Consensus Statements among European Sleep Surgery Experts on Snoring and Obstructive Sleep Apnea: Part 2 Decision-Making in Surgical Management and Peri-Operative Considerations

Background: Reaching consensus on decision-making in surgical management and peri-operative considerations regarding snoring and obstructive sleep apnea (OSA) among sleep surgeons is critical in the management of patients with such conditions, where there is a large degree of variability. Methods: A set of statements was developed based on the literature and circulated among eight panel members of European experts, utilizing the Delphi method. Responses were provided as agree and disagree on each statement, and the comments were used to assess the level of consensus and develop a revised version. The new version, with the level of consensus and anonymized comments, was sent to each panel member as the second round. This was repeated for a total of five rounds. Results: The final set included a total of 71 statements: 29 stand-alone and 11 with 42 sub-statements. On the 33 statements regarding decision-making in surgical management, there was 60.6%, 27.3%, and 6.1% consensus among all eight, seven, and six panelists, respectively. On the 38 statements regarding the peri-operative considerations, there was 55.3%, 18.4%, and 15.8% consensus among all eight, seven, and six panelists, respectively. Conclusions: These results indicate the need for an expanded review of the literature and discussion to enhance consensus among the sleep surgeons that consider surgical management in patients with snoring and OSA.

Neighborhood Disadvantage, Quality of Life, and Symptom Burden in Children with Mild Sleep-disordered Breathing

Rationale: Neighborhood disadvantage (ND) has been associated with sleep-disordered breathing (SDB) in children. However, the association between ND and SDB symptom burden and quality of life (QOL) has not yet been studied.Objectives: To evaluate associations between ND with SDB symptom burden and QOL.Methods: Cross-sectional analyses were performed on 453 children, ages 3-12.9 years, with mild SDB (habitual snoring and apnea-hypopnea index < 3/h) enrolled in the PATS (Pediatric Adenotonsillectomy Trial for Snoring) multicenter study. The primary exposure, neighborhood disadvantage, was characterized by the Child Opportunity Index (COI) (range, 0-100), in which lower values (specifically COI ⩽ 40) signify less advantageous neighborhoods. The primary outcomes were QOL assessed by the obstructive sleep apnea (OSA)-18 questionnaire (range, 18-126) and SDB symptom burden assessed by the Pediatric Sleep Questionnaire-Sleep-related Breathing Disorder (PSQ-SRBD) scale (range, 0-1). The primary model was adjusted for age, sex, race, ethnicity, maternal education, recruitment site, and season. In addition, we explored the role of body mass index (BMI) percentile, environmental tobacco smoke (ETS), and asthma in these associations.Results: The sample included 453 children (16% Hispanic, 26% Black or African American, 52% White, and 6% other). COI mean (standard deviation [SD]) was 50.3 (29.4), and 37% (n = 169) of participants lived in disadvantaged neighborhoods. Poor SDB-related QOL (OSA-18 ⩾ 60) and high symptom burden (PSQ-SRBD ⩾ 0.33) were found in 30% (n = 134) and 75% (n = 341) of participants, respectively. In adjusted models, a COI increase by 1 SD (i.e., more advantageous neighborhood) was associated with an improvement in OSA-18 score by 2.5 points (95% confidence interval [CI], -4.34 to -0.62) and in PSQ-SRBD score by 0.03 points (95% CI, -0.05 to -0.01). These associations remained significant after adjusting for BMI percentile, ETS, or asthma; however, associations between COI and SDB-related QOL attenuated by 23% and 10% after adjusting for ETS or asthma, respectively.Conclusions: Neighborhood disadvantage was associated with poorer SDB-related QOL and greater SDB symptoms. Associations were partially attenuated after considering the effects of ETS or asthma. The findings support efforts to reduce ETS and neighborhood-level asthma-related risk factors and identify other neighborhood-level factors that contribute to SDB symptom burden as strategies to address sleep-health disparities.Clinical trial registered with www.clinicaltrials.gov (NCT02562040).

Genetic Association of Allergic Rhinitis with Sleep and Neuropsychological Disorders: A Mendelian Randomization Study

BACKGROUND

The genetic association of allergic rhinitis (AR) with other physiological systems throughout the human body remains unknown.

OBJECTIVE

The aim of this Mendelian randomization (MR) study was to explore the association of this respiratory disorder with multiple common sleep and neuropsychological disorders at the genetic level.

METHODS

Summary data for total AR and pollen AR were collected from the most updated FinnGen genome-wide association studies involving more than 340 000 European subjects. Summary data for 12 sleep and neuropsychological disorders (including snoring) were included from UK Biobank studies involving 63 392 to 462 933 European subjects. Three MR methods, including inverse-variance weighting (IVW), weighted median and MR-Egger, were used to determine the relationships between the exposures and outcomes. Several sensitivity analyses, including Cochran's Q, MR-Egger intercept, MR-PRESSO, "leave-one-out" test and funnel plot, were used to detect heterogeneity and horizontal pleiotropy.

RESULTS

IVW revealed that total and pollen AR were associated with an increased risk of snoring (odds ratio (OR) = 1.011, 95% confidence interval (CI) = 1.004∼1.019, P = .003; OR = 1.006, 95% CI = 1.001∼1.011, P = .014). Two other MR methods supported the results from the IVW analysis. No heterogeneity or horizontal pleiotropy was confirmed by sensitivity analyses. In addition, IVW did not reveal any association between AR and other included disorders.

CONCLUSION

AR (specifically AR caused by pollen) might be an independent risk factor for snoring at the genetic level, which should be verified in the future.

Predicting the Outcomes of Oropharyngeal Surgery in Patients With Obstructive Sleep Apnea Using Tongue-Retaining Devices

OBJECTIVE

To determine the efficacy of a tongue-retaining device (TRD) in predicting the outcomes of oropharyngeal surgery in patients with obstructive sleep apnea (OSA) before surgery.

STUDY DESIGN

A prospective case-control study.

SETTING

A single tertiary medical center.

METHODS

Patients with moderate-severe OSA who underwent both uvulopalatopharyngoplasty and tongue base suspension between January 2022 and July 2022 were included. Each patient underwent a series of 3 overnight polysomnography. Objective outcomes include apnea-hypopnea index (AHI), minimal oxygen saturation, and reduction rate of AHI. The correlation between the reduction rate of AHI with TRD and surgery was analyzed with linear regression.

RESULTS

The reduction rates of AHI were significantly different between the group using TRD (44 ± 24%) and the postoperative group (55 ± 21%). The cross-tabulation revealed a strong association between a positive response to TRD treatment and a positive response to surgery. The use of TRD to evaluate surgical response demonstrated a positive predictive value of 90% and a negative predictive value of 70%. A strong correlation between the decrease in AHI was observed in both TRD and surgery groups, which was demonstrated by a steep slope in the scatter plot and a significant simple linear regression line.

CONCLUSION

Preoperative TRD response is an accurate tool for predicting the success of oropharyngeal surgery in managing OSA patients before surgical treatment. Furthermore, a quantifiable positive linear correlation exists between the efficacy of preoperative TRD treatment and surgery.

Effect of hypoglossal nerve stimulation on snoring: an evaluation using objective acoustic parameters

STUDY OBJECTIVES

Hypoglossal nerve stimulation is an established therapy for sleep apnea syndrome. Whether or not this therapy on snoring and nighttime noise exposure is effective and how strong this effect may be has not been objectively investigated thus far and was the aim of this study.

METHODS

In 15 participants (14 males; age: 30-72 years; mean: 51.7 years), polysomnography and acoustic measurements were performed before and after hypoglossal nerve stimulation.

RESULTS

The therapy led to a significant improvement in sleep apnea (apnea-hypopnea index from 35.8 events/h to 11.2 events/h, P < .001). Acoustic parameters showed a highly significant reduction in the average sound pressure level (42.9 db[A] to 36.4 db[A], P < .001), averaged sound energy, A-weighted (LAeq; 33.1 db[A] to 28.7 db[A], P < .001), snoring index (1,068 to 506, P < .001), percentage snoring time (29.7-14.1%, P < .001), and psychoacoustic snore score, the latter being a measure of annoyance due to snoring (47.9 to 24.5, P < .001).

CONCLUSIONS

This study was able to show for the first time by means of objective acoustic and psychoacoustic parameters that hypoglossal nerve stimulation can not only cause a significant improvement in sleep apnea but also has a positive effect on snoring and thus noise annoyance experienced by the bed partner.

CLINICAL TRIAL REGISTRATION

Registry: German Clinical Trials Register; Name: Effect of Hypoglossal Nerve Stimulation on Snoring: An Evaluation Using Objective Acoustic Parameters; URL: https://drks.de/search/de/trial/DRKS00032354; Identifier: DRKS00032354.

CITATION

Fischer R, Vielsmeier V, Kuehnel TS, et al. Effect of hypoglossal nerve stimulation on snoring: an evaluation using objective acoustic parameters. J Clin Sleep Med. 2024;20(3):363-370.

High Prevalence of Obstructive Sleep-Disordered Breathing in Pediatric Patients With Turner Syndrome

OBJECTIVE

Girls with Turner syndrome (TS) often have features that have been associated with obstructive sleep-disordered breathing (oSDB). However, little is known about oSDB in TS. Herein, we aimed to characterize oSDB in young patients with TS and identify associated risk factors.

STUDY DESIGN

Retrospective cross-sectional study.

SETTING

Tertiary care pediatric hospital.

METHODS

We reviewed medical records for patients diagnosed with TS seen at our institution between October 1, 2007 and December 31, 2019 with the first outpatient visit before age 6 years. The prevalence of oSDB was compared to the general pediatric population with 1-sample binomial proportion tests. Clinical characteristics were compared between those diagnosed with oSDB and those without oSDB, and risk factors for oSDB were identified.

