Predictors of moderate to severe obstructive sleep apnea: identification of sex differences

A Novel Screening Tool for Severe Obstructive Sleep Apnea

Purpose: Obstructive sleep apnea (OSA) is a prevalent condition with long waiting lists for the gold standard polysomnography (PSG) test. Screening tests are essential to identify and prioritize patients with severe OSA. Current questionnaires do not accurately detect severe cases. This study aims to develop an alternative screening tool based on anthropometric and morphological characteristics to determine the severity of OSA. Methods: The study included 149 patients with sleep apnea symptoms who did not have additional diseases. The obstructive sleep apnea morphologic scale (OSAMS) was created using 5 parameters: 3 internal parameters related to the upper respiratory tract (tonsil size, oropharyngeal passage, and hypopharyngeal-laryngeal examination) and 2 external parameters (neck circumference and body mass index). Each parameter was scored, and the total scores were correlated with the apnea-hypopnea index (AHI) of PSG to determine the severity of OSA. Results: A statistically significant moderate positive correlation was found between AHI and OSAMS scores (rho = .491; P < .001). A grand total score >4 provided 80.3% sensitivity and 53.9% specificity to identify patients with severe OSA. OSAMS demonstrated superior results compared to existing questionnaires for OSA screening in our study group. Conclusions: OSAMS is a potential alternative to existing questionnaires to screen patients with severe OSA, offering a practical approach based on morphology during physical examinations.

Sex-dependent GOAL screening performance in adults at risk for obstructive sleep apnea

OBJECTIVE

To evaluate possible sex-related differences in the performance of the GOAL, a 4-item obstructive sleep apnea (OSA) screening instrument in adults.

METHODS

Between July 2019 and June 2021, this cross-sectional study included consecutively recruited patients from one Brazilian sleep laboratory undergoing overnight polysomnography. Individuals with GOAL scores ≥ 2 of a maximum of 4 points are classified at high risk for OSA diagnosis. Actual OSA severity was based on the apnea-hypopnea index: ≥ 5.0/h as any OSA, ≥ 15.0/h as moderate-to-severe OSA, and ≥ 30.0/h as severe OSA. Performance of the GOAL instrument in women and men was assessed by the discriminatory ability (obtained from area under the curve [AUC]-Receiver Operating Characteristic curves) and 2×2 contingency tables.

RESULTS

A total of 2,978 subjects (55.3% males) were evaluated. The frequency of GOAL-defined OSA high-risk was statistically higher in men when compared to women (p < 0.001). The GOAL predictive parameters for screening all severity OSA levels were as follows: in females, sensitivity ranging from 58.2% to 78.3% and specificity ranging from 60.0% to 77.6%, while in males, sensitivity ranging from 90.5% to 96.9% and specificity from 20.7% to 46.8%. The GOAL questionnaire had similar discriminatory properties, assessed by AUC, in women and in men: i) any OSA: 0.741 vs. 0.771 (p = 0.204), ii) moderate-to-severe OSA: 0.727 vs. 0.737 (p = 0.595), and iii) severe OSA: 0.728 vs. 0.703 (p = 0.240); respectively.

CONCLUSIONS

The GOAL instrument emerges as a useful tool for screening adult individuals and displays similar performance in both women and men.

Louis EK, Chahal AA, Schulte PJ, Mansukhani MP, Xie J, Lipford MC, Li N, Ramar K, Caples SM, Gay PC, Olson EJ, Silber MH, Li J, Somers VK. Sex-specific associations between daytime sleepiness, chronic diseases and mortality in obstructive sleep apnea

Objective

Excessive daytime sleepiness (EDS) is common in obstructive sleep apnea (OSA) and has been linked to adverse outcomes, albeit inconsistently. Furthermore, whether the prognostic impact of EDS differs as a function of sex is unclear. We aimed to assess the associations between EDS and chronic diseases and mortality in men and women with OSA.

Methods

Newly-diagnosed adult OSA patients who underwent sleep evaluation at Mayo Clinic between November 2009 and April 2017 and completed the Epworth Sleepiness Scale (ESS) for assessment of perceived sleepiness (N = 14,823) were included. Multivariable-adjusted regression models were used to investigate the relationships between sleepiness, with ESS modeled as a binary (ESS > 10) and as a continuous variable, and chronic diseases and all-cause mortality.

