International Consensus Document on Obstructive Sleep Apnea

[Home CPAP Remote Monitoring as a System to Control Adaptation and Titration in Obstructive Sleep Apnoea and its Impact on the Management of this Pathology (T-CPAP Project)]

Introduction

Continuous Positive Airway Pressure (CPAP) constitutes the most effective treatment for Obstructive Sleep Apnea (OSA). Automatic titration systems (ATS) are predominantly used to achieve adaptation to the equipment. Home CPAP devices allow telemonitoring (TM) of the same parameters as those provided by ATS but with access to continuous usage data. Under this premise, we conducted a study on the potential validity of TM for home CPAP devices as a titration system, its direct impact on proper adaptation (AD) to the equipment, and secondarily on the healthcare resources employed to achieve it.

Material and methods

An observational study involving 318 patients with OSA who were titrated using TM to achieve AD to CPAP. Patients with OSA were consecutively recruited and evaluated at 1, 3, and 6 months after initiating treatment. Results were compared with a historical group of 307 patients with OSA who achieved AD to CPAP using ATS. Additionally, we assessed the impact on required healthcare resources.

Results

Patients with OSA who initiated CPAP treatment with TM over the first six months showed a similar AD rate compared to the historical group titrated using ATS, with lower resource usage in the TM group.

Conclusion

Data provided by TM of home CPAP devices allow for titration and achieving similar AD as with ATS in non-complex patients.

[Highlights 57th SEPAR Congress]

The Spanish Society of Pneumology and Thoracic Surgery (SEPAR) has held its 57th Congress in Valencia from 6 to 8 of June 2024. The SEPAR Congress is the leading meeting for the entire respiratory scientific community, which allows learning about the main scientific advances in this area and provides the ideal situation to create and strengthen ties. This year, under the title "Respiratory Health for everybody", the SEPAR Congress stressed the importance of raising awareness about the importance of caring for and protecting our respiratory system. In this review, we offer a summary of some notable issues addressed in six selected areas of interest: chronic obstructive pulmonary disease (COPD), asthma, interstitial lung diseases (ILDs), pulmonary vascular diseases, sleep and breathing disorders and respiratory physiotherapy.

Does the number of loops affect the results of barbed pharyngoplasties? A retrospective comparison in two techniques

INTRODUCTION

The use of barbed sutures for pharyngoplasty techniques is a new trend in sleep apnea surgery, but little is known about its short-term results depending on the different techniques. The purpose of this study was to analyse the surgical results in two different centres using barbed sutures with different barbed pharyngoplasty techniques.

MATERIAL AND METHODS

This is a multicenter retrospective study of patients with obstructive sleep apnea (OSA) undergoing surgery, all of whom underwent pharyngoplasty with barbed suture using a classic or modified technique, which may or may not be associated with other surgical techniques. A univariate and multivariate statistical analysis were performed to assess the relationship of these surgical techniques with surgical success and with different descriptive variables.

RESULTS

The final sample size was 126 patients. A surgical success rate of 39.7% was obtained for a postoperative AHI < 10/h and a 51.6% success rate according to Sher's criteria. A greater proportion of success was observed in the modified barbed pharyngoplasty technique that was not maintained after the multivariate analysis, as with other factors such as age, ODI or the presence of nasal surgery.

CONCLUSION

Non-resective pharyngoplasty with barbed sutures is an effective technique for the treatment of OSA in selected patients, with both the classic technique and the modified alternatives having good postoperative results, with no differences observed in relation to surgical success between both. More studies are necessary to evaluate the differences between both techniques in more homogeneous groups.

Influence of Comorbidity and Obesity on the Occurrence of Vascular Events in Obstructive Apnoea Treated with CPAP

BACKGROUND

Obesity has increased cardiovascular morbidity and mortality. It is the leading risk factor for obstructive sleep apnoea (OSA). The relationship between obesity-OSA and vascular disease seems clear. There is no consensus on whether CPAP (continuous positive airway pressure) treatment prevents vascular events.

OBJECTIVE

The aim of this study was to determine the effect of comorbidity and obesity on the risk of vascular events in patients with OSA treated with CPAP.

METHOD

This study was a prospective study of historical cohorts of adult patients with OSA and CPAP. The sample was 3017 patients. Descriptive, survival (Kaplan-Meier) and Cox regression analyses were performed, calculating crude and adjusted association relationships to explain the risk of vascular events.