RESULTS

Of 151 patients with TS, 73 (48%) were diagnosed with oSDB which is 4-fold higher than the general pediatric population (12%, P < 0.0001). In the multivariable model, adenoid, tonsillar, and inferior turbinate hypertrophy, birthweight, failure to thrive, and older age at the last clinic visit were all associated with increased odds for oSDB.

CONCLUSION

Young children with TS have a high prevalence of oSDB and thus should be screened for oSDB. Polysomnography should be performed in those with associated risk factors and symptoms oSDB. Treatment of oSDB is imperative as individuals with TS are already at increased risk of behavioral problems, neurocognitive deficits, and growth impairment that may be worsened with oSDB.

Snoring Patterns During Hypoglossal Nerve Stimulation Therapy Up-Titration

Longitudinal snoring changes can be captured using a mobile phone application. During hypoglossal nerve stimulator (HNS) therapy up-titration, increasing stimulation voltage was associated with reduced snoring frequency and intensity in this case series of six patients. Laryngoscope, 134:987-992, 2024.

Association of sleep characteristics with cardiovascular disease risk in adults over 40 years of age: a cross-sectional survey

Background

The relationship between sleep characteristics and cardiovascular disease (CVD) risk has yet to reach a consistent conclusion, and more research needs to be carried out. This study aimed to explore the relationship between snoring, daytime sleepiness, bedtime, sleep duration, and high-risk sleep patterns with CVD risk.

Methods

Data from the National Health and Nutrition Examination Survey (NHANES) 2015-2018 were collected and analyzed. Multivariable logistic regression was used to evaluate the relationship between snoring, daytime sleepiness, bedtime, sleep duration, high-risk sleep patterns, and CVD risk. Stratified analysis and interaction tests were carried out according to hypertension, diabetes and age.

Results

The final analysis contained 6,830 participants, including 1,001 with CVD. Multivariable logistic regression suggested that the relationship between snoring [OR = 7.37,95%CI = (6.06,8.96)], daytime sleepiness [OR = 11.21,95%CI = (9.60,13.08)], sleep duration shorter than 7 h [OR = 9.50,95%CI = (7.65,11.79)] or longer than 8 h [OR = 6.61,95%CI = (5.33,8.19)], bedtime after 0:00 [OR = 13.20,95%CI = (9.78,17.80)] compared to 22:00-22:59, high-risk sleep patterns [OR = 47.73,95%CI = (36.73,62.04)] and CVD risk were statistically significant. Hypertension and diabetes interacted with high-risk sleep patterns, but age did not.

Conclusions

Snoring, daytime sleepiness, excessive or short sleep duration, inappropriate bedtime, and high-risk sleep patterns composed of these factors are associated with the CVD risk. High-risk sleep patterns have a more significant impact on patients with hypertension and diabetes.

A New Screening Tool (BAMSA) for Sleep Apnea in Male Professional Truck Drivers

Obstructive sleep apnea (OSA) is common in professional truck drivers. It is important that OSA is recognized since undiagnosed and/or untreated sleep apnea is a risk factor for sleepiness-related traffic accidents. In this study, we developed a new simple tool to screen for obstructive sleep apnea (OSA) in this population. Altogether, 2066 professional truck drivers received a structured questionnaire. A total of 175 drivers had a clinical examination and were invited to participate in sleep laboratory studies, including cardiorespiratory polygraphy. We studied associations of different risk factors with the presence of sleep apnea. We established a new simple screening tool for obstructive sleep apnea (OSA) that was compared to other existing screening tools. A total of 1095 drivers completed the questionnaire. Successful cardiorespiratory polygraphy was obtained for 172 drivers. Full data were available for 160 male drivers included in the analyses. The following five risk factors for sleep apnea formed the BAMSA score (0 to 5): BMI > 30 kgm-2, age > 50 years, male gender, snoring at least one night per week, and the presence of apnea at least sometimes. BAMSA showed a sensitivity of 85.7% and a specificity of 78.8% in detecting AHI ≥ 15 when using a cut-off point of 4, and the ROC area was 0.823. BAMSA is a sensitive and easy-to-use tool in predicting obstructive sleep apnea in male professional drivers.

Consensus Statements among European Sleep Surgery Experts on Snoring and Obstructive Sleep Apnea: Part 1 Definitions and Diagnosis

Seeking consensus on definitions and diagnosis of snoring and obstructive sleep apnea (OSA) among sleep surgeons is important, particularly in this relatively new field with variability in knowledge and practices. A set of statements was developed based on the literature and circulated among eight panel members of European experts, utilizing the Delphi method. Responses in agreement and disagreement on each statement and the comments were used to assess the level of consensus and develop a revised version. The new version with the level of consensus and anonymized comments was sent to each panel member as the second round. This was repeated a total of five rounds. The total number of statements included in the initial set was 112. In the first round, of all eight panelists, the percentage of questions that had consensus among the eight, seven, and six panelists were 45%, 4.5%, and 7.1%, respectively. In the final set of statements consisting of 99, the percentage of questions that had consensus among the 8, 7, and 6 panelists went up to 66.7%, 24.2%, and 6.1%, respectively. Delphi's method demonstrated an efficient method of interaction among experts and the establishment of consensus on a specific set of statements.

Self-reported oral moistening disorders in obstructive sleep apnoea: A scoping review

BACKGROUND

Obstructive sleep apnoea (OSA) is a highly prevalent problem with significant consequences. Continuous positive airway pressure (CPAP) and oral mandibular advancement device (MAD) are considered the standard treatments for OSA. Patients may experience self-reported oral moistening disorders (OMDs) (i.e. xerostomia or drooling) at the beginning, throughout and after treatment. This affects oral health, quality of life and treatment effectiveness. The exact nature of the associations between OSA and self-reported OMD is still unknown. We aimed to provide an overview of the associations between self-reported OMD on the one hand and OSA and its treatment (namely CPAP and MAD) on the other hand. In addition, we sought to determine whether OMD affects treatment adherence.

MATERIALS AND METHODS

A literature search in PubMed was performed up to 27 September 2022. Two researchers independently assessed studies for eligibility.

RESULTS

In total, 48 studies were included. Thirteen papers investigated the association between OSA and self-reported OMD. They all suggested an association between OSA and xerostomia but not between OSA and drooling. The association between CPAP and OMD was addressed in 20 articles. The majority of studies have indicated xerostomia as a CPAP side effect; however, some have observed that xerostomia diminishes with CPAP therapy. In 15 papers, the association between MAD and OMD was investigated. In most publications, both xerostomia and drooling have been described as common side effects of MADs. These side effects are often mild and transient, and they improve as patients continue to use their appliance. Most studies found that these OMDs do not cause or are not a strong predictor of non-compliance.

CONCLUSION

Xerostomia is a common side effect of CPAP and MAD, as well as a significant symptom of OSA. It may be regarded as one of the indicators of sleep apnoea. Moreover, MAD therapy can be associated with OMD. However, it seems that OMD may be mitigated by being adherent to the therapy.

Untangling the relationship between childhood risk factors and obstructive sleep apnoea in adulthood

See related article

Physiological Determinants of Snore Loudness

Rationale: The physiological factors modulating the severity of snoring have not been adequately described. Airway collapse or obstruction is generally the leading determinant of snore sound generation; however, we suspect that ventilatory drive is of equal importance. Objective: To determine the relationship between airway obstruction and ventilatory drive on snore loudness. Methods: In 40 patients with suspected or diagnosed obstructive sleep apnea (1-98 events/hr), airflow was recorded via a pneumotachometer attached to an oronasal mask, ventilatory drive was recorded using calibrated intraesophageal diaphragm electromyography, and snore loudness was recorded using a calibrated microphone attached over the trachea. "Obstruction" was taken as the ratio of ventilation to ventilatory drive and termed flow:drive, i.e., actual ventilation as a percentage of intended ventilation. Lower values reflect increased flow resistance. Using 165,063 breaths, mixed model analysis (quadratic regression) quantified snore loudness as a function of obstruction, ventilatory drive, and the presence of extreme obstruction (i.e., apneic occlusion). Results: In the presence of obstruction (flow:drive = 50%, i.e., doubled resistance), snore loudness increased markedly with increased drive (+3.4 [95% confidence interval, 3.3-3.5] dB per standard deviation [SD] change in ventilatory drive). However, the effect of drive was profoundly attenuated without obstruction (at flow:drive = 100%: +0.23 [0.08-0.39] dB per SD change in drive). Similarly, snore loudness increased with increasing obstruction exclusively in the presence of increased drive (at drive = 200% of eupnea: +2.1 [2.0-2.2] dB per SD change in obstruction; at eupneic drive: +0.14 [-0.08 to 0.28] dB per SD change). Further, snore loudness decreased substantially with extreme obstruction, defined as flow:drive <20% (-9.9 [-3.3 to -6.6] dB vs. unobstructed eupneic breathing). Conclusions: This study highlights that ventilatory drive, and not simply pharyngeal obstruction, modulates snore loudness. This new framework for characterizing the severity of snoring helps better understand the physiology of snoring and is important for the development of technologies that use snore sounds to characterize sleep-disordered breathing.

Efficacy of Roncolab mobile application for diagnosing the primary sign of sleep-disordered breathing (snoring) in children

Sleep-disordered breathing (SDB) is a group of disorders associated with breathing anomalies during sleep. Easily detectable by sound, snoring is one of the most common manifestations and the main sign of SDB. Snoring is characteristic of breathing sound during sleep, without apnea, hypoventilation, or interrupted sleep. It may reduce the percentage of sleep and increase microarousals due to breathing effort or gas exchange. A range of questionnaires have been validated and adapted to the pediatric population to screen for patients who require laboratory testing. The Pediatric Sleep Questionnaire (PSQ) screens for SDB and identifies primary signs such as snoring. RoncoLab is a mobile application that records and measures snoring intensity and frequency.