Results

In cross-sectional analysis, ESS > 10 was independently associated with lower risk of hypertension in male OSA patients (odds ratio [OR], 95% confidence interval [CI]: 0.76, 0.69-0.83) and with higher risk of diabetes mellitus in both OSA men (OR, 1.17, 95% CI 1.05-1.31) and women (OR 1.26, 95% CI 1.10-1.45). Sex-specific curvilinear relations between ESS score and depression and cancer were noted. After a median 6.2 (4.5-8.1) years of follow-up, the hazard ratio for all-cause death in OSA women with ESS > 10 compared to those with ESS ≤ 10 was 1.24 (95% CI 1.05-1.47), after adjusting for demographics, sleep characteristics and comorbidities at baseline. In men, sleepiness was not associated with mortality.

Conclusion

The implications of EDS for morbidity and mortality risk in OSA are sex-dependent, with hypersomnolence being independently associated with greater vulnerability to premature death only in female patients. Efforts to mitigate mortality risk and restore daytime vigilance in women with OSA should be prioritized.

Clinical and polysomnographic predictors of suboptimal auto-adjusting CPAP titration in adult OSA patients: a single-center study

PURPOSE

To examine potential clinical, demographic, anthropometric, and polysomnographic predictors of successful auto-adjusting continuous positive airway pressure (CPAP) titration for treatment of obstructive sleep apnea (OSA).

METHODS

This cross-sectional study was conducted in adults diagnosed with moderate-to-severe OSA (baseline apnea-hypopnea index [AHI] ≥ 15.0/h), who underwent auto-adjusting CPAP titration (S9 or S10 AutoSet ResMed^®) in a sleep laboratory setting while wearing a nasal or pillow mask. Participants were then grouped into two groups: optimal CPAP titration (residual AHI < 5.0/h) or suboptimal CPAP titration (residual AHI ≥ 5.0/h). Multivariate logistic regression analysis was used to assess possible independent predictive factors for suboptimal CPAP titration.

RESULTS

A total of 1222 adults consisting of 874 subjects with optimal CPAP titration (71.5%) and 348 subjects with suboptimal CPAP titration (28.5%) were evaluated. Multivariate analysis resulted in a model with an adequate calibration (Hosmer-Lemeshow chi-square-test: 7.088; p = 0.527), with male sex, higher values of baseline AHI, therapeutic pressure (95th percentile), and mask leak (95th percentile) emerging as significant and independent predictors for suboptimal CPAP titration: adjusted odds ratio (OR): 1.456 (95% confidence interval [CI] 1.076-1.971; p = 0.015), OR: 1.009 (95% CI 1.002-1.016; p = 0.013), OR: 1.281 (95% CI 1.206-1.361; p < 0.001), and 1.035 (1.026-1.043; p < 0.001), respectively.

CONCLUSIONS

In a large cohort of adults undergoing auto-adjusting CPAP titration due to moderate-to-severe OSA, male sex, increased values of baseline AHI, pressure requirements, and mask leak were significant predictors for less than optimal CPAP titration.

Snoring Index and Neck Circumference as Predictors of Adult Obstructive Sleep Apnea

Background. Snoring is the cardinal symptom of obstructive sleep apnea (OSA). The acoustic features of snoring sounds include intra-snore (including snoring index [SI]) and inter-snore features. However, the correlation between snoring sounds and the severity of OSA according to the apnea−hypopnea index (AHI) is still unclear. We aimed to use the snoring index (SI) and the Epworth Sleepiness Scale (ESS) to predict OSA and its severity according to the AHI among middle-aged participants referred for polysomnography (PSG). Methods. In total, 50 participants (mean age, 47.5 ± 12.6 years; BMI: 29.2 ± 5.6 kg/m2) who reported snoring and were referred for a diagnosis of OSA and who underwent a whole night of PSG were recruited. Results. The mean AHI was 30.2 ± 27.2, and the mean SI was 87.9 ± 56.3 events/hour. Overall, 11 participants had daytime sleepiness (ESS > 10). The correlation between SI and AHI (r = 0.33, p = 0.021) was significant. Univariate linear regression analysis showed that male gender, body mass index, neck circumference, ESS, and SI were associated with AHI. SI (β = 0.18, p = 0.004) and neck circumference (β = 2.40, p < 0.001) remained significantly associated with AHI by the multivariate linear regression model. Conclusion. The total number of snores per hour of sleep and neck circumference were positively associated with OSA among adults referred for PSG.

