay were carried out to investigate the adhesion and chemotaxis of monocytes. In addition, the mRNA expression of CCR5 in monocytes isolated from peripheral blood of 72 adults was analyzed.

Results

Intermittent hypoxia upregulated the expression of CCR5 in THP-1 cells and enhanced the adhesion and chemotaxis of monocytes to vascular endothelial cells mediated by RANTES. The CCR5 expression induced by intermittent hypoxia was inhibited by inhibitor for p42/44 MAPK. Besides, the expression of CCR5 in monocytes increased along the AHI value especially in severe OSA patients that was statistically significant compared with mild and moderate OSA groups.

Conclusions

This study demonstrated the increased monocytic CCR5 gene expression in patients with severe OSA. Intermittent hypoxia, the characteristic of OSA, induced monocytic CCR5 gene expression and the enhanced RANTES-mediated chemotaxis and adhesion through p42/44 MAPK signal pathways.

Elevated Serum Markers of Acute Kidney Injury in Patients With Obstructive Sleep Apnea

STUDY OBJECTIVES

Previous research revealed a positive correlation between endothelial cell injury (indicated by albuminuria) and obstructive sleep apnea (OSA). However, little else has been revealed about acute kidney injury (AKI) in patients with OSA.

METHODS

This prospective study recruited consecutive patients undergoing overnight polysomnography for evaluation of sleep apnea. Patients in whom any major disease or recent infection had been previously diagnosed were excluded. Ultimately, data from 75 patients with apnea-hypopnea indices of 5 or more were analyzed. Baseline values for the urinary albumin-creatinine ratio (UACR), serum levels for three markers of AKI (cystatin C, neutrophil gelatinase-associated lipocalin [NGAL], interleukin-18 [IL-18]), and polysomnography data were recorded and analyzed. Patients then were followed for 6 months of continuous positive airway pressure (CPAP) treatment.

RESULTS

At baseline, UACRs were greater in patients with more severe OSA (P = .005, r = .329). All three serum markers of AKI (cystatin C, NGAL, and IL-18) studied were positively correlated with OSA severity, and two (cystatin C and IL-18) were positively correlated with the frequency of oxygen desaturation during sleep. However, none of the AKI markers had positive correlations with UACR. After 6 months of CPAP treatment, UACR and IL-18 were decreased significantly in patients with good adherence.

CONCLUSIONS

Albuminuria and levels of three serum markers of AKI (cystatin C, NGAL, IL-18) were positively correlated with OSA severity, and good adherence with CPAP treatment decreased albuminuria and interleukin-18 levels. These results may provide additional tools for assessing early renal injury in patients with OSA.

Effects of Electrical Muscle Stimulation in Subjects Undergoing Prolonged Mechanical Ventilation

BACKGROUND

Muscle atrophy and deconditioning are common complications in patients on prolonged mechanical ventilation (PMV). There are few studies that reviewed the effects of electrical muscle stimulation in this population. The purpose of this study was to examine the effects of electrical muscle stimulation on muscle function and hospitalization outcomes in subjects with PMV.

METHODS

Subjects on mechanical ventilation for ≥21 d were randomly assigned to the electrical muscle stimulation group (n = 16) or the control group (n = 17). The electrical muscle stimulation group received daily muscle electrical stimulation for 30 min/session for 10 d. The measurement of muscle strength (by medical research council [MRC] scale), leg circumference, and physical functional status (by Functional Independence Measure [FIM] scores) were performed before and after completion of the study. The length of stay in respiratory care center of subjects were recorded.

RESULTS

After electrical muscle stimulation, there was no difference in pulmonary function between the electrical muscle stimulation and control groups. Significantly increased in MRC points was found in the electrical muscle stimulation group after intervention (2 [1-7] points vs 2 [1-3.5] points, respectively, P = .034). No difference in MRC points was found between baseline and post-measurement in the control group (1[1-2] points vs 1[1-2.5] points, respectively, P > .99). At the end of the study, leg circumference in control group significantly decreased when compared with baseline (47.5 ± 8.3 cm vs 44.6 ± 5.7 cm, respectively, P = .004) and remained unchanged in the EMS group. However, no significant differences were found between the electrical muscle stimulation and control groups. There was no difference in physical functional status and hospital stay between the electrical muscle stimulation and control groups.

CONCLUSIONS

Electrical muscle stimulation enhanced muscle strength in subjects who received PMV. Electrical muscle stimulation can be considered a preventive strategy for muscle weakness in patients who receive PMV. (ClinicalTrials.gov registration NCT02227810.).