Aim

To compare the RoncoLab app and the PSQ regarding how efficiently they diagnose snoring.

Materials and Method

This was an observational, analytical study of 31 children aged 7 to 11 years who visited the pediatric dental clinic at Benemérita Universidad Autónoma de Puebla, Mexico (BUAP). The PSQ was applied to diagnose SDB. Guardians were then instructed on how to download and use the mobile application to record data while the child was sleeping at home. Agreement between RoncoLab and the PSQ was analyzed statistically by Cohen's Kappa index at 95% confidence level.

Results

The Kappa index for identification of primary snoring was 0.743 (p<0.05). App sensitivity was 0.92, and specificity 0.82.

Conclusion

There is good agreement between PSQ and RoncoLab for diagnosing primary snoring, with acceptable sensitivity and specificity.

Impact of Breastfeeding Duration on Adenoid Hypertrophy, Snoring and Acute Otitis Media: A Case-Control Study in Preschool Children

BACKGROUND

The aim of this study was to analyze the relationship between breastfeeding duration and adenoid size, snoring and acute otitis media (AOM).

METHODS

We analyzed the medical history of children admitted to the ENT outpatient clinic in 2022 and 2023, reported symptoms, ear, nose and throat (ENT) examination, and flexible nasopharyngoscopy examination of 145 children aged 3-5 years.

RESULTS

Breastfeeding duration of 3 and 6 months or more had a significant effect on the reduction of snoring (p = 0.021; p = 0.039). However, it had no effect on the adenoid size, mucus coverage and sleeping with an open mouth. Snoring was correlated with open mouth sleeping (p < 0.001), adenoid size with a 75% A/C ratio or more (p < 0.001), and adenoid mucus coverage in the Mucus of Adenoid Scale by Nasopharyngoscopy Assessment-MASNA scale (p = 0.009). Children who were breastfed for less than 3 months had more than a four-fold greater risk of snoring. There was a statistically significant correlation between AOM and gender (p = 0.033), breastfeeding duration in groups fed 1, 3 or 6 months or more (p = 0.018; p = 0.004; p = 0.004) and those fed with mother's breast milk 3 or 6 months or more (p = 0.009; p = 0.010). Moreover, a correlation was found between adenoid size and mucus coverage, tympanogram, and open-mouth sleeping (p < 0.001). Independent factors of snoring in 3- to 5-year-old children were breastfeeding duration of less than 3 months (p = 0.032), adenoid size with an A/C ratio of 75% or more (p = 0.023) and open mouth sleeping (p = 0.001).

CONCLUSIONS

Children breastfed for 3 and 6 months or more exhibited reduced rates of snoring. There was no effect of breastfeeding duration on adenoid size in children aged 3 to 5 years, suggesting that the link between breastfeeding duration and snoring is primarily associated with craniofacial development and muscle tone stimulation. A breastfeeding duration of 1 month or more plays a key role in reducing the rate of AOM. The mother's milk plays a protective role against AOM. The presence of mucus might be responsible for snoring in preschool children. A medical history of breastfeeding should be taken into consideration when snoring children are suspected of adenoid hypertrophy.

Vibro-Acoustic Platelet Activation: An Additive Mechanism of Prothrombosis with Applicability to Snoring and Obstructive Sleep Apnea

Introduction: Obstructive sleep apnea (OSA) and loud snoring are conditions with increased cardiovascular risk and notably an association with stroke. Central in stroke are thrombosis and thromboembolism, all related to and initiaing with platelet activation. Platelet activation in OSA has been felt to be driven by biochemical and inflammatory means, including intermittent catecholamine exposure and transient hypoxia. We hypothesized that snore-associated acoustic vibration (SAAV) is an activator of platelets that synergizes with catecholamines and hypoxia to further amplify platelet activation. Methods: Gel-filtered human platelets were exposed to snoring utilizing a designed vibro-acoustic exposure device, varying the time and intensity of exposure and frequency content. Platelet activation was assessed via thrombin generation using the Platelet Activity State assay and scanning electron microscopy. Comparative activation induced by epinephrine and hypoxia were assessed individually as well as additively with SAAV, as well as the inhibitory effect of aspirin. Results: We demonstrate that snore-associated acoustic vibration is an independent activator of platelets, which is dependent upon the dose of exposure, i.e., intensity x time. In snoring, acoustic vibrations associated with low-frequency sound content (200 Hz) are more activating than those associated with high frequencies (900 Hz) (53.05% vs. 22.08%, p = 0.001). Furthermore, SAAV is additive to both catecholamines and hypoxia-mediated activation, inducing synergistic activation. Finally, aspirin, a known inhibitor of platelet activation, has no significant effect in limiting SAAV platelet activation. Conclusion: Snore-associated acoustic vibration is a mechanical means of platelet activation, which may drive prothrombosis and thrombotic risk clinically observed in loud snoring and OSA.

Screening for sleep apnoea risk in testosterone-treated transgender men

Introduction

Obstructive sleep apnoea (OSA) is more prevalent in men. Several studies suggested that higher testosterone levels were associated with a greater risk of OSA. We aimed to determine whether testosterone administration in transgender men would accentuate symptoms of OSA.

Methods

The study involved 94 adult people undergoing a female-to-male transition with testosterone administration. The participants answered the Berlin Questionnaire (BQ) and a separate question on snoring before starting testosterone treatment and after at least 1 year of being on testosterone treatment.

Results

A higher proportion of participants at the follow-up answered positively to the first category of BQ devoted to snoring. A lower proportion of participants at follow-up answered positively to the second category of BQ devoted to tiredness. The percentage of subjects with a high risk of sleep apnoea, according to BQ, and of those who answered the question on snoring positively did not change significantly.

Conclusion

An increased number of transgender men who reported snoring in BQ after testosterone administration indicate a higher risk of OSA development.

Screening for sleep disordered breathing among children hospitalized for asthma exacerbation

BACKGROUND

Sleep disordered breathing (SDB) may exacerbate asthma and is a treatable comorbidity.

OBJECTIVE

To design and implement a screening process for SDB in patients hospitalized for asthma exacerbation using quality improvement (QI) methods. We sought to improve screening for SDB from zero to 60% from July 2019 to December 2020.

DESIGN/METHODS

A multidisciplinary team used QI methods to screen for SDB using the Michigan pediatric sleep questionnaire (PSQ) in patients 2-18 years hospitalized for asthma exacerbation. Key interventions included: pairing the PSQ screen with another element of routine care (the asthma risk factor screen), educating staff and physicians, engaging respiratory therapists to complete the PSQ and document scores, and modifying the electronic medical record (asthma order set and flowsheet for PSQ score documentation). A run chart tracked progress and descriptive statistics were generated.

RESULTS

There were 2067 patients admitted for asthma exacerbation during this project. The PSQ was completed for 1531 patients (74%) overall. Of screened patients, 360 (24%) had a positive PSQ; the mean age was 8.6 years. Approximately 14 months after the project began, ~90% of children admitted for asthma were being screened; subsequently, >80% of patients were being screened until May 2022. Screening with the PSQ occurred approximately 90% of the time when routine asthma risk screens were completed.

CONCLUSION

A screening process for SDB was successfully implemented and appeared feasible and sustainable. The high proportion of positive screens reinforces the importance of evaluating for SDB in the high-risk population of children requiring hospitalization for asthma exacerbation.

Women's perception of fetal movements and perinatal outcomes: results of a prospective cohort study

BACKGROUND

Active fetal movements (AFMs) are a sign of the well-being of the baby during pregnancy and suggests the integrity of the cardiovascular, musculoskeletal, and nervous systems of the fetus. The abnormal perception of AFMs is associated with an increased risk of adverse perinatal outcomes such as stillbirth (SB) and brain damage. Several definitions of " decreased fetal movements" have been proposed, but none of them has been universally accepted. The aim of the study is to investigate the perinatal outcomes in relation to AFMs frequency and perception in term pregnancy with an ad hoc questionnaire administered to the women before delivery.

STUDY DESIGN

This was a prospective case-control study on pregnant women at term referring to the Obstetric Unit of the University Hospital of Modena, Italy, between January 2020 and March 2020. A validated questionnaire was administered to women who agreed to participate in the study. Therefore, women were subdivided into the case and control groups: cases included women who experienced adverse perinatal outcomes (APO) such as perinatal mortality (SB and early neonatal mortality), operative delivery (cesarean section or vacuum) due to fetal distress, Apgar 5' < 7, neonatal resuscitation at birth and NICU Admission, while controls were women who experienced delivery and birth without APO in the same period.

RESULTS

Seventy-seven cases and 178 controls that compiled the questionnaire were included in the analysis. Characteristics significantly associated with APO were low education (OR 1.57, CI 95% 1.11-2.22), nulliparity (OR 1.76, CI 95% 1.20-2.58), obesity (OR 1.55, CI 95% 1.10-2.17), neonatal male gender (OR 1.92 CI95% 1.33-2.78) and centile at birth (< 10° and >90°) (OR 2.77, 95%CI 2.17, 3.55). There was no association between any answer about strengths, frequency and vigor of perceived fetal movements and APO. Even any maternal perception of fetal hiccups or uterine contractions wasn't associated with APO. On the other hand, women who referred to frequent change positions during sleep (OR 1.55 CI95% 1.05-2.30) and women who snore (OR 1.43 CI95% 1.01-2.05) showed a statistically significant increase of APO.

CONCLUSIONS

Our data confirm the significant association between modifiable risk factors (such as obesity and low education) and APO. Thus, healthcare providers should be aware of the importance of intervention in reducing obesity, therefore snoring and related sleep apnea syndrome. Finally, changing position during sleep while not the perception of modified/reduced fetal movements significantly could induce the worst obstetric outcomes.