Accuracy and modification of the STOP ‐bang questionnaire for screening patients with obstructive sleep apnea in China

Despite the high sensitivity of the STOP-Bang questionnaire [snoring, tiredness, observed apneas, high blood pressure, body mass index, age, neck size, gender] questionnaire (SBQ), which is widely used to screen individuals at high risk of obstructive sleep apnea (OSA), few studies have evaluated the discrimination related to sex in the SBQ. Therefore, our study aimed to assess whether SBQ performance is gender-related and modified by changing body mass index (BMI) and neck circumference (NC) cut-off values. A total of 470 patients attended the sleep centres. They were divided into moderate-to-severe OSA and non-moderate-to-severe OSA groups based on the apnea-hypopnea index (AHI) and the results of the SBQ screening. The predictive performance of the SBQ screening instrument was evaluated by 2 × 2 contingency tables and discriminatory ability, which was estimated from the area under the curve (AUC) obtained from receiver operating characteristic curve. Our results suggest that when screening for moderate-to-severe OSA, the original SBQ has higher sensitivity and lower specificity for men; however, women have higher specificity and lower sensitivity. The SBQ achieved the maximum AUC of 0.783 for men and 0.634 for women when the BMI cut-off value was established at 30 kg/m² and the NC cut-off value was established at 38 cm in men, and the BMI cut-off value was established at 25 kg/m² and the NC cut-off value at 36 cm in women. Balancing the optimal sensitivity and specificity, the cut-off value of the optimal modified SBQ total scores for men was determined to be ≥4 and ≥3 for women.

Predictive Factors for Obstructive Sleep Apnea Diagnosis in Bariatric Surgery Candidates with or Without Chronic Insomnia Complaints

OBJECTIVE

This study aims to evaluate the frequency of insomnia complaints in bariatric patients and to assess obstructive sleep apnea (OSA) predictors according to the presence or absence of chronic insomnia.

METHODS

Insomnia was defined as the presence of at least one specific symptom: difficulty falling asleep, difficulty maintaining sleep, and/or waking up earlier than expected. Diagnosis of OSA was objectively obtained from in-laboratory polysomnography. Multivariate logistic regression analysis was used to assess OSA predictors.

RESULTS

This cross-sectional study contains 1,737 bariatric surgery candidates: 59.6% without insomnia and 40.4% with insomnia. OSA prevalence was similar among participants with or without insomnia either for any OSA (p = 0.168) or for moderate-to-severe OSA (p = 0.185). Patients without insomnia showed a higher prevalence of severe OSA than those with insomnia (p = 0.005). In both cohorts, five parameters were independent OSA predictors: sex, age, body mass index (BMI), neck circumference (NC), and excessive daytime sleepiness (EDS). Male sex was the most important predictor, whether in individuals without insomnia (adjusted odds ratio [OR] ranging from 4.874 to 8.369) or in those with insomnia (adjusted OR ranging from 5.672 to 12.441).

CONCLUSIONS

A considerable proportion of bariatric patients report insomnia complaints. The probability of suffering from OSA was similar among bariatric candidates with or without insomnia, except for severe OSA diagnosis. Sex, age, BMI, NC, and EDS were independent predictors for OSA diagnosis irrespective of insomnia symptoms, and male sex was the main predictor for OSA in bariatric individuals with or without insomnia.

Influence of nocturnal insomnia symptoms on obstructive sleep apnea diagnosis in a clinical referral cohort

STUDY OBJECTIVES

To assess whether nocturnal symptoms of insomnia influence the prevalence of obstructive sleep apnea (OSA) in a clinical referral cohort.

METHODS

Insomnia was defined by the presence of one or more of the following complaints: difficulty initiating sleep, difficulty maintaining sleep, and/or early morning awakenings. OSA severity was based on an apnea-hypopnea index: ≥ 5.0/h (any OSA), ≥ 15.0/h (moderate/severe OSA), and ≥ 30/h (severe OSA). Multivariate logistic regression analysis was used to evaluate predictive factors for OSA diagnosis and severity.