RESULTS

A total of 1726 patients were obese, 782 were diabetics, and 1800 were hypertensive. The mean adherence was 6.2 (±1.8 h/day), and the mean follow-up time was 2603 days (±953.3). In the COX regression analysis, the event-related variables were baseline age (HR: 1.025: 1.012-1.037; p < 0.001), pre-treatment vascular event (HR; 2.530: 1.959-3.266; p < 0.001), hypertension (HR; 1.871: 1.187-2.672; p = 0.005) and abbreviated Charlson comorbidity index (HR; 1.289: 1.100-1.510; p = 0.002).

CONCLUSIONS

The occurrence of vascular events in OSA patients on CPAP treatment is related to hypertension, having a vascular event before treatment, age at the start of CPAP use and abbreviated Charlson comorbidity index.

Phenotypes of obstructive sleep apnea in women: A real-life cohort study

OBJECTIVE

Obstructive sleep apnea (OSA) is a complex, heterogeneous disease. Categorizing the disorder into phenotypes can help us better understand its pathology and guide us toward more personalized treatment approaches. Nevertheless, most of the previous cluster analysis (CA) studies in OSA predominantly included middle-aged to older men and may not adequately represent the heterogeneity of OSA phenotypes in women. Our aim is to identify these phenotypes in women using an extensive, exclusively female cohort.

METHODS

Cross-sectional study of 1886 women diagnosed with OSA (apnea-hypopnea index >5 events/h) by PSG (polysomnography) and RP (respiratory polygraphy) at a tertiary hospital Sleep Unit. A CA was performed including general data, clinical variables, comorbidities and sleep study results.

RESULTS

Four phenotypic subtypes were identified: Cluster 1 "Middle-aged paucisymptomatic women without cardiovascular risk factors" (507 patients, 27 %); Cluster 2 "Older paucisymptomatic women with established cardiovascular disease and severe OSA" (228 patients, 12 %); Cluster 3 "Middle-aged women with "classic" symptoms and cardiovascular risk factors" (892 patients, 47 %), and Cluster 4 ″Middle-aged women with mood disorders, nonrestorative sleep and cardiovascular risk factors" (259 patients, 14 %).

CONCLUSIONS

Conducting a CA exclusively within a female cohort reveals a heterogeneous presentation of OSA in women, similar to what has been previously reported in the literature for men. The "classical" presentation is notably the most prevalent, while the "atypical" presentation, which was previously more frequently associated with women, is less prevalent. Additionally, paucisymptomatic presentations, with or without associated comorbidities, are also present.

Role of Nasal Surgery in Adult Obstructive Sleep Apnea: A Systematic Review

Objective  To perform a systematic review to determine if isolated nasal surgery has any impact on subjective or objective parameters in adult obstructive sleep apnea (OSA) patients. Materials and Methods  From December 2022 to March 2023, we conducted a search on the PubMed, Cochrane, Scopus, and Web of Science databases. Two independent investigators performed a study selection according to the established criteria, as well as data collection, including the study design, the subjective and objective parameters addressed, the type of intervention, and the outcomes, considering the methodological quality and risk of bias. Results  In total, 25 studies met the selection criteria, and they showed that there is a significant improvement in sleep quality, sleepiness, nasal resistance, and snoring after isolated nasal surgery. Still, there is no relevant modification of other polysomnographic parameters. It also reduces the required titration pressures of continuous positive airway pressure (CPAP) and increases the duration of its use. Conclusion  Isolated nasal surgery is not a primary treatment for OSA. Still, it improves the subjective parameters and can lead to CPAP therapy success by enhancing its effectiveness and long-term compliance.

Crossectional Study on the Performance of Screening Questionnaires for Prediction of Moderate to Severe Obstructive Sleep Apnea in Women