The role of rigid laryngo-tracheo-bronchoscopy in children with obstructive sleep apnoea: a case series of 65 children

OBJECTIVE

To assess the role of laryngo-tracheo-bronchoscopy in children with obstructive sleep apnoea by identifying airway abnormalities at surgery, that occur separately or in addition to adenotonsillar hypertrophy, and examining the correlation with respiratory parameters.

METHODS

A retrospective study was conducted of children with obstructive sleep apnoea who underwent laryngo-tracheo-bronchoscopy intra-operatively, performed by a single ENT surgeon from February 2016 to July 2019. Pre- and post-operative minimum oxygen saturation, apnoea-hypopnoea index, and oxygen desaturation index were recorded.

RESULTS

Sixty-five children were identified; 34 were aged less than three years and 31 were aged three years or more. 77 per cent and 13 per cent respectively had an airway abnormality; the t-test showed a significantly higher mean oxygen desaturation index and lower mean minimum oxygen saturation pre-operatively compared to children without an airway abnormality.

CONCLUSION

An update of the surgical pathway for children aged less than three years with obstructive sleep apnoea is required to include laryngo-tracheo-bronchoscopy intra-operatively. A t-test analysis of the pre-operative respiratory parameters suggests that airway abnormalities contribute to obstructive sleep apnoea severity.

Prevalence of bruxism in obstructive sleep apnea syndrome (OSAS) patients: A systematic review conducted according to PRISMA guidelines and the cochrane handbook for systematic reviews of interventions

BACKGROUND

Sleep bruxism (SB) and obstructive sleep apnea syndrome (OSAS) are two sleep-related conditions that have been associated with significantly conflicting results in literature. Understanding the prevalence of bruxism among OSA patients is crucial for identifying possible comorbidities and optimising treatment strategies.

OBJECTIVE

This systematic review aimed at analysing the prevalence of SB in OSAS sufferers and understanding the association between the two.

METHODS

Five online databases were searched for relevant articles in accordance with the PRISMA guidelines for conduction of systematic reviews. Studies reporting the prevalence of bruxism in OSAS patients and diagnosed through clinical assessments or polysomnography were included. Data extraction and quality assessment were performed independently by two reviewers. Methodological quality of the included studies was assessed using Risk of Bias In Non-randomised Studies of Interventions (ROBINS-I).

RESULTS

A thorough search of literature yielded only two studies were eligible for this review. SB was found to be significantly present in the OSAS group. Despite methodological variations, the majority of studies reported higher rates of bruxism in OSAS patients compared to the general population or control groups.

CONCLUSION

The results of this systematic review point to a significant association between bruxism and obstructive sleep apnea. Further research is required to determine a more precise prevalence rate and investigate the potential therapeutic implications of the bruxism-OSAS association that uses a standardised assessment techniques and larger sample sizes.

Minimally invasive, single-stage, multilevel surgery for obstructive sleep apnoea: A systematic review and meta-analysis

OBJECTIVES

Minimally invasive, single-staged multilevel surgery (MISS MLS) could be an optimal treatment for selected patients with obstructive sleep apnea (OSA). We aim to systematically review the efficacy of MISS MLS for patients with OSA, as well as the clinical outcomes and possible complications in OSA patients before and after MISS MLS.

DESIGN AND SETTING

Systematic review and meta-analysis. Six databases were searched, and the PRISMA guideline was followed.

PARTICIPANTS

Patients with OSA receiving MISS MLS.

MAIN OUTCOME MEASURES

The random-effects model was adopted for the statistical synthesis. The percentage and 95% confidence interval (CI) were adopted as the effect measurements of MISS MLS for OSA. Subgroup analyses and sensitivity analyses were also performed to identify the heterogeneity among the studies.

RESULTS

There were initially 154 articles for identification. Eventually, six studies with a total of 848 OSA patients completely met the inclusion criteria and were further enrolled for analysis. The pooled analysis showed statistically significant lower AHI (apnea/hypopnea index, /hr.; mean difference: -8.931, 95% CI: -11.591 to -6.271, I2  = 87.4%), ESS (mean difference: -2.947, 95% CI: -4.465 to -1.429, I2  = 94.9%), and snoring severity with 0-10 visual analog scale after surgery (mean difference: -4.966, 95% CI: -5.804 to -4.128, I2  = 96.4%). The success rate was 46% in mild/moderate OSA; however, 18% in severe OSA. There were no major complications occurred.

CONCLUSIONS

The acceptable surgical outcomes, esp. in mild/moderate OSA, and rare complications are the major advantages of MISS MLS. The evidence of this study could aid the decision making in selecting suitable treatment programs for OSA patients.

Clinical Impact of Preoperative Tonsil and Adenoid Size on Symptomatic Outcomes Following Adenotonsillectomy in Pediatric Patients

Background Adenotonsillar hypertrophy is a common clinical problem in pediatric patients. Adenotonsillectomy is a surgical intervention to remove airway obstruction and alleviate symptoms. However, some children continue to experience persistent symptoms after surgery. Objective This study aimed to investigate the relationship between preoperative tonsils and adenoid size and the persistence of symptoms, including snoring, mouth breathing, noisy breathing, and sleep apnea, after adenotonsillectomy in pediatric patients. Method This study was conducted in Taif, Saudi Arabia, and included 109 pediatric patients aged three to 14 years who underwent adenotonsillectomy. Data on preoperative and postoperative symptoms were collected through patient records and follow-up surveys. Tonsil and adenoid size were assessed using the Brodsky scale and endoscopic grading scales, respectively. Statistical analysis was performed using SPSS Version 26 (IBM Corp., Armonk, NY). Results The most prevalent presenting symptoms were snoring, mouth breathing, and noisy breathing. Tonsil size grades 3+ and 4+ were significantly more prevalent than the other grades (p<0.05). Adenoid size grades 3 and 4 were also significantly more prevalent than the other grades (p<0.05). Significant associations were observed between tonsil and adenoid size grades and specific presenting symptoms, such as snoring, mouth breathing, and noisy breathing. No significant correlations were found between preoperative tonsil or adenoid size and postoperative persistent symptoms. Conclusion While tonsil and adenoid size are essential factors in determining the need for surgery, they may not predict postoperative resolution of symptoms. A comprehensive evaluation of various clinical factors is necessary to understand the persistence of symptoms after surgery. Although adenotonsillectomy is an effective treatment for upper airway obstruction in pediatric patients, some individuals may experience residual symptoms.

Association of dual use of cigarettes with obstructive sleep apnea assessed by the STOP-Bang score

INTRODUCTION

Although previous studies have addressed the association between smoking and obstructive sleep apnea (OSA), there are few studies on the association between electronic cigarette use and OSA. Thus, we aimed to evaluate the association between the dual use of electronic and conventional cigarettes and OSA.

METHODS

Data from 7350 participants of the 2019-2021 Korean National Health and Nutrition Examination Survey were analyzed in this population-based study. The STOP-Bang score was calculated using eight items: snoring, tiredness, observed apnea, high blood pressure, body mass index, age, neck circumference, and sex. The main independent variable was smoking behavior. A multiple logistic regression analysis was performed. Subgroup analysis was conducted to analyze the association between smoking behavior in detail and OSA, and stratified analyses were additionally performed.

RESULTS

Of the 7350 participants, 417 (5.7%) had a high risk of OSA, according to the STOP-Bang score. Compared to the non-smoker group, the dual user group had a 2.46-fold increase in the odds of OSA (adjusted odds ratio, AOR = 2.45; 95% CI: 1.04-5.79). Current non-smokers who were dual users in the past had increased odds of having OSA (AOR=3.61; 95% CI: 1.32-9.92). In the stratified analyses, dual cigarette use was significantly associated with OSA in females and those with a low physical activity level.

CONCLUSIONS

Dual users and cigarette-only users had an increased probability of developing OSA. Even if they are not currently smoking or vaping, individuals who were dual users in the past were associated with a higher risk of OSA. The association between dual cigarette use and OSA was more pronounced in females and those with a low physical activity level. While intervening for obstructive sleep apnea or investigating risk factors, new smoking methods such as vaping and dual use should be considered along with conventional smoking.

Associations of actigraphy measures of sleep duration and continuity with executive function, vigilance, and fine motor control in children with snoring and mild sleep-disordered breathing

STUDY OBJECTIVES

Children with snoring and mild sleep-disordered breathing may be at increased risk for neurocognitive deficits despite few obstructive events. We hypothesized that actigraphy-based sleep duration and continuity associate with neurobehavioral functioning and explored whether these associations vary by demographic and socioeconomic factors.

METHODS

298 children enrolled in the Pediatric Adenotonsillectomy Trial, ages 3 to 12.9 years, 47.3% from racial or ethnic minority groups, with habitual snoring and an apnea-hypopnea index < 3 were studied with actigraphy (mean 7.5 ± 1.4 days) and completed a computerized vigilance task (Go-No-Go) and a test of fine motor control (9-Hole Pegboard). Caregivers completed the Behavior Rating Inventory of Executive Function. Regression analyses evaluated associations between sleep exposures (24-hour and nocturnal sleep duration, sleep fragmentation index, sleep efficiency) with the Behavior Rating Inventory of Executive Function Global Executive Composite index, pegboard completion time (fine motor control), and vigilance (d prime on the Go-No-Go), adjusting for demographic factors and study design measures.

RESULTS

Longer sleep duration, higher sleep efficiency, and lower sleep fragmentation were associated with better executive function; each additional hour of sleep over 24 hours associated with more than a 3-point improvement in executive function (P = .002). Longer nocturnal sleep (P = .02) and less sleep fragmentation (P = .001) were associated with better fine motor control. Stronger associations were observed for boys and children less than 6 years old.

CONCLUSIONS

Sleep quantity and continuity are associated with neurocognitive functioning in children with mild sleep-disordered breathing, supporting efforts to target these sleep health parameters as part of interventions for reducing neurobehavioral morbidity.