RESULTS

Overall, 12,021 outpatients referred for polysomnography (PSG) were grouped into two cohorts: without insomnia (58.2%) and with insomnia (41.8%). Individuals without insomnia had a higher prevalence of OSA than those with insomnia (p < 0.001, for all OSA severity levels). The presence of insomnia was negatively associated with diagnosis of any OSA (adjusted odds ratio [OR]: 0.852; 95% confidence interval [CI]: 0.769-0.944), moderate/severe OSA (adjusted OR: 0.819; 95% CI: 0.751-0.892), and severe OSA (adjusted OR: 0.816; 95% CI: 0.746-0.892). Moreover, the number of nocturnal symptoms of insomnia was associated with a lower likelihood of OSA, even when adjusted for other confounders such as sex, age, body mass index, neck circumference, excessive daytime sleepiness, hypertension, and type 2 diabetes mellitus.

CONCLUSIONS

In this present study that included a large sample of consecutive outpatients, there was an inverse relationship between the number of nocturnal symptoms of insomnia and OSA diagnosis.

Neck Circumference Is Associated With Poor Outcome in Patients With Spontaneous Intracerebral Hemorrhage

Objective: This study aimed to assess the association between neck circumference (NC) and functional outcome in intracerebral hemorrhage (ICH) patients.

Methods: We prospectively analyzed data from ICH patients who received treatment at our institution from January 2018 to November 2019. Patients were categorized into two groups according to 180-day modified Rankin scale (MRS) scores. Univariate and multivariate analyses were performed to assess whether NC was associated with poor outcome in ICH patients. Receiver operating characteristic (ROC) curve analysis was performed to determine the significance of NC in predicting the functional outcome of ICH patients.

Results: A total of 312 patients were enrolled in our study. Multivariate logistic regression analysis indicated that NC was an independent predictor of poor 180-day functional outcome [odds ratio (OR) = 1.205, 95% confidence interval (CI): 1.075–1.350, p = 0.001]. ROC analysis revealed that NC could predict poor functional outcome at 6 months.

Conclusions: NC is an independent predictor of unfavorable functional outcome at 6 months in ICH patients.

Prevalence and factors correlated with hypertension secondary from obstructive sleep apnea

Background

In 2003, the JNC 7 reported obstructive sleep apnea (OSA) as a cause of secondary hypertension. The prevalence of OSA in hypertension ranges from 30-80%. There are limited data on the prevalence and risk factors of OSA in hypertensive patients. This study thus aimed to evaluate prevalence and clinical predictors of obstructive sleep apnea (OSA) in these patients.

Methods

This was a cross-sectional study and conducted at the hypertension clinic at Khon Kaen University’s Srinagarind Hospital, Thailand. We enrolled patients with hypertension treated at the clinic. OSA was defined as apnea-hypopnea index of 5 events/hour or over according to cardiopulmonary monitoring. Patients whose hypertension was due to any other causes were excluded. The prevalence of OSA was calculated and risk factors for OSA were analyzed using multivariate logistic regression.

Results

There were 726 hypertensive patients treated at the clinic. Out of those, 253 (34.8%) were randomly studied and categorized as either non-OSA (147 patients, 58.1%) or OSA (106 patients, 41.9%). There were four independent factors associated with OSA-induced hypertension: age, sex, history of snoring, and history of headache. Headache had an adjusted odds ratio (95% confidence interval) of 3.564 (95% confidence interval of 1.510, 8.411).

Conclusion

Age, male sex, history of snoring, and headache were independent predictors of hypertension caused by OSA.

Gender and Polysomnographic Profiles Findings in Obstructive Sleep Apnea Syndrome Patients Living in High Altitude

PURPOSE

Obstructive sleep apnea (OSA) is a common sleep disorder which prevalence is 22% in men and 17% in women. It is well described that females presented different clinical and polysomnographic characteristics compared with men. Those studies were performed in plain areas. We described the analysis by gender and clinical profiles of a sample of patients with diagnostic of OSA and living at high altitude.

PATIENTS AND METHODS

It is an observational study that describes differences between clinical and polysomnographic characteristics by gender in patients with OSA. Additionally, an unsupervised cluster algorithm was used to find groups of patients with similar clinical and polysomnographic characteristics.

RESULTS

We included 709 patients, 51.6% were females and 48.3% were males with mean age of 64 and 62 years old, respectively, in which 90.97% presented OSA. Men presented a higher apnea and hypopnea index than women (p=0.002), besides presented more sleep polysomnographic alterations. Meanwhile, women evidenced better sleep quality based on parameters. Additionally, in the sample of patients, we found four separated clinical profiles characterized mainly by differences in the severity of polysomnographic parameters.