Introduction  The clinical manifestations of obstructive sleep apnea (OSA) are different between genders. Though there are several screening questionnaires for OSA, their performance in females is not fully understood, as women have been historically underrepresented in research studies. Objective  To assess the performance of screening questionnaires and their capacity to identify a moderate to severe apnea-hypopnea index (AHI) in women. Materials and Methods  The Epworth sleep scale (ESS), Berlin questionnaire, and STOP-BANG questionnaire (SBQ) were correlated with AHI. Also, the sensitivity (S), specificity (Sp), and area under the receiver operating characteristic (AUC-ROC) curve were calculated for each questionnaire and combinations thereof. Multiple regression models were used to identify ≥15 ev/h AHI. Results  Our study included 5,344 patients: 1978 women (37.1%) aged 55.06 ± 14 years with body mass index (BMI): 32.6 ± 8.30 kg/m 2 , ESS: 7.69 ± 5.2 points, and high-risk Berlin score: 87.25%. An AHI ≥15 ev/h was found in 30.4% of women. In terms of the capacity to identify an ≥15 ev/h AHI in women, the AUC-ROC of ESS >10 and high-risk Berlin was 0.53 and 0.58, respectively. Three components of SBQ in any combination showed: a S of 65.1% (95% CI: 61.2-68.9), a Sp: 61.5% (95% CI: 58.9-64.1), with the AUC-ROC: 0.67. Conclusions  Questionnaires perform differently in women. Therefore, it is necessary to take a gender-specific approach. The SBQ showed a higher discriminative power and more specificity than the ESS and the Berlin questionnaire. The best performance was obtained with any combination of 3 SBQ components. Age, BMI, neck circumference, and hypertension were the strongest predictors.

Personalized Treatment for Obstructive Sleep Apnea: Beyond CPAP

Obstructive sleep apnea (OSA) is a sleep disorder characterized by repetitive episodes of partial or complete obstruction of the upper airway during sleep. Continuous positive airway pressure (CPAP) is a method used as a first-line treatment for obstructive sleep apnea (OSA). However, intolerance and resistance to CPAP can limit its long-term effectiveness. Alternative treatments are available, such as Mandibular Advancement Devices (MADs), positional therapy, upper airway surgery, and maxillomandibular osteotomy. However, often less efficient in reducing the apnea-hypopnea index, the higher tolerance of and compliance to alternative treatment has resulted in the adequate treatment of OSA in CPAP-intolerant patients. This paper describes the protocol of a prospective single-center cohort study including adult patients with moderate to severe OSA (15 events/h ≤ apnea-hypopnea index (AHI) < 65 events/h) that failed to comply with CPAP therapy. Selected patients will be invited to the clinic to explore alternative treatment options where DISE will be a first step in further identifying upper airway collapse during sleep. By exploring alternative treatment options in CPAP-intolerant patients and systematically documenting their treatment paths, an algorithm can be defined to better guide patients towards personalized treatment for OSA. The follow-up is aimed at 5 years with an inclusion of 170 patients per year, including a drop-out rate of 15%. By leveraging a real-world database, this study aims to bridge the gap between research and clinical practice, facilitating the development of evidence-based guidelines and personalized treatment algorithms for CPAP-intolerant patients.

Long-term effect of obstructive sleep apnoea management on blood pressure in patients with resistant hypertension: the SARAH study

BACKGROUND

There is a close relationship between obstructive sleep apnoea (OSA) and resistant hypertension (RH). However, studies assessing the long-term effect of diagnosing and treating OSA on blood pressure (BP) control in these patients are lacking.

METHODS

To address this gap, we recruited 478 RH patients from hypertension units and followed them prospectively after they were screened for OSA through a sleep study. By performing 24-h ambulatory BP monitoring (ABPM) annually, the effect of OSA management was assessed.

RESULTS

The patients had a median (interquartile range (IQR)) age of 64.0 (57.2-69.0) years, 67% were males and most were nonsleepy, with a median (IQR) apnoea-hypopnoea index (AHI) of 15.8 (7.9-30.7) events·h-1. The median (IQR) follow-up time was 3.01 (2.93-3.12) years. At baseline, severe OSA was associated with uncontrolled BP, nocturnal hypertension and a nondipper circadian BP pattern. Moreover, these patients had higher BP values during follow-up than did patients in the other groups. However, among patients with moderate and severe OSA, the management of sleep disordered breathing, including the implementation of continuous positive airway pressure treatment, was associated with a reduction in 24-h ABPM parameters, especially night-time BP values, at the 1-year follow-up. These benefits were attenuated over time and only subjects with severe OSA maintained an ABPM night-time reduction at 3 years. Furthermore, clinical variables such as uncontrolled BP, sex and age showed a predictive value for the BP response at 1 year of follow-up.

CONCLUSION

A favourable long-term decrease in BP was detected by diagnosing and treating OSA in a cohort of RH patients from hypertension units, but over time this decrease was only partially maintained in severe OSA patients.

Characteristics of obstructive sleep apnea related to insulin resistance

BACKGROUND

Obstructive sleep apnea (OSA) is associated with multiple comorbidities, including diabetes. Its development is preceded by alterations in the initial phase of carbohydrate metabolism characterized by insulin resistance. This study aims to evaluate the role of intermittent hypoxia and sleep fragmentation characteristic of OSA on the risk of insulin resistance among apneic patients without diabetes.