CLINICAL TRIAL REGISTRATION

Registry: ClinicalTrials.gov; Name: Pediatric Adenotonsillectomy for Snoring (PATS); URL: https://clinicaltrials.gov/ct2/show/NCT02562040; Identifier: NCT02562040.

CITATION

Robinson KA, Wei Z, Radcliffe J, et al. Associations of actigraphy measures of sleep duration and continuity with executive function, vigilance, and fine motor control in children with snoring and mild sleep-disordered breathing. J Clin Sleep Med. 2023;19(9):1595-1603.

[Clinical thinking of acupuncture for snoring based on "disharmony qi leads to restlessness"]

This study summarizes the clinical thinking of acupuncture for snoring based on "disharmony qi leads to restlessness". According to the pathological characteristics of qi stagnation and blood stasis, phlegm dampness and internal obstruction in snoring patients, combined with the etiology, pathogenesis and location of the disease, the innovative viewpoint of "disharmony qi leads to restlessness" is proposed. It is believed that the key to snoring treatment lies in "regulating qi ". In clinical practice, acupuncture can directly regulate the qi of the disease's location, regulate the qi of the organs and viscera, and regulate the qi of the meridians to achieve overall regulation of the body's internal and external qi, smooth circulation of qi and blood, and ultimately achieve the therapeutic goal of harmonizing qi, stopping snoring, and improving sleep quality.

Exploring acupuncture treatment strategies for snoring based on meridian theory

Starting from the perspective of meridian theory, this article briefly analyzes the meridian pathophysiology of snoring and the relationship between snoring and meridian theory. It proposes that acupuncture treatment for snoring should focus on regulating qi from the shaoyang meridians, harmonizing the spirit by the governor vessel, resolving phlegm through the three yang meridians, and harmonizing qi and blood from the yangming meridians. Additionally, attention is placed on both the root cause and the symptoms, the theory of "four seas". The ultimate goal is to promote the flow of meridian and qi-blood, improve symptoms such as nighttime snoring, poor sleep quality, and daytime sleepiness, and achieve the desired outcome of stopping snoring and ensuring restful sleep.

Erbium:Yttrium Aluminum Garnet (Er:YAG) Laser: A Minimally Invasive Treatment Method in Selected Patients with Impaired Breathing During Sleep-The Assessment of Treatment Effectiveness After 4 Years

Objective: The aim of this study was to assess the long-term outcomes of nonablative Er:YAG laser treatment for snoring. Background data: Nonablative Er:YAG laser treatment has been shown to improve subjective quality of sleep without serious adverse effects, but long-term data are lacking. Materials and methods: Twenty-four patients with snoring problems due to soft palate hypertrophy were treated with three treatment procedures with Er:YAG laser performed at 2-week intervals. Subjective (questionnaires) and objective (polygraph) outcome measures were assessed at baseline, 3 months, and 4 years after the final laser treatment. Results: Twenty patients returned for the 4 years follow-up. The significant improvement in subjective sleep outcomes observed 3 months after Er:YAG laser treatment was still significant 4 years after treatment. No significant improvement or deterioration in objective polygraph outcome measures was observed during the 4 years of follow-up in our study. No side effects of laser treatment were observed. Conclusions: The Er:YAG laser treatment presents a safe and well-tolerated snoring treatment alternative for patients with airway obstruction in the oropharynx with improvement in subjective sleep outcomes lasting up to 4 years.

Discrepancies Between Caregiver Reported Early Childhood Sleep Problems and Clinician Documentation and Referral

OBJECTIVE

The American Academy of Pediatrics recommends routine sleep problem screenings during child well-visits. However, studies suggest a discrepancy between caregiver- and clinician-reported child sleep problems. The present study examines whether caregiver-reported child sleep problems (ie, habitual snoring, insomnia symptoms, poor sleep health) and clinician-documented child sleep problems and management are congruent.

METHODS

The sample included 170 caregiver-child dyads (child Mage = 3.3 years, range = 2-5 years; 56.5% girls; 64.1% Black, 20.0% non-Latinx White, and 4.1% Latinx; 86.5% maternal caregiver reporter). Caregivers' questionnaire-based reports of habitual snoring, insomnia symptoms, and sleep health behaviors (nighttime electronics, caffeine intake, insufficient sleep) were compared with clinician documentation in the electronic health record.

RESULTS

About 92.3% of children had at least 1 caregiver-reported sleep problem (66% insomnia symptoms, 64% electronics, 38% insufficient sleep, 21% caffeine, 17% snoring). In contrast, a substantially lower percent of children had a clinician documented sleep problem (20% overall; 10% insomnia symptoms, 7% electronics, 0% insufficient sleep, 3% caffeine, 4% snoring), sleep-related referral (1% overall; 0.6% Otolaryngology, 0.6% polysomnogram, 0% sleep clinic), or recommendation (12% overall; 8% insomnia symptoms, 4% electronics, 0% insufficient sleep, 1% caffeine).

CONCLUSIONS

There is a vast discrepancy between caregiver-reported child sleep problems and clinician-documented sleep problems and management, with a higher proportion of caregiver reports. To benefit overall child health and well-being, future research and quality improvement initiatives should focus on enhancing screening tools and educational opportunities to improve clinician documentation and enhance family conversations about early childhood sleep problems.

Treatment of Severe Obstructive Sleep Apnea Using Mandibular Advancement Device: A Case Report

Obstructive Sleep Apnea (OSA) is one of the most common sleep disorders. A mandibular advancement device (MAD) can be used to manage primary snoring and OSA cases. It is mostly indicated in cases with mild to moderate OSA. This case reports shows the successful management of severe OSA using MAD. A 34-year-old male presented to the orthodontic clinic with a diagnosis of severe OSA, apnea-hypopnea index (AHI) of 71 events per hour with symptoms of loud snoring, witnessed gasping, morning headache, and excessive daytime sleepiness. The case was managed using MAD to position the lower jaw in a forward position during sleep with 7 mm advancement. Progress sleep study results showed that the AHI reached normal levels, with only two hypopnea events per hour and a complete resolution of apnea episodes. The patient's symptoms subsided after using MADs. This case report documents that severe OSA can be managed with MAD in suitable cases.

[Prevalence of childhood obstructive sleep apnoea syndrome in a referral sleep unit]

INTRODUCTION

Obstructive sleep apnoea syndrome (OSAS) affects between 1% and 6% of children. Its diagnosis includes: a) snoring and/or apnoea; and b) an apnoea and hypopnoea index >3/hour obtained by polysomnography (PSG). The main aim of this work is to determine the prevalence of OSAS in our study population.

PATIENTS AND METHODS

We conducted a descriptive study with a sample of 151 children aged between 1 and 12 years, who had been referred to the sleep unit of the Hospital General Universitario Gregorio Maranon for a PSG. We analysed the demographic variables sex and age; the clinical variables snoring, apnoeas and tonsillar hypertrophy; and the presence of OSAS based on the polysomnographic diagnostic criterion of an apnoea and hypopnoea index >3/hour.

RESULTS

The mean age of the sample was 5.37 years (standard deviation: 3.05) and 64.9% were males. In 90.1% of cases, the reason for the visit was suspected OSAS. Snoring, apnoeas and tonsillar hypertrophy were observed in 73.5, 48.7 and 60% of cases, respectively. OSAS was diagnosed en 19 children (12.6%); in 13.5% of snorers; in 15.1% of those with apnoeas; and in 15.6% of the children with tonsillar hypertrophy.

CONCLUSIONS

In our study, the prevalence of OSAS in children was 12.6%, which is higher than that reported in most epidemiological studies that include PSG for the diagnosis of OSAS.

Homocysteine Levels in Severe OSA Patients Before and After TORS-OSA Surgery

OBJECTIVE

The increased risk of cardiovascular diseases owing to a high level of serum homocysteine has been widely reported. Literature has demonstrated that patients with obstructive sleep apnea/hypopnea syndrome (OSA) had a higher homocysteine level than control group. This study aimed to investigate the alteration of serum homocysteine levels in severe OSA patients receiving transoral robotic surgery (TORS).

STUDY DESIGN

Retrospective chart review.

SETTING

Tertiary academic medical center.

METHODS

Data of polysomnography (PSG) and serum homocysteine levels before and at least 3 months after the surgery were collected and analyzed via paired t tests. A subgroup analysis based on the preoperative homocysteine level (≥15 mcmol/L, as hyperhomocysteinemia group) was conducted to compare the intergroup differences of homocysteine decrease. Pearson's correlation was used to survey the relationships between the changes of major PSG parameters and the levels of homocysteine decrease at baseline and after TORS-OSA surgery.

RESULTS

Two hundred sixty-one patients with severe OSA were enrolled. There were significant improvements in major PSG parameters after TORS-OSA surgery. Homocysteine levels significantly decreased from 12.1 ± 3.9 to 11.4 ± 3.7 mcmol/L (difference = -0.7 ± 2.8 mcmol/L, p = .001) postoperatively, which was shown in the hyperhomocysteinemia group (difference = -2.9 ± 4.7 mcmol/L, p = .007) to a greater extent. Pearson's correlation revealed that ΔODI (oxygen desaturation index/h) was the predominant estimate with a positive association with Δhomocysteine (r = 0.525, p = .012).

CONCLUSION

TORS-OSA surgery could decrease homocysteine levels in OSA patients. The effects were more relevant in severe OSA patients with abnormal preoperative homocysteine levels.

Treatment of sleep disordered breathing relapse after surgery

This narrative review provides a general overview of the management of relapses after surgery for the treatment of sleep disordered breathing. This clinical scenario represents a challenging field, but fortunately several therapeutic options are included in sleep surgeons’ armamentarium. Each therapeutic modality is described in detail in a dedicated section.