Pharyngeal distensibility during expiration is an independent predictor of the severity of obstructive sleep apnoea

BACKGROUND AND OBJECTIVE

Pharyngeal distensibility and collapsibility reflect the passive properties of tissue in the airway, are an indicator of the ease with which an airway can be deformed and are related to the severity of obstructive sleep apnoea (OSA). During normal tidal respiration, the collapsibility of the pharynx during expiration is passive without confounding by neuromuscular activation that occurs during inspiration. We evaluated the distensibility and collapsibility of the upper airway in subjects with OSA during wakefulness using sophisticated dynamic computed tomography (CT) imaging. We hypothesized that the dynamic changes of the upper airway during expiration would be related to the severity of OSA.

METHODS

Twenty-three patients with OSA and eight normal subjects underwent simultaneous measurement of respiratory flow and airway calibre using ultrafast CT. The change in pharyngeal cross-sectional area divided by the change in concomitant flow (as distensibility or collapsibility) was measured and compared across different severities of OSA.

RESULTS

The slope of this relationship between delta area and delta flow during expiration was significantly higher in severe OSA when compared with normal controls and mild-moderate OSA. Differences in airway distensibility or collapsibility between severity groups were significant in expiration but not in inspiration. Distensibility or collapsibility contributed most to the apnoea-hypopnoea index in regression modelling. Age, gender, and body mass index (BMI) were not significant independent predictors.

CONCLUSION

Our study demonstrates that airway distensibility during the expiratory phase of awake respiration is correlated with the severity of OSA.

Recognizable clinical subtypes of obstructive sleep apnea across international sleep centers: a cluster analysis

Study Objectives

A recent study of patients with moderate-severe obstructive sleep apnea (OSA) in Iceland identified three clinical clusters based on symptoms and comorbidities. We sought to verify this finding in a new cohort in Iceland and examine the generalizability of OSA clusters in an international ethnically diverse cohort.

Methods

Using data on 972 patients with moderate-severe OSA (apnea-hypopnea index [AHI] ≥ 15 events per hour) recruited from the Sleep Apnea Global Interdisciplinary Consortium (SAGIC), we performed a latent class analysis of 18 self-reported symptom variables, hypertension, cardiovascular disease, and diabetes.

Results

The original OSA clusters of disturbed sleep, minimally symptomatic, and excessively sleepy replicated among 215 SAGIC patients from Iceland. These clusters also generalized to 757 patients from five other countries. The three clusters had similar average AHI values in both Iceland and the international samples, suggesting clusters are not driven by OSA severity; differences in age, gender, and body mass index were also generally small. Within the international sample, the three original clusters were expanded to five optimal clusters: three were similar to those in Iceland (labeled disturbed sleep, minimal symptoms, and upper airway symptoms with sleepiness) and two were new, less symptomatic clusters (labeled upper airway symptoms dominant and sleepiness dominant). The five clusters showed differences in demographics and AHI, although all were middle-aged (44.6-54.5 years), obese (30.6-35.9 kg/m2), and had severe OSA (42.0-51.4 events per hour) on average.

Conclusions

Results confirm and extend previously identified clinical clusters in OSA. These clusters provide an opportunity for a more personalized approach to the management of OSA.

The Risk of Latent Tuberculosis Infection in Respiratory Therapists in a Country with Intermediate Incidence

BACKGROUND

Respiratory therapists (RTs) are exposed to aerosols more frequently than other health care workers (HCWs) and might bear a higher risk for tuberculosis (TB) infection. The QuantiFERON-TB Gold (QFTG) test was used to evaluate the risk for TB infection in Taiwan, a country with intermediate TB incidence.

METHODS

A cross-sectional screening of HCWs, including RTs and other HCWs, with the QFTG test was conducted in Taiwan between October 2008 and December 2011. Those with initially negative QFTG results accepted repeated QFTG testing 1 y later. The positive rates of QFTG in RTs and other HCWs were compared. The risk factors for positive QFTG and QFTG conversion, including occupational group, age, duration of employment, and gender, were analyzed.

RESULTS

A total of 274 HCWs were enrolled, including 43 RTs, 163 nurses, and 68 other HCWs. The positive rates of QFTG were 14.0% in RTs, 6.1% in nurses, and 8.8% in other HCWs, which were not significantly different among the 3 groups. Multivariate analysis demonstrated that the risk for positive QFTG positively correlated with increased age and the duration of employment, but did not relate to gender or occupational group. Of 81 HCWs with initially negative QFTG results, 4 (4.9%) had positive conversion on repeat QFTG testing 1 y later. The risk for QFTG conversion in HCWs was not related to occupational group, gender, age, or duration of employment.