METHODOLOGY

92 consecutive patients with OSA without evidence of diabetes were recruited. Overnight video polysomnography was performed and, the following morning, fasting blood glucose, insulin and glycosylated hemoglobin were determined. Insulin resistance was measured using the HOMA-IR index.

RESULTS

Insulin resistance was present in 52.2% of OSA patients. In these subjects, insulin resistance was independently associated to the apnea index during REM sleep (adjusted odds ratio [aOR] 1.09; 95% CI, 1.03 to 1.16; p = 0.004), desaturation index (aOR 1.08; 95% CI: 1.04 to 1.13; p = 0.027), and sleep time with oxygen saturation below 90% (aOR 1.04; 95% CI 1.00 to 1.08; p = 0.049). Furthermore, the HOMA-IR level was also directly related to the desaturation index (standardized regression coefficient [B] = 0.514, p < 0.001) and to the apnea index during REM sleep (B = 0.344, p = 0.002).

CONCLUSIONS

Intermittent hypoxia and disturbances in REM sleep emerge as main contributors to insulin resistance in OSA patients yet to experience diabetes onset.

DISE with CPAP: a useful procedure to evaluate upper airway collapsibility

PURPOSE

Drug-induced sleep endoscopy (DISE) is commonly performed in patients suffering obstructive sleep apnea (OSA) with continuous positive airway pressure (CPAP) intolerance. We aimed to evaluate the effects of adding CPAP to DISE to provide understanding of the reason of its failure and better guidance in future therapeutic decisions.

METHODS

A retrospective observational descriptive study was conducted on CPAP-intolerant patients with moderate-severe OSA. DISE was used to evaluate upper airway collapsibility, and CPAP was tested to better describe anatomical sites of obstruction and to measure the opening pharyngeal pressure.

RESULTS

Sample size consisted of 38 patients with a mean age of 49 ± 9 years. Mean BMI was 28.4 ± 2.4 kg/m2, mean apnea-hypopnea index (AHI) was 35.4 events per hour ± 20.1, and mean saturation under 90% (TSat90) was 14.5%. In DISE we found a collapse at Velum in 92% of patients, at Oropharyngeal level in 89%, at tongue in 42%, and at epiglottis in 36%. In the subgroup of patients with clinical failure with CPAP, we observed 100% of epiglottic collapse and 50% of tongue obstruction. In this specific population, we recommended personalized surgery and myofunctional therapy.

CONCLUSION

DISE-CPAP is a useful tool to select the treatment that better fits to each patient taking care all information available. It improves our ability to prescribe a multilevel treatment with an exhaustive topographic evaluation of upper airway collapsibility that complements CPAP classic titration, and it can be helpful to distinguish better candidates for surgery, myofunctional therapy or CPAP.

Obstructive Sleep Apnea and Oxygenation in Very Old Adults: A Propensity-Score Match Study

OBJECTIVES

The prevalence of obstructive sleep apnea (OSA) escalates with advancing age. Although the apnea-hypopnea index (AHI) is the standard measure for assessing OSA severity, it does not account for additional oximetric parameters that may influence disease progression in older adults. This study aimed to evaluate disparities in respiratory polygraphy/polysomnography parameters among patients with OSA, stratified by age and sex.

DESIGN

Retrospective propensity score-matched study.

SETTING AND PARTICIPANTS

Sleep unit of a university hospital; 11,747 participants, 210 aged 80 years or older.

METHODS

Propensity score matching was used to establish 4 age cohorts, with the 210 oldest adults serving as the reference group. Primary outcome variables included the total sleep time with oxygen saturation (SaO2) below 90% (T90), average SaO2, minimum SaO2, and AHI. The association between T90 and AHI, as well as the severity of OSA, was assessed across the 4 age categories.

RESULTS

Despite comparable AHI scores, the oldest patients with OSA exhibited the highest T90 and the lowest SaO2 levels compared to younger counterparts. The proportion of patients with severe OSA and T90 in the highest quartile increased with age: 12.5% in young adults, 14.8% in adults, 21.7% in the old, and 34% in the very old participants (P < .001). old and very old patients had a greater likelihood of being in the most severe OSA category compared to the younger ones, with odds ratios (OR) 2.57 (95% CI 1.42-4.65) and 5.52 (95% CI 3.06-9.97), respectively. These patterns were more pronounced in women of advanced age, indicating a sex-specific variation in disease severity with increasing age.