Bidirectional associations of sleep and discretionary screen time in adults: Longitudinal analysis of the UK biobank

The direction of the association between discretionary screen time (DST) and sleep in the adult population is largely unknown. We examined the bidirectional associations of DST and sleep patterns in a longitudinal sample of adults in the general population. A total of 31,361 UK Biobank study participants (52% female, 56.1 ± 7.5 years) had two repeated measurements of discretionary screen time (TV viewing and leisure-time computer use) and self-reported sleep patterns (five sleep health characteristics) between 2012 and 2018 (follow-up period of 6.9 ± 2.2 years). We categorised daily DST into three groups (low, <3 h/day; medium, 3-4 h/day; and high, >4 h/day), and calculated a sleep pattern composite score comprising morning chronotype, adequate sleep duration (7-8 h/day), never or rare insomnia, never or rare snoring, and infrequent daytime sleepiness. The overall sleep pattern was categorised into three groups (healthy: ≥ 4; intermediate: 2-3; and poor: ≤ 1 healthy sleep characteristic). Multiple logistic regression analyses were applied to assess associations between DST and sleep with adjustments for potential confounders. Participants with either an intermediate (OR: 1.40; 95% CI: 1.15, 1.71) or a poor (OR: 1.16; 95% CI: 1.10, 1.24) sleep pattern at baseline showed higher odds for high DST at follow-up, compared with those with a healthy baseline sleep pattern. Participants with medium (OR: 1.40; 95% CI: 1.14, 1.71) or high DST (OR: 1.62; 95% CI: 1.30, 2.00) at baseline showed higher odds for poor sleep at follow-up, compared with participants with a low DST. In conclusion, our findings provide consistent evidence that a high DST at baseline is associated with poor sleep over a nearly 7 year follow-up period, and vice versa.

Obstructive Sleep Apnea and Its Management: A Narrative Review

Obstructive sleep apnea (OSA) is a disorder in which there is repeated collapse of the upper airway when the person is in sleep, which causes oxygen desaturation and interrupted sleep. While asleep, airway blockages and collapse are accompanied by awakenings with or without oxygen desaturation. OSA is a prevalent disorder, especially in people with known risk factors and other illnesses. Pathogenesis is variable, and the risk factors include low chest volume, erratic respiratory regulation, and muscular dysfunction in the upper airway dilators. The high-risk factors include overweight, male sex, aging, adenotonsillar hypertrophy, interruption of the menstrual cycle, preservation of liquids, and smoking. The signs are snoring, drowsiness, and apneas. A sleep history, assessment of symptoms, and physical examination are all part of the screening process for OSA, and the data can help determine which people need to be tested for the condition. The results of the polysomnogram or at-home sleep apnea test assist in determining the presence and severity of OSA. Still, it is seen many times that the accuracy of home sleep apnea tests is significantly less, so one should take an expert opinion for the same. OSA results in systemic hypertension, drowsiness, and driving accidents. It is additionally related to diabetes mellitus, congestive heart failure (CHF), cerebral infarction, and myocardial infarction, but the exact mechanism is not known. The preferred treatment is continuous positive airway pressure with 60-70% adherence. Other management options include reducing weight, therapy of oral appliances, and correcting any anatomical obstruction (narrow pharyngeal airway, adenoid hypertrophy, and mass in the pharynx). OSA indirectly causes headaches just after awakening and daytime sleepiness. However, there are no age boundaries in OSA as it can occur in any age group. Still, more prevalence is seen in individuals of more than 60 years of age.

Discovery of genomic loci associated with sleep apnea risk through multi-trait GWAS analysis with snoring

STUDY OBJECTIVES

Despite its association with severe health conditions, the etiology of sleep apnea (SA) remains understudied. This study sought to identify genetic variants robustly associated with SA risk.

METHODS

We performed a genome-wide association study (GWAS) meta-analysis of SA across five cohorts (NTotal = 523 366), followed by a multi-trait analysis of GWAS (multi-trait analysis of genome-wide association summary statistics [MTAG]) to boost power, leveraging the high genetic correlation between SA and snoring. We then adjusted our results for the genetic effects of body mass index (BMI) using multi-trait-based conditional and joint analysis (mtCOJO) and sought replication of lead hits in a large cohort of participants from 23andMe, Inc (NTotal = 1 477 352; Ncases = 175 522). We also explored genetic correlations with other complex traits and performed a phenome-wide screen for causally associated phenotypes using the latent causal variable method.

RESULTS

Our SA meta-analysis identified five independent variants with evidence of association beyond genome-wide significance. After adjustment for BMI, only one genome-wide significant variant was identified. MTAG analyses uncovered 49 significant independent loci associated with SA risk. Twenty-nine variants were replicated in the 23andMe GWAS adjusting for BMI. We observed genetic correlations with several complex traits, including multisite chronic pain, diabetes, eye disorders, high blood pressure, osteoarthritis, chronic obstructive pulmonary disease, and BMI-associated conditions.

CONCLUSION

Our study uncovered multiple genetic loci associated with SA risk, thus increasing our understanding of the etiology of this condition and its relationship with other complex traits.

The influence of alcohol on genioglossus single motor units in men and women during wakefulness

NEW FINDINGS

What is the central question of this study? How does alcohol intake, which worsens obstructive sleep apnoea, alter motor control of the genioglossus muscle, an upper airway dilator, in healthy awake human volunteers, and does alcohol alter genioglossus muscle afterdischarge? What is the main finding and its importance? Alcohol consumption had a very minor effect on the activity of the genioglossus in healthy young individuals studied during wakefulness and did not alter afterdischarge, leaving open the possibility that alcohol worsens obstructive sleep apnoea via other mechanisms.

ABSTRACT

Alcohol worsens obstructive sleep apnoea (OSA). This effect is thought to be due to alcohol's depressant effect on upper airway dilator muscles such as the genioglossus, but how alcohol reduces genioglossal activity is unknown. The aim of this study was to investigate the effect of alcohol consumption on genioglossus muscle single motor units (MUs). Sixteen healthy individuals were studied on two occasions (alcohol: breath alcohol concentration ∼0.07% and placebo). They were instrumented with a nasal mask, four intramuscular genioglossal EMG electrodes, and an ear oximeter. They were exposed to 8-12 hypoxia trials (45-60 s of 10% O2 followed by one breath of 100% O2 ) while awake. MUs were sorted according to their firing patterns and quantified during baseline, hypoxia and recovery. For the alcohol and placebo conditions, global muscle activity (mean ± SD peak inspiratory EMG = 119.3 ± 44.1 and 126.5 ± 51.9 μV, respectively, P = 0.53) and total number of MUs recorded at baseline (68 and 67, respectively) were similar. Likewise, the peak discharge frequency did not differ between conditions (21.2 ± 4.28 vs. 22.4 ± 4.08 Hz, P = 0.09). There was no difference between conditions in the number (101 vs. 88, respectively) and distribution of MU classes during hypoxia, and afterdischarge duration was also similar. In this study, alcohol had a very minor effect on genioglossal activity and afterdischarge in these otherwise healthy young individuals studied while awake. If similar effects are observed during sleep, it would suggest that the worsening of OSA following alcohol may be related to increased upper airway resistance/nasal congestion or arousal threshold changes.

Barbed Pharyngoplasty for Snoring: Does It Meet the Expectations? A Systematic Review

To date, the use of barbed sutures for the surgical management of patients suffering from obstructive sleep apnea and snoring with retropalatal collapse and vibration has significantly increased. A systematic review was carried out, which included clinical studies that used barbed sutures for the treatment of snoring. A qualitative analysis, including six clinical studies, was conducted. Of these, five were studies on barbed pharyngoplasties, and one study involved a minimally invasive surgical procedure. The population consisted of 176 patients, aged 26 to 58 years old. Overall, the included studies showed a mean gain in the snoring Visual Analog Scale of 5.67 ± 1.88, with a mean preoperative value of 8.35 ± 1.17 and a postoperative value of 2.68 ± 1.27. No major complications were described. Given the lack and heterogeneity of this evidence, the conclusion calls for being cautious. In carefully selected snorers and obstructive sleep apnea patients, the use of barbed sutures could represent a valid therapeutic strategy for snoring, ensuring a statistically significant improvement in the subjective parameters. Further studies on a larger scale that assess the role of barbed pharyngoplasties in snoring surgery and more extended follow-up studies are needed in order to confirm these promising results.

Snoring was related to self-reported daytime sleepiness and tiredness in young adults performing compulsory conscript service

STUDY OBJECTIVES

In young adults performing compulsory military service, fatigue and somnolence are common and presumably associated with objective or self-reported sleep deprivation. We aimed to find out whether objective sleep parameters from ambulatory polysomnography could explain their self-reported tiredness and sleepiness and whether habits were associated with sleep parameters or tiredness.

METHODS

Seventy (67 male, age 18-24 years) participants had their sleep assessed with polysomnography. Their self-reported symptoms and demographic data were obtained from online survey including Epworth Sleepiness Scale, Beck's Depression Inventory, items from Basic Nordic Sleep Questionnaire, Internet Addiction Scale, and lifestyle questions.

RESULTS

Snoring (audio recording, percentage of total sleep time) was associated with self-reported sleepiness (P = .010) and tiredness (P = .030) and snoring seemed to, partially, explain sleepiness (P = .029). Twenty-six percent of the conscripts had self-reported sleep deprivation (mismatch between reported need for sleep and reported sleep). Self-reported sleep deprivation was significantly associated with somnolence (P = .016) and fatigue (P = .026). Smartphone usage, both average time (P = .022) and frequency of usage (P = .0093) before bedtime, was associated with shorter total sleep time. On average, objective sleep time was rather short (7 hours, 6 minutes), sleep efficiency high (94.9%), proportion of N3 sleep high (27.7%), and sleep latency brief (9 minutes)-suggesting that many of the conscripts might have chronic partial sleep deprivation.