CONCLUSION

RTs had no higher risk for latent TB infection than other HCWs in a country with intermediate TB incidence.

Snoring sound energy as a potential biomarker for disease severity and surgical response in childhood obstructive sleep apnoea: A pilot study

OBJECTIVE

To investigate the relationship between baseline snoring sound energy (SSE) and disease severity, changes in SSE after adenotonsillectomy, and the predictors of surgical success in children with obstructive sleep apnoea (OSA).

DESIGN

Prospective cohort study.

SETTING

Tertiary referral medical centre.

PARTICIPANTS

Thirty-two children with OSA whose apnoea-hypopnoea index ≥5 or apnoea-hypopnoea index ≥1.5 with OSA comorbidities were recruited. Patients with complicated OSA were excluded. All participants underwent snoring sound analysis, polysomnography, and adenotonsillectomy.

MAIN OUTCOME MEASURES

Snoring sound energy and apnoea-hypopnoea index were assessed at baseline and 6 months after adenotonsillectomy. Surgical success was defined as a postoperative apnoea-hypopnoea index <1.5.

RESULTS

The median age, body mass index, and apnoea-hypopnoea index was 9 years, 19.0 kg/m² , and 13.2 events/h, respectively. Multivariate logistic regression showed that a baseline tonsil size of IV (odds ratio 15.7 [95% CI: 1.5-166.3]) and SSE of 801-1000 Hz > 21.9 dB (odds ratio 32.3 [95% CI: 2.6-396.6]) were significantly related to severe OSA. Following adenotonsillectomy, apnoea-hypopnoea index decreased significantly (P < 0.001). SSE of 41-200 Hz, 201-400 Hz and 801-1000 Hz also decreased significantly (P = 0.04, 0.01 and 0.006, respectively). Baseline SSE of 801-1000 Hz < 8.5 dB significantly predicted surgical success (odds ratio 11.0 [95% CI: 1.4-85.2]).

CONCLUSIONS

Our findings suggest the potential utility of SSE of 801-1000 Hz to screen for severe OSA, predict surgical success and assess therapeutic outcomes. Specific baseline SSE may represent a potential biomarker for childhood OSA.

The impact of 2011 and 2017 Global Initiative for Chronic Obstructive Pulmonary Disease (GOLD) guidelines on allocation and pharmacological management of patients with COPD in Taiwan: Taiwan Obstructive Lung Disease (TOLD) study

BACKGROUND

This nationwide study was performed to evaluate the evolution of distributions of patients with COPD according to the 2011 and 2017 Global Initiative for Chronic Obstructive Pulmonary Disease (GOLD) guidelines and to assess the concordance between the prescribed medications and the pharmacological management recommended by the two distinct classification systems in Taiwan.

SUBJECTS AND METHODS

Data were retrospectively retrieved from stable COPD patients in 11 participating hospitals across Taiwan. Patients were grouped according to GOLD 2011 and 2017 guidelines respectively. Definitions of undertreatment and overtreatment were based on the pharmacological recommendations in the individual guidelines.

RESULTS

A total of 1,053 COPD patients were included. The percentages of patients in GOLD 2011 groups A, B, C and D were 18.4%, 40.6%, 6.7% and 34.2%, respectively. When reclassified according to the GOLD 2017, the percentages of group A and B increased to 23.3% and 63.2%, and groups C and D decreased to 1.9% and 11.6%, respectively. Up to 67% of patients in GOLD 2011 groups C and D were reclassified to GOLD 2017 groups A and B. The pharmacological concordance rate was 60.9% for GOLD 2011 and decreased to 44.9% for GOLD 2017. Overtreatment was found in 29.5% of patients according to GOLD 2011 and the rate increased to 46.1% when classified by the GOLD 2017. The major cause of overtreatment was unnecessary inhaled corticosteroids and the main cause of undertreatment was a lack of maintenance long-acting bronchodilators.

CONCLUSION

The distribution of COPD patients in Taiwan was more uneven with the GOLD 2017 than with the GOLD 2011. A pharmacological discordance to the guidelines was identified. Updated guidelines with reclassification of COPD patients resulted in more discordance between prescribed medications and the guidelines. Physicians should make proper adjustments of the prescriptions according to the updated guidelines to ensure the mostly appropriate treatment for COPD patients.

Home sleep apnea testing: comparison of manual and automated scoring across international sleep centers

PURPOSE

To determine the agreement between the manual scoring of home sleep apnea tests (HSATs) by international sleep technologists and automated scoring systems.