CONCLUSIONS AND IMPLICATIONS

Old patients with OSA, particularly women, demonstrate elevated T90 and reduced SaO2 levels, irrespective of AHI, indicating a hypoxemia increased risk. The diagnostic criteria, management, and outcomes for OSA may require adaptations to address the unique needs of very old populations.

Obstructive sleep apnea and cardiovascular risk

Patients with obstructive sleep apnea (OSA) experience repetitive episodes of upper airway obstruction due to recurrent collapse during sleep. This leads to intermittent hypoxia episodes, which, through complex pathophysiological mechanisms, trigger sympathetic overactivation, endothelial dysfunction, hypercoagulation, and metabolic dysregulation. Consequently, other cardiovascular risk factors such as hypertension, metabolic syndrome, and diabetes are induced. Furthermore, this enhances target organ damage, affecting the heart, arteries, and kidneys, leading to an increased risk of cardiovascular morbidity and mortality. Among the various treatments for OSA, Continuous Positive Airway Pressure (CPAP) has been extensively studied. To date, this treatment has shown mild benefits in reducing blood pressure, particularly noticeable in patients with resistant hypertension. Furthermore, CPAP treatment appears to reduce cardiovascular events, both in primary and secondary prevention, though this benefit is limited to individuals with good compliance (CPAP use ≥4h/night). Future research perspectives in OSA seem to focus on identifying patients in whom the condition significantly influences cardiovascular risk, thus determining those who would benefit the most from treatment in the reduction of cardiovascular risk.

Changes in plasma concentrations of novel vascular and inflammatory biomarkers in obstructive sleep apnea patients pre- and post-stroke

BACKGROUND

Obstructive sleep apnea (OSA) is increasingly recognized as a common condition in the general population and causes significant OSA-associated morbidities including cardiovascular and cerebrovascular events such as cerebral small vessel disease (CSVD) and stroke.

METHODS

In this study, using sensitive ELISA immunoassays, we measured subset of endothelial/vascular and inflammatory biomarkers as well as neurofilament light chain (NfL), a sensitive marker for neuroaxonal injury, using plasma from OSA patients post-stroke (Acute Cerebral Infarction (ACI), N = 26) to determine their usefulness as potential prognostic markers in disease progression.

RESULTS

Our results showed significantly increased plasma TNFα and NfL concentrations and decreased concentrations of platelet derived growth factor (PDGF-AA) in post-stroke OSA patients with more severe white matter hyperintensities (WMHs). And after separating the patients based on sex, compared to females, male post-stroke OSA patients with severe WMHs have increased circulating levels of inflammatory chemokine CXCL10 and cytokine Interleukin-10 (IL-10) and significantly decreased levels of Angiopoietin-1 (Ang-1) an important protein responsible for endothelial/vascular integrity functions. Importantly, in a subset of newly diagnosed OSA patients (without prior history of stroke), significantly increased plasma CXCL10 levels and decreased plasma Ang-1 levels were also readily observed when compared to healthy controls, indicating possible altered endothelial integrity and ongoing vascular inflammation in these newly diagnosed OSA patients.

CONCLUSIONS

In summary, our study has identified a novel set of plasma biomarkers including PDGF-AA, CXCL10 and Ang-1 for their potential prognostic value for disease outcomes pre- and post-stroke in OSA patients and use as surrogate markers to measure efficacy of treatment modalities.

Treating sleep-disordered breathing of idiopathic pulmonary fibrosis patients with CPAP and nocturnal oxygen treatment. A pilot study : Sleep-disordered breathing treatment in IPF

INTRODUCTION

Sleep-disordered breathing (SDB) is a major comorbidity in idiopathic pulmonary fibrosis (IPF) and is associated with a poor outcome. There is a lack of knowledge regarding the impact of SDB treatment on IPF. We assessed at one year: (1) the effect of CPAP and/or nocturnal oxygen therapy on IPF regarding lung function, blood mediators, and quality of life; (2) adherence to SDB treatment and SDB changes.

METHODOLOGY

This is a prospective study of consecutive newly diagnosed IPF patients initiating anti-fibrotic treatment. Lung function, polysomnography, blood tests and quality of life questionnaires were performed at inclusion and after one year. Patients were classified as obstructive sleep apnoea (OSA), central sleep apnoea (CSA), and sleep-sustained hypoxemia (SSH). SDB therapy (CPAP and/or nocturnal oxygen therapy) was initiated if needed.