CONCLUSION

The patients were more obese, older, and had lower SpO₂ values than most of those previously reported. Men had greater severity in most of the parameters measured by polysomnography. Polysomnographic variables were different both in the OSA patient profiles and in the gender comparison. However, the REM sleep apnea hypopnea index did not differ between sexes, indicating the importance of this variable in the evaluation of OSA severity in women. In contrast to previous reports, clinical and demographic characteristics showed few differences in both analyses. This result suggests that the behavior of OSA at high altitudes may have particularities with respect to low altitudes.

Evaluation of Obstructive Sleep Apnea in Female Patients in Primary Care: Time for Improvement?

Obstructive sleep apnea (OSA) has historically been regarded as a male disease. However, there are a number of significant gender-related differences in the symptoms, diagnosis, and consequences of OSA, which seems to be more severe in male than in female patients, although this sex difference decreases with increasing age. Female patients with OSA tend to present nonspecific symptoms, such as insomnia, depressive symptoms, fatigue, morning headache, and nightmares, often resulting in underdiagnosis and undertreatment compared to male patients. Understanding these differences in women is essential for early identification and referral of patients for diagnosis and treatment of OSA.

Nutritional Status and Dietary Patterns in Adults with Severe Obstructive Sleep Apnea

Obstructive sleep apnea (OSA) is associated with daytime sleepiness, obesity, and lifestyle and dietary changes. The potential role of diet in OSA has been largely unexplored. The aim of the study was to assess nutritional status and dietary patterns in OSA patients. The study was conducted in 137 adult patients (48 women and 89 men) aged 31-79 suffering from OSA. The following diagnostic procedures were undertaken: polysomnography, anthropometric measurements, and a dietary pattern questionnaire. We found that 128 (93.4%) patients were overweight or obese with the mean body mass index (BMI) of 33.2 ± 6.1 kg/m² and weight of 98.0 ± 20.2 kg. The mean percentage of total body fat was 45.0 ± 5.5% in women and 32.5 ± 5.5% in men. Obesity was associated with the severity of OSA, expressed by apnea/hypopnea index. We further found that the waist-to-hip ratio in women, but the neck circumference or percentage of body fat in men, characterizes best the OSA patients. Referring to dietary habits, half of the patients consumed white bread on a daily basis, 35.8% of them had whole grain bread in the diet, and only 16.8% consumed fish at least two portions a week. A third of patients used butter as a spread for bread or a source of fat for cooking, 2.9% of them used soft margarine, and 20.4% used olive or canola oil. Fruits and vegetables were consumed by 60% and 38% of patients, respectively. Refined sugar and sweets were used by 31.4% of patients every day. We conclude that excessive body weight, which may portend the development of OSA, is characterized by different anthropometric variables in men and women. Further, improper dietary habits seem conducive to the gain in body weight and thus may be at play in the pathogenesis of OSA.

Effect of mean apnea-hypopnea duration in patients with obstructive sleep apnea on clinical and polysomnography parameter

OBJECTIVE

Apnea-hypopnea index is the number of apnea-hypopnea events observed during polysomnography within an hour. Mean apnea-hypopnea duration is the mean duration of all apneas and hypopneas. In this study, we aimed to investigate the association of mean apnea-hypopnea duration in patients with obstructive sleep apnea with clinical and polysomnographic parameters.

METHODS

In our hospital, a total of 764 patients were diagnosed with OSA by polysomnography in 2017. Age, body mass index, and the current diseases were recorded. Sleep structures obtained from polysomnography readings, blood oxygen levels, apnea-hypopnea index, and mean average duration were recorded. Patients with mean average duration of 20 s or more were assigned to the long average duration group and those with less than 20 s were assigned to the short average duration group. Groups were compared in terms of clinical and polysomnographic parameters.

RESULTS

Snoring, witnessed apnea, morning tiredness, and hypertension were significantly higher in the long average duration group. There was statistically significantly more male patients and higher neck circumference in the MAD group. Total wake duration, percentage of sleep, stage 3, stage 1, and mean oxygen saturation percentage of the long average duration group were significantly reduced.

CONCLUSION

In present study, the patients with obstructive sleep apnea with long average duration were found to have more negative effects of sleep apnea than the patients with short average duration. We think that the use of mean apnea-hypopnea duration as an indicator with apnea-hypopnea index will be beneficial for the follow-up and treatment of the disease.