METHODS

Fifteen HSATs, previously recorded using a type 3 monitor, were saved in European Data Format. The studies were scored by nine experienced technologists from the sleep centers of the Sleep Apnea Global Interdisciplinary Consortium (SAGIC) using the locally available software. Each study was scored separately by human scorers using the nasal pressure (NP), flow derived from the NP signal (transformed NP), or respiratory inductive plethysmography (RIP) flow. The same procedure was followed using two automated scoring systems: Remlogic (RLG) and Noxturnal (NOX).

RESULTS

The intra-class correlation coefficients (ICCs) of the apnea-hypopnea index (AHI) scoring using the NP, transformed NP, and RIP flow were 0.96 [95% CI 0.93-0.99], 0.98 [0.96-0.99], and 0.97 [0.95-0.99], respectively. Using the NP signal, the mean differences in AHI between the average of the manual scoring and the automated systems were - 0.9 ± 3.1/h (AHI_RLG vs AHI_MANUAL) and - 1.3 ± 2.6/h (AHI_NOX vs AHI_MANUAL). Using the transformed NP, the mean differences in AHI were - 1.9 ± 3.3/h (AHI_RLG vs AHI_MANUAL) and 1.6 ± 3.0/h (AHI_NOX vs AHI_MANUAL). Using the RIP flow, the mean differences in AHI were - 2.7 ± 4.5/h (AHI_RLG vs AHI_MANUAL) and 2.3 ± 3.4/h (AHI_NOX vs AHI_MANUAL).

CONCLUSIONS

There is very strong agreement in the scoring of the AHI for HSATs between the automated systems and experienced international technologists. Automated scoring of HSATs using commercially available software may be useful to standardize scoring in future endeavors involving international sleep centers.

Recovery of pulmonary functions, exercise capacity, and quality of life after pulmonary rehabilitation in survivors of ARDS due to severe influenza A (H1N1) pneumonitis

Background

Acute respiratory distress syndrome (ARDS) due to severe influenza A H1N1 pneumonitis would result in impaired pulmonary functions and health‐related quality of life (HRQoL) after hospital discharge.

Objectives

The recovery of pulmonary functions, exercise capacity, and HRQoL in the survivors of ARDS due to 2009 pandemic influenza A H1N1 pneumonitis (H1N1‐ARDS) was evaluated in a tertiary teaching hospital in northern Taiwan between May 2010 and June 2011.

Patients and Methods

Data of spirometry, total lung capacity (TLC), diffusing capacity of carbon monoxide (DL_CO), and 6‐minute walk distance (6MWD) in the patients survived from H1N1‐ARDS were collected 1, 3, and 6 months post‐hospital discharge. HRQoL was evaluated with St. George respiratory questionnaire (SGRQ).

Results

Nine survivors of H1N1‐ARDS in the study period were included. All these patients received 2 months’ pulmonary rehabilitation program. Pulmonary functions and exercise capacity included TLC, forced vital capacity (FVC), forced expiratory volume in the first second (FEV₁), DL_CO, and 6MWD improved from 1 to 3 months post‐hospital discharge. Only TLC had further significant improvement from 3 to 6 months. HRQoL represented as the total score of SGRQ had no significant improvement in the first 3 months but improved significantly from 3 to 6 months post‐discharge.

Conclusion

The impaired pulmonary functions and exercise capacity in the survivors of H1N1‐ARDS improved soon at 3 months after hospital discharge. Their quality of life had keeping improved at 6 months even though there was no further improvement of their pulmonary functions and exercise capacity.

Factors associated with undiagnosed obstructive sleep apnoea among hypertensive patients: A multisite cross-sectional survey study in Taiwan

AIMS AND OBJECTIVES

To investigate the distribution and risk factors associated with undiagnosed obstructive sleep apnoea among hypertensive patients.

BACKGROUND

Obstructive sleep Apnoea has been deemed a cardinal risk factor affecting cardiovascular event, and the condition is still frequently overlooked clinically. The lack of advanced diagnosis often causes hypertensive patients with obstructive sleep apnoea to miss opportunities for preventing chronic diseases.

DESIGN

A cross-sectional design.

METHODS

A total of 215 hypertensive participants were recruited from the cardiovascular outpatients of medical centre in northern and middle Taiwan. The Chinese version of Pittsburgh Sleep Quality Index, the Chinese version of the Epworth Sleep Scale and a portable sleep monitoring device were used for data collection. Logistic regression analysis was conducted to identify the factors affecting hypertensive patients with obstructive sleep apnoea, and a multinomial logistic regression analysis was used to examine the major influence factors for each obstructive sleep apnoea severity level.