RESULTS

Fifty patients were enrolled (36% had OSA, 22% CSA, and 12% SSH). CPAP was started in 54% of patients and nocturnal oxygen therapy in 16%. At one-year, polysomnography found improved parameters, though 17% of patients had to add nocturnal oxygen therapy or CPAP, while 33% presented SDB onset at this second polysomnography. CPAP compliance at one year was 6.74 h/night (SD 0.74). After one year, matrix metalloproteinase-1 decreased in OSA and CSA (p = 0.029; p = 0.027), C-reactive protein in OSA (p = 0.045), and surfactant protein D in CSA group (p = 0.074). There was no significant change in lung function.

CONCLUSIONS

Treatment of SBD with CPAP and NOT can be well tolerated with a high compliance. IPF patients may exhibit SDB progression and require periodic re-assessment. Further studies to evaluate the impact of SDB treatment on lung function and serological mediators are needed.

Quality assessment of clinical practice guidelines for adult obstructive sleep apnea: A systematic review

OBJECTIVE

Clinical Practice Guidelines (CPGs) are crucial in standardizing the management of obstructive sleep apnea (OSA) in adults. However, there has been insufficient evaluation of the overall quality of CPGs for adult OSA. This review aimed to comprehensively assess the overall quality of CPGs in the field of adult OSA.

METHODS

A systematic search was conducted on various literature databases, guideline-related databases, and academic websites from January 2013 to December 2023 to select CPGs relevant to adult OSA. The methodological and reporting quality of the eligible CPGs were thoroughly appraised by three reviewers using the AGREE II instrument and RIGHT checklist, respectively.

RESULTS

This review included 44 CPGs, consisting of 42 CPGs in English and 2 CPGs in Chinese. The assessment of methodological quality revealed that four domains attained an average standardized score above 60%. Among the domains, "clarity of presentation" received the highest standardized score of 85.10%, while the lowest standardized score was observed in the "rigor of development" domain with the value of 56.77%. The evaluation of reporting quality indicated an overall reporting rate of 51.30% for the eligible CPGs, with only three domains achieving an average reporting rate higher than 50%. The domain with the highest reporting rate was "basic information" at 60.61%, while the domain with the lowest reporting rate was "review and quality assurance" at 15.91%. Furthermore, a significantly positive correlation was found between the AGREE II standardized scores and the RIGHT reporting rates (r = 0.808, P < 0.001).

CONCLUSIONS

The overall quality of the currently available guidelines for adult OSA demonstrated considerable variability. Researchers should prioritize the utilization of evidence-based methods and adhere to the items listed in the RIGHT checklist when developing CPGs to enhance efficient clinical decision-making and promote the translation of evidence into practice.

The Association of Serum Uric Acid with Risk of Obstructive Sleep Apnea: The Korean National Health and Nutrition Examination Survey 2019-2021

Upper airway collapse and apneas in obstructive sleep apnea (OSA) induce intermittent hypercapnia and hypoxia, eventually contributing to excessive uric acid production. This study aimed to evaluate the association between hyperuricemia and OSA in the general population via analysis of the eighth KNHANES dataset (2019-2021). OSA risk was identified via the STOP-Bang questionnaire, with a score ≥3 indicating high risk. Among 11,981 total participants, 4572 (38.2%) had a high OSA risk. Participants with a high OSA risk had higher uric acid levels compared to those with a low risk (5.5 ± 1.4 mg/dL vs. 4.8 ± 1.2 mg/dL, p < 0.001). Serum uric acid levels were positively correlated with STOP-Bang score (r: 0.317, p < 0.001). Multivariate analysis revealed that hyperuricemia was associated with a high OSA risk after adjusting for confounders (odds ratio: 1.30, 95%CI: 1.11-1.53, p = 0.001). Therefore, serum uric acid levels are significantly higher in those with a high OSA risk and correlate with the risk of OSA. Further, hyperuricemia is an independently associated risk factor for high OSA risk. More research is warranted to evaluate the long-term clinical outcomes of hyperuricemia in OSA and to determine whether treatment targeting hyperuricemia is effective in the clinical course of OSA.

Comparing efficacy of the mandibular advancement device after drug-induced sleep endoscopy and continuous positive airway pressure in patients with obstructive sleep apnea

PURPOSE

The purpose of this study was to compare objective and self-reported outcomes of two treatments for managing mild, moderate, and severe obstructive sleep apnea (OSA) in adults: a mandibular advancement device (MAD) and continuous positive airway pressure (CPAP).

METHODS

Patients diagnosed with OSA by means of polysomnography (PSG) included one group