CONCLUSIONS

Snoring might predispose to tiredness in presumably healthy young adults. Conscripts may have partial sleep deprivation.

CITATION

Orjatsalo M, Toppila J, Heimola M, et al. Snoring was related to self-reported daytime sleepiness and tiredness in young adults performing compulsory conscript service. J Clin Sleep Med. 2023;19(2):243-251.

Associations between snoring and dental sleep conditions: A systematic review

BACKGROUND

It is important for dentists to know if the presence of snoring is associated with the presence of other dental sleep conditions (e.g. obstructive sleep apnea [OSA], sleep bruxism [SB], gastroesophageal reflux disease [GERD], xerostomia and oro-facial pain). If so, dentists could play a significant role in the early recognition and management of these conditions.

OBJECTIVES

This systematic review aimed to: (i) investigate the associations between the presence of snoring and the presence of other dental sleep conditions; and (ii) determine if it is clinically relevant that dentists assess snoring in their population.

METHODS

The literature search was performed in PubMed and Embase.com in collaboration with a medical librarian. Studies were eligible if they employed regression models to assess whether snoring was associated with other dental sleep conditions, and/or investigated the incidence of snoring in patients with other dental sleep conditions and vice versa.

RESULTS

Of the 5299 retrieved references, 36 eligible studies were included. The available evidence indicates that the presence of snoring is associated with higher probabilities of OSA, GERD and headache. Due to limited evidence and conflicting findings, the currently available articles are not indicative of associations between the presence of snoring and the presence of SB and oral dryness.

CONCLUSION

Within the limitations of this study, it can be concluded that the presence of snoring is associated with higher probabilities of OSA, GERD and headache. Therefore, it is clinically relevant that dentists assess snoring in their patient population.

Influence of Snoring on the Incidence of Metabolic Syndrome: A Community-Based Prospective Cohort Study in Rural Northeast China

In recent years, there has been an increase in the incidence of metabolic syndrome (MetS) in rural China. Thus, for better intervention, it is necessary to identify the possible risk factors of MetS. This community-based prospective cohort study was performed to evaluate the relationship between the snoring status and incidence of MetS. In this Northeast China rural cardiovascular health study, 4980 residents aged ≥35 years (2586 men and 2394 women; follow-up proportion: 87.5%) at baseline were recruited between 2012 and 2013 and were followed up between 2015 and 2017. The primary outcome was the incidence of MetS, as defined by the unified criteria for MetS defined in 2009. The residents were classified based on their snoring status, and the outcomes were compared between the two groups. The odds ratio (OR) for MetS incidence was estimated using a logistic regression model and adjusted for confounding factors. With a median follow-up duration of 4.6 years, the MetS incidence was higher among the snorers (men, 26.2%; women, 33.5%) than in the non-snorers (men, 19.7%; women, 23.2%). The participants' diastolic blood pressure was increased at follow-up as compared with the baseline values among the male snorers; however, a decrease was noted among the male non-snorers. Similarly, the female snorers had higher blood glucose levels during the follow-up, whereas the non-snorers had lower blood sugar levels. A significant association was noted between snoring and the incidence of MetS (adjusted OR = 1.51; 95% confidence interval = 1.32-1.74). Moreover, the incidence of severe snoring increased with increased levels of snoring, with severe snorers having an OR twice as high as that of the non-snorers (adjusted OR = 2.10; 95% confidence interval = 1.38-3.20). Overall, snoring was independently associated with a higher incidence of newly diagnosed MetS in rural Northeast China. Thus, more attention should be paid to residents with snoring problems.

Clinical and functional characteristics of OSA in children with comorbid asthma treated by leukotriene receptor antagonist: A descriptive study

Background

Obstructive sleep apnea (OSA) is the most common form of respiratory disorders during sleep in children, especially those with severe asthma. However, optimal treatment of asthma might significantly improve OSA severity.

Methods

It was a cohort study including children aged >5 years old and diagnosed with asthma according to GINA (Global Initiative for Asthma). The data related to age, gender, height, weight, body mass index (BMI), clinical symptoms and medical history of asthma, spirometry (FEV₁: forced expiratory in 1 s), and exhaled nitric oxide (F_ENO) were recorded for analysis. Respiratory polygraphy (RPG) was done for each study subject to diagnose OSA and its severity.

Results

Among 139 asthmatic children, 99 patients with OSA (71.2%) were included in the present study (9.3 ± 0.2 years): 58.6% with uncontrolled asthma and 32.3% with partial controlled asthma. The mean ACT (asthma control testing) score was 19.0 ± 3.4. The most frequent night-time symptoms were restless sleep (76.8%), snoring (61.6%), sweating (52.5%), and trouble breathing during sleep (48.5%). The common daytime symptoms were irritable status (46.5%) and abnormal behavior (30.3%). The mean AHI (apnea-hypopnea index) was 3.5 ± 4.0 events/h. There was a significant correlation between BMI and snoring index (R = 0.189 and P = 0.027), bronchial and nasal F_ENO with AHI (R = 0.046 and P < 0.001; R = 0.037 and P < 0.001; respectively). There was no significant correlation between asthma level, FEV₁ and AHI. The severity of asthma and respiratory function were improved significantly after 3 months and 6 months of asthma treatment in combination with leukotriene receptor antagonist (LRA) treatment. The symptoms related to OSA were significantly improved after treatment with LRA. The severity of OSA was decreased significantly after 3 months and 6 months of treatment.

Conclusion

The treatment of asthmatic children with comorbid OSA by LRA in combination with standard therapy for asthma could improve the control of asthma and the symptoms and severity of OSA.

[An analysis of complaints about sleep disorders as an indicator of poor sleep quality in patients with primary headache disorders]

OBJECTIVE

To assess the prevalence of various complaints indicating poor sleep quality and its disturbances in men and women with primary headaches.

MATERIAL AND METHODS

In total 305 patients (mean age 45 years, age range 18-89 years) with primary headache disorders and complaints of poor quality of sleep were included in the study. Women prevailed among these patients (79%). The average age of men (41.6) and women (45.8) had no statistically significant differences (p=0.8). The initial examination and professional face-to-face interview were initially conducted by an experienced neurologist specializing in the treatment of headaches. Within a week after that, before the start of treatment, patients were interviewed by telephone using standardized questionnaires by specially trained students and physicians.

RESULTS

A frequent occurrence of many complaints of sleep disturbances were found in primary headache disorders, both in men and women, they included daytime sleepiness (75.7%), lack of sleep (69.2%), difficulty in falling asleep (57.4%), sleep disruption (51.5%), early morning awakening (47.5%), snoring (18.7%). We found the predominance of these complaints in people over 50 years old. Women had these complaints more frequently than men, besides we determined sex differences in the prevalence of these complaints.

CONCLUSION

Complaints about poor sleep quality are quite common in patients with primary headache disorders and have sex and age differences. Identification of the described complaints of poor sleep quality is a simple tool for the initial analysis of sleep disorders in the practice of any specialist. We recommend paying great attention to these complaints for further diagnostics of sleep disorders and their timely treatment.

Decreased Peripapillary and Macular Vascular Densities in Patients with Moderate/Severe Obstructive Sleep Apnea/Hypopnea Syndrome

PURPOSE

To compare peripapillary and macular vascular densities (PVDs and MVDs) between patients with obstructive sleep apnea/hypopnea syndrome (OSA) and control subjects with symptoms of sleep-related breathing disorders only by swept-source optical coherence tomography angiography (OCTA).

PARTICIPANTS AND METHODS

In this prospective study, 192 participants underwent a full-night polysomnography to determine OSA severity and subsequently received OCTA measurements as well as AngioTool software analysis.

RESULTS

A total of 146 patients with OSA (51 mild, 43 moderate, 52 severe) and 24 control subjects (apnea/hypopnea index, AHI <5) were enrolled. PVDs and MVDs in the superficial and choroidal layers were significantly different among the four groups. When participants with simple snoring/mild OSA (AHI <15) were grouped together and compared with moderate/severe OSA (AHI ≥15), PVDs were significantly lower for the latter group in the superficial layer (p = 0.0003), deep layer (p = 0.004), and choroidal layer (p = 0.003). MVDs were also lower for the moderate/severe OSA group in the superficial (p = 0.012) and choroidal layer (p = 0.004). Negative correlations were identified between AHI and PVDs in the superficial layer (ρ = -0.257, p = 0.0007), deep layer (ρ = -0.197, p = 0.0102) and choroidal layer (ρ = -0.220, p = 0.0039) and between AHI and MVDs in the superficial layer (ρ = -0.199, p = 0.0094) and choroid layer (ρ = -0.186, p = 0.0152).

CONCLUSION

PVDs and MVDs were significantly lower in patients with moderate/severe OSA as compared to subjects with simple snoring/mild OSA. Furthermore, decreased PVDs and MVDs significantly correlated with OSA severity.

Short-term positive effects of a mandibular advancement device in a selected phenotype of patients with moderate obstructive sleep apnea: a prospective study

STUDY OBJECTIVES

To evaluate (determinants of) treatment success of mandibular advancement device application in a selected phenotype of patients with obstructive sleep apnea (OSA).

METHODS

Ninety nonobese patients with moderate OSA (obstructive apnea-hypopnea index [OAHI] ≥ 15 and < 30 events/h) without comorbidities were prospectively included. Polysomnography was performed at baseline and with a mandibular advancement device. A drug-induced sleep endoscopy with jaw thrust was performed in 83%.