RESULTS

81.9% of the hypertensive participants were found having obstructive sleep apnoea. Concerning to the obstructive sleep apnoea severity, 50.0% of participants had mild obstructive sleep apnoea. After controlling the confounding variables, the supine position (odds ratio, 1.04; 95% CI, 1.01-1.07), SO₂ (odds ratio, 0.58; 95% CI, 0.38-0.89) and oxygen desaturation index (odds ratio, 2.70; 95% CI, 1.18-6.18) were significantly associated with obstructive sleep apnoea. Furthermore, severe obstructive sleep apnoea was significantly correlated with gender (odds ratio, 0.04; 95% CI, 0.00-0.66), excessive daytime sleepiness (odds ratio, 20.27; 95% CI, 1.58-26.97) and oxygen desaturation index (odds ratio, 4.05; 95% CI, 1.86-8.81).

CONCLUSIONS

Nearly 82% of the hypertensive participants were found having undiagnosed obstructive sleep apnoea, and 80% of them were mild or moderate severity. Oxygen desaturation index, SO₂ and the supine position were found to be major predictors for obstructive sleep apnoea. Remarkably, oxygen desaturation index was the most significant predictor for mild, moderate and severe obstructive sleep apnoea.

RELEVANCE TO CLINICAL PRACTICE

Healthcare providers should enhance their sensitivities to hypertensive patients at a high risk for obstructive sleep apnoea by actively assessing common obstructive sleep apnoea symptoms and providing strategies to alleviate obstructive sleep apnoea symptoms.

Three-dimensional photography for the evaluation of facial profiles in obstructive sleep apnoea

BACKGROUND AND OBJECTIVE

Craniofacial structure is an important determinant of obstructive sleep apnoea (OSA) syndrome risk. Three-dimensional stereo-photogrammetry (3dMD) is a novel technique which allows quantification of the craniofacial profile. This study compares the facial images of OSA patients captured by 3dMD to three-dimensional computed tomography (3-D CT) and two-dimensional (2-D) digital photogrammetry. Measurements were correlated with indices of OSA severity.

METHODS

Thirty-eight patients diagnosed with OSA were included, and digital photogrammetry, 3dMD and 3-D CT were performed. Distances, areas, angles and volumes from the images captured by three methods were analysed.

RESULTS

Almost all measurements captured by 3dMD showed strong agreement with 3-D CT measurements. Results from 2-D digital photogrammetry showed poor agreement with 3-D CT. Mandibular width, neck perimeter size and maxillary volume measurements correlated well with the severity of OSA using all three imaging methods. Mandibular length, facial width, binocular width, neck width, cranial base triangle area, cranial base area 1 and middle cranial fossa volume correlated well with OSA severity using 3dMD and 3-D CT, but not with 2-D digital photogrammetry.

CONCLUSION

3dMD provided accurate craniofacial measurements of OSA patients, which were highly concordant with those obtained by CT, while avoiding the radiation associated with CT.

Comparison of Obstructive Sleep Apnea Syndrome in Children with Cleft Palate following Furlow Palatoplasty or Pharyngeal Flap for Velopharyngeal Insufficiency

Objective

To evaluate the incidence and severity of obstructive sleep apnea syndrome (OSAS) in patients with cleft palate having a Furlow palatoplasty or pharyngeal flap for correction of velopharyngeal insufficiency (VPI).

Patients

A total of 48 nonsyndromic children with repaired cleft palate with VPI were enrolled in the study. Twenty of the children had a Furlow palatoplasty (F group) and 28 children had a pharyngeal flap (P group) for correction of VPI.

Interventions

An overnight polysomnography evaluation was done to evaluate the incidence and severity of OSAS 6 months or more postoperatively.

Main Outcome Measures

Symptoms of OSAS, respiratory disturbance index (RDI), oxyhemoglobin desaturation index (DI), and sleep stages were measured.

Results

In the P group, the mean percentage of stage 2 sleep was lower than the F group (p < .05). The mean RDI and DI were larger in the P group, compared with the F group (p < .001). The incidence and severity of OSAS were higher in the P group, compared with the F group (p < .001 and p = 0.05, respectively).

Conclusions

A Furlow palatoplasty should be used in deference to a pharyngeal flap whenever possible on the basis of the preoperative evaluation of VPI because of the decreased incidence and severity of OSAS.

Hypercapnic Ventilatory Response in the Weaning of Patients with Prolonged Mechanical Ventilation

OBJECTIVE

To investigate whether hypercapnic ventilatory response (defined as the ratio of the change in minute ventilation [[Formula: see text]] to the change in end-tidal partial pressure of carbon dioxide [ΔPETCO2 ]) is a predictor of successful weaning in patients with prolonged mechanical ventilation (PMV) and to determine a reference value for clinical use.

METHODS

A hypercapnic challenge test was performed on 32 PMV subjects (average age: 74.3 years ± 14.9 years). The subjects were divided into two groups (i.e., weaning successes and weaning failures) and their hypercapnic ventilatory responses were compared.

RESULTS

PMV subjects had an overall weaning rate of 68.8%. The weaning-success and weaning-failure groups had hypercapnic ventilatory responses ([Formula: see text]) of 0.40 ± 0.16 and 0.28 ± 0.12 L/min/mmHg, respectively (P = .036). The area under the receiver operating characteristic curve was 0.716 of the hypercapnic ventilatory response, and the practical hypercapnic ventilatory response cut-off point for successful weaning was 0.265 with 86.4% sensitivity and 50% specificity.

CONCLUSIONS

PMV subjects who failed weaning had a lower hypercapnic ventilatory response than successfully weaned subjects. However, the prediction capacity of this test, assessed by the area under the receiver operating characteristic (ROC) curve, poorly predicted weaning outcome.

Airway Changes after Cleft Orthognathic Surgery Evaluated by Three-Dimensional Computed Tomography and Overnight Polysomnographic Study

Cleft lip and palate is the most common congenital craniofacial anomaly. Up to 60% of these patients will benefit from cleft orthognathic surgery, which consists primarily of maxillary advancement and mandibular setback to address midface retrusion and relative mandibular protrusion, respectively. It is believed that maxillary advancement can enlarge the airway whilst mandibular setback can reduce the airway, but this has not previously been quantified for cleft patients undergoing orthognathic surgery. This unique longitudinal prospective study of 18 patients was conducted between April 2013 and July 2016. No significant changes occurred by six months postoperatively in body mass index, apnoea-hypopnoea index or lowest oxygen saturation (LSAT). There was a mean increase of 0.73 cm3 in velopharyngeal volume, a mean decrease of 0.79 cm3 in oropharyngeal volume, an improvement in snoring index, and no statistically significant change in hypopharyngeal volume. In conclusion, cleft orthognathic surgery that produced anterior advancement of the maxilla, setback of the mandible and clockwise rotation of the maxillo-mandibular complex resulted in increased velopharyngeal, decreased oropharyngeal and unchanged hypopharyngeal airways, and improved snoring, but did not significantly alter objective sleep-related breathing function.

Nintedanib reduces ventilation-augmented bleomycin-induced epithelial-mesenchymal transition and lung fibrosis through suppression of the Src pathway

Mechanical ventilation (MV) used in patients with acute respiratory distress syndrome (ARDS) can increase lung inflammation and pulmonary fibrogenesis. Src is crucial in mediating the transforming growth factor (TGF)‐β1‐induced epithelial–mesenchymal transition (EMT) during the fibroproliferative phase of ARDS. Nintedanib, a multitargeted tyrosine kinase inhibitor that directly blocks Src, has been approved for the treatment of idiopathic pulmonary fibrosis. The mechanisms regulating interactions among MV, EMT and Src remain unclear. In this study, we suggested hypothesized that nintedanib can suppress MV‐augmented bleomycin‐induced EMT and pulmonary fibrosis by inhibiting the Src pathway. Five days after administrating bleomycin to mimic acute lung injury (ALI), C57BL/6 mice, either wild‐type or Src‐deficient were exposed to low tidal volume (V_T) (6 ml/kg) or high V_T (30 ml/kg) MV with room air for 5 hrs. Oral nintedanib was administered once daily in doses of 30, 60 and 100 mg/kg for 5 days before MV. Non‐ventilated mice were used as control groups. Following bleomycin exposure in wild‐type mice, high V_T MV induced substantial increases in microvascular permeability, TGF‐β1, malondialdehyde, Masson's trichrome staining, collagen 1a1 gene expression, EMT (identified by colocalization of increased staining of α‐smooth muscle actin and decreased staining of E‐cadherin) and alveolar epithelial apoptosis (P < 0.05). Oral nintedanib, which simulated genetic downregulation of Src signalling using Src‐deficient mice, dampened the MV‐augmented profibrotic mediators, EMT profile, epithelial apoptotic cell death and pathologic fibrotic scores (P < 0.05). Our data indicate that nintedanib reduces high V_T MV‐augmented EMT and pulmonary fibrosis after bleomycin‐induced ALI, partly by inhibiting the Src pathway.

Trichostatin A attenuates ventilation-augmented epithelial-mesenchymal transition in mice with bleomycin-induced acute lung injury by suppressing the Akt pathway

Background

Mechanical ventilation (MV) used in patients with acute respiratory distress syndrome (ARDS) can cause diffuse lung inflammation, an effect termed ventilator-induced lung injury, which may produce profound pulmonary fibrogenesis. Histone deacetylases (HDACs) and serine/threonine kinase/protein kinase B (Akt) are crucial in modulating the epithelial–mesenchymal transition (EMT) during the reparative phase of ARDS; however, the mechanisms regulating the interactions among MV, EMT, HDACs, and Akt remain unclear. We hypothesized that trichostatin A (TSA), a HDAC inhibitor, can reduce MV-augmented bleomycin-induced EMT by inhibiting the HDAC4 and Akt pathways.

Methods

Five days after bleomycin treatment to mimic acute lung injury (ALI), wild-type or Akt-deficient C57BL/6 mice were exposed to low-tidal-volume (low-V_T, 6 mL/kg) or high-V_T (30 mL/kg) MV with room air for 5 h after receiving 2 mg/kg TSA. Nonventilated mice were examined as controls.

Results

Following bleomycin exposure in wild-type mice, high-V_T MV induced substantial increases in microvascular leaks; matrix metalloproteinase-9 (MMP-9) and plasminogen activator inhibitor-1 proteins; free radical production; Masson’s trichrome staining; fibronectin, MMP-9, and collagen 1a1 gene expression; EMT (identified by increased localized staining of α-smooth muscle actin and decreased staining of E-cadherin); total HDAC activity; and HDAC4 and Akt activation (P < 0.05). In Akt-deficient mice, the MV-augmented lung inflammation, profibrotic mediators, EMT profiles, Akt activation, and pathological fibrotic scores were reduced and pharmacologic inhibition of HDAC4 expression was triggered by TSA (P < 0.05).

Conclusions

Our data indicate that TSA treatment attenuates high-V_T MV-augmented EMT after bleomycin-induced ALI, in part by inhibiting the HDAC4 and Akt pathways.

Agreement in the Scoring of Respiratory Events Among International Sleep Centers for Home Sleep Testing

STUDY OBJECTIVES

Home sleep testing (HST) is used worldwide to confirm the presence of obstructive sleep apnea (OSA). We sought to determine the agreement of HST scoring among international sleep centers.

METHODS

Fifteen HSTs, previously recorded using a type 3 monitor, were deidentified and saved in European Data Format. The studies were scored by nine technologists from the sleep centers of the Sleep Apnea Global Interdisciplinary Consortium (SAGIC) using the locally available software. Each study was scored separately using one of three different airflow signals: nasal pressure (NP), transformed (square root) nasal pressure signal (transformed NP), and uncalibrated respiratory inductive plethysmography (RIP) flow. Only one of the three airflow signals was visible to the scorer at each scoring session. The scoring procedure was repeated to determine the intrarater reliability.

RESULTS

The intraclass correlation coefficients (ICCs) using the NP were: apnea-hypopnea index (AHI) = 0.96 (95% confidence interval [CI]: 0.93-0.99); apnea index = 0.91 (0.83-0.96); and hypopnea index = 0.75 (0.59-0.89). The ICCs using the transformed NP were: AHI = 0.98 (0.96-0.99); apnea index = 0.95 (0.90-0.98); and hypopnea index = 0.90 (0.82-0.96). The ICCs using the RIP flow were: AH I = 0.98 (0.96-0.99); apnea index = 0.66 (0.48-0.84); and hypopnea index = 0.78 (0.63-0.90). The mean difference of first and second scoring sessions of the same respiratory variables ranged from -1.02 to 0.75/h.

CONCLUSION

There is a strong agreement in the scoring of the respiratory events for HST among international sleep centers. Our results suggest that centralized scoring of HSTs may not be necessary in future research collaboration among international sites.

COMMENTARY

A commentary on this article appears in this issue on page 7.

Invasive fungal tracheobronchitis in mechanically ventilated critically ill patients: underlying conditions, diagnosis, and outcomes

Background

Invasive fungal tracheobronchitis (IFT) is a severe form of pulmonary fungal infection that is not limited to immunocompromised patients. Although respiratory failure is a crucial predictor of death, information regarding IFT in critically ill patients is limited.

Methods

In this retrospective, multicenter, observational study, we enrolled adults diagnosed as having IFT who had been admitted to the intensive care unit between January 2007 and December 2015. Their demographics, clinical imaging data, bronchoscopic and histopathological findings, and outcomes were recorded.

Results

This study included 31 patients who had been diagnosed as having IFT, comprising 24 men and 7 women with a mean age of 64.7 ± 13.7 years. All patients developed respiratory failure and received mechanical ventilation before diagnosis. Eighteen (58.1%) patients had diabetes mellitus, and 12 (38.7%) had chronic lung disease. Four (12.9%) patients had hematologic disease, and none of the patients had neutropenia. Twenty-five (80.6%) patients were diagnosed as having proven IFT, and the remaining patients had probable IFT. Aspergillus spp. (61.3%) were the most common pathogenic species, followed by Mucorales (25.8%) and Candida spp. (6.5%). The diagnoses in six (19.4%) patients were confirmed only through bronchial biopsy and histopathological examination, whereas their cultures of bronchoalveolar lavage fluid were negative for fungi. The overall in-hospital mortality rate was 93.5%.

Conclusions

IFT in critically ill patients results in a high mortality rate. Diabetes mellitus is the most prevalent underlying disease, followed by chronic lung disease. In addition to Aspergillus spp., Mucorales is another crucial pathogenic species. Bronchial lesion biopsy is the key diagnostic strategy.

Diagnostic accuracy of the Berlin questionnaire, STOP-BANG, STOP, and Epworth sleepiness scale in detecting obstructive sleep apnea: A bivariate meta-analysis

Obstructive sleep apnea (OSA) is a highly prevalent sleep disorder; however, it remains underdiagnosed and undertreated. Although screening tools such as the Berlin questionnaire (BQ), STOP-BANG questionnaire (SBQ), STOP questionnaire (STOP), and Epworth sleepiness scale (ESS) are widely used for OSA, the findings regarding their diagnostic accuracy are controversial. Therefore, this meta-analysis investigated and compared the summary sensitivity, specificity, and diagnostic odds ratio (DOR) among the BQ, SBQ, STOP, and ESS according to the severity of OSA. Electronic databases, namely the Embase, PubMed, PsycINFO, ProQuest dissertations and theses A&I databases, and China knowledge resource integrated database, were searched from their inception to July 15, 2016. We included studies examining the sensitivity and specificity of the BQ, SBQ, STOP, and ESS against the apnea-hypopnea index (AHI) or respiratory disturbance index (RDI). The revised quality assessment of diagnostic accuracy studies was used to evaluate the methodological quality of studies. A random-effects bivariate model was used to estimate the summary sensitivity, specificity, and DOR of the tools. We identified 108 studies including a total of 47 989 participants. The summary estimates were calculated for the BQ, SBQ, STOP, and ESS in detecting mild (AHI/RDI ≥ 5 events/h), moderate (AHI/RDI ≥ 15 events/h), and severe OSA (AHI/RDI ≥ 30 events/h). The performance levels of the BQ, SBQ, STOP, and ESS in detecting OSA of various severity levels are outlined as follows: for mild OSA, the pooled sensitivity levels were 76%, 88%, 87%, and 54%; pooled specificity levels were 59%, 42%, 42%, and 65%; and pooled DORs were 4.30, 5.13, 4.85, and 2.18, respectively. For moderate OSA, the pooled sensitivity levels were 77%, 90%, 89%, and 47%; pooled specificity levels were 44%, 36%, 32%, and 621%; and pooled DORs were 2.68, 5.05, 3.71, and 1.45, respectively. For severe OSA, the pooled sensitivity levels were 84%, 93%, 90%, and 58%; pooled specificity levels were 38%, 35%, 28%, and 60%; and pooled DORs were 3.10, 6.51, 3.37, and 2.10, respectively. Therefore, for mild, moderate, and severe OSA, the pooled sensitivity and DOR of the SBQ were significantly higher than those of other screening tools (P < .05); however, the specificity of the SBQ was lower than that of the ESS (P < .05). Moreover, age, sex, body mass index, study sample size, study populations, presence of comorbidities, PSG or portable monitoring performance, and risk of bias in the domains of the index test and reference standard were significant moderators of sensitivity and specificity (P < .05). Compared with the BQ, STOP, and ESS, the SBQ is a more accurate tool for detecting mild, moderate, and severe OSA. Sleep specialists should use the SBQ to conduct patient interviews for the early diagnosis of OSA in clinical settings, particularly in resource-poor countries and sleep clinics where PSG is unavailable.