RESULTS

OAHI reduction ≥ 50% was observed in 73%, OAHI reduction ≥ 50% with OAHI < 10 events/h in 70%, and complete OSA resolution (OAHI < 5 events/h) in 40%. Patients with nonpositional OSA showed a significantly higher rate of complete OSA resolution: Posttest probability increased to 67%. In patients with total disappearance of collapse at velum level and at all levels during drug-induced sleep endoscopy with jaw thrust, the drop in OAHI was impressive with an infinitively high positive likelihood ratio. However, the proportion of patients having nonpositional OSA or the drug-induced sleep endoscopy characteristics as described above was < 20%. The change in snoring disturbance based on a visual analog scale was 76% (interquartile range 40-89%, P < .001) and a statistically significant amelioration in Epworth Sleepiness Scale (especially in somnolent subjects) was observed. High adherence was reported.

CONCLUSIONS

In this predefined OSA phenotype, a mandibular advancement device was effective in reduction of OAHI and in amelioration of symptoms. Stratification by nonpositional OSA and findings on drug-induced sleep endoscopy with jaw thrust increased treatment success defined as reduction in OAHI. However, the clinical relevance can be questioned because only a small number of patients demonstrated these characteristics.

CITATION

Buyse B, Nguyen PAH, Leemans J, et al. Short-term positive effects of a mandibular advancement device in a selected phenotype of patients with moderate obstructive sleep apnea: a prospective study. J Clin Sleep Med. 2023;19(1):5-16.

A Prediction Nomogram for Severe Obstructive Sleep Apnea in Snoring Patients: A Retrospective Study

Purpose

Snoring patients, as a high-risk group for OSA, are prone to the combination of severe OSA and face serious health threats. The aim of our study was to develop and validate a nomogram to predict the occurrence of severe OSA in snorers, in order to improve the diagnosis rate and treatment rate in this population.

Patients and Methods

A training cohort of 464 snoring patients treated at our institution from May 2021 to October 2022 was divided into severe OSA and non-severe OSA groups. Univariate and multivariate logistic regression were used to identify potential predictors of severe OSA, and a nomogram model was constructed. An external hospital cohort of 210 patients was utilized as an external validation cohort to test the model. Area under the receiver operating characteristic curve, calibration curve, and decision curve analyses were used to assess the discriminatory power, calibration, and clinical utility of the nomogram, respectively.

Results

Multivariate logistic regression demonstrated that body mass index, Epworth Sleepiness Scale total score, smoking history, morning dry mouth, dream recall, and hypertension were independent predictors of severe OSA. The area under the curve (AUC) of the nomogram constructed from the above six factors is 0.820 (95% CI: 0.782-0.857). The Hosmer-Lemeshow test showed that the model had a good fit (P = 0.972). Both the calibration curve and decision curve of the nomogram demonstrated the corresponding dominance. Moreover, external validation further confirmed the reliability of the predicted nomograms (AUC=0.805, 95% CI: 0.748-0.862).

Conclusion

A nomogram predicting the occurrence of severe OSA in snoring patients was constructed and validated with external data for the first time, and the findings all confirmed the validity of the model. This may help to improve existing clinical decision making, especially at institutions that do not yet have devices for diagnosing OSA.

Genetic insights into the risk of snoring on stroke and ischemic stroke: A single-variable and multivariable Mendelian randomization

Background

Multiple risk factors of stroke have been identified in previous studies; however, the causal role of snoring in the onset of stroke is less investigated. To clarify the causal association of snoring on stroke and its subtypes, this study is performed.

Methods

The single nucleotide polymorphisms in relation to snoring were retrieved from the UK biobank cohort with 408,317 participants. The data for stroke and its subtypes of European ancestry (67,162 cases and 453,702 controls) were obtained from the MEGASTROKE consortium. In single-variable Mendelian randomization (SVMR) and multivariable MR (MVMR) analyses, inverse variance weighting was used as the primary estimate, complemented with sensitivity analyses more robust to pleiotropy.

Results

Genetically predicted snoring increased the risk of stroke (odds ratio [OR] = 2.69, 95% confidence interval [CI] = 1.19-6.08, P = 0.016) and ischemic stroke (IS) (OR = 2.82, 95% CI = 1.23-6.44, P = 0.013), but not large artery stroke (LAS) (OR = 3.02, 95% CI = 0.31-29.44, P = 0.339), cardioembolic stroke (CES) (OR = 1.51, 95% CI = 0.58-3.92, P = 0.395). We provide novel genetic evidence that snoring increases the risk of stroke and IS, but not LAS, CES, and SVS.

Conclusion

Our findings provide novel genetic evidence that snoring increases the risk of stroke and IS, but not LAS, CES, and SVS.

Snoring may transmit infectious aerosols from the upper to the lower respiratory tract

Migration to the lungs of an initial upper airway infection with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) or other respiratory pathogens can lead to pneumonia, associated with progression from mild to severe symptoms. Chemical pneumonitis or bacterial pneumonia may be caused by the ‘macroaspiration’ of large volumes of oropharyngeal or gastroesophageal secretions into the lower respiratory tract. ‘Microaspiration’, i.e., a similar mechanism but involving much smaller amounts of oropharyngeal secretions, is considered the pathogenetic mechanism for most pneumonias, including that associated with COVID-19. Here, we hypothesize an alternative mechanism: Rather than by microaspiration, these fluids enter the lungs as microdroplets that are generated by snoring and then carried by the inspired airstream. Laboratory measurements indicate that snoring generates (a) comparable numbers and sizes of oral fluid droplets as loud speaking and (b) total fluid quantities that are similar to those reported for microaspiration. Snoring propensity is strongly correlated to known risk factors for severe COVID-19, including male gender, age, obesity, diabetes, obstructive sleep apnea, and pregnancy. Therefore, more research is urgently needed to determine if various methods that decrease snoring can prevent progression to pneumonia after initial infection of the upper airways.

STOP-Bang Score and Prediction of Severity of Obstructive Sleep Apnea in a First Nation Community in Saskatchewan, Canada

The STOP-Bang questionnaire is an easy-to-administer scoring model to screen and identify patients at high risk of obstructive sleep apnea (OSA). However, its diagnostic utility has never been tested with First Nation peoples. The objective was to determine the predictive parameters and the utility of the STOP-Bang questionnaire as an OSA screening tool in a First Nation community in Saskatchewan. The baseline survey of the First Nations Sleep Health Project (FNSHP) was completed between 2018 and 2019. Of the available 233 sleep apnea tests, 215 participants completed the STOP-Bang score questionnaire. A proportional odds ordinal logistic regression analysis was conducted using the total score of the STOP-Bang as the independent variable with equal weight given to each response. Predicted probabilities for each score at cut-off points of the Apnea Hypopnea Index (AHI) were calculated and plotted. To assess the performance of the STOP-Bang questionnaire, sensitivity, specificity, positive predictive values (PPVs), negative predictive values (NPVs), and area under the curve (AUC) were calculated. These data suggest that a STOP-Bang score ≥ 5 will allow healthcare professionals to identify individuals with an increased probability of moderate-to-severe OSA, with high specificity (93.7%) and NPV (91.8%). For the STOP-Bang score cut-off ≥ 3, the sensitivity was 53.1% for all OSA and 72.0% for moderate-to-severe OSA. For the STOP-Bang score cut-off ≥ 3, the specificity was 68.4% for all OSA and 62.6% for moderate-to-severe OSA. The STOP-Bang score was modestly superior to the symptom of loud snoring, or loud snoring plus obesity in this population. Analysis by sex suggested that a STOP-Bang score ≥ 5 was able to identify individuals with increased probability of moderate-to-severe OSA, for males with acceptable diagnostic test accuracy for detecting participants with OSA, but there was no diagnostic test accuracy for females.

Cluster Analysis of Home Polygraphic Recordings in Symptomatic Habitually-Snoring Children: A Precision Medicine Perspective

(1) Background: Sleep-disordered breathing (SDB) is a frequent problem in children. Cluster analyses offer the possibility of identifying homogeneous groups within a large clinical database. The application of cluster analysis to anthropometric and polysomnographic measures in snoring children would enable the detection of distinctive clinically-relevant phenotypes; (2) Methods: We retrospectively collected the results of nocturnal home-based cardiorespiratory polygraphic recordings and anthropometric measurements in 326 habitually-snoring otherwise healthy children. K-medoids clustering was applied to standardized respiratory and anthropometric measures, followed by Silhouette-based statistics. Respiratory Disturbance Index (RDI) and oxygen desaturation index (≤3%) were included in determining the optimal number of clusters; (3) Results: Mean age of subjects was 8.1 ± 4.1 years, and 57% were males. Cluster analyses uncovered an optimal number of three clusters. Cluster 1 comprised 59.5% of the cohort (mean age 8.69 ± 4.14 years) with a mean RDI of 3.71 ± 3.23 events/hour of estimated sleep (e/ehSleep). Cluster 2 included 28.5% of the children (mean age 6.92 ± 3.43 years) with an RDI of 6.38 ± 3.92 e/ehSleep. Cluster 3 included 12% of the cohort (mean age 7.58 ± 4.73 years) with a mean RDI of 25.5 ± 19.4 e/ehSleep. Weight z-score was significantly lower in cluster 3 [-0.14 ± 1.65] than in cluster 2 [0.86 ± 1.78; p = 0.015] and cluster 1 [1.04 ± 1.78; p = 0.002]. Similar findings emerged for BMI z scores. However, the height z-score was not significantly different among the 3 clusters; (4) Conclusions: Cluster analysis of children who are symptomatic habitual snorers and are referred for clinical polygraphic evaluation identified three major clusters that differed in age, RDI, and anthropometric measures. An increased number of children in the cluster with the highest RDI had reduced body weight. We propose that the implementation of these approaches to a multicenter-derived database of home-based polygraphic recordings may enable the delineation of objective unbiased severity categories of pediatric SDB. Our findings could be useful for clinical implementation, formulation of therapeutic decision guidelines, clinical management, prevision of complications, and long-term follow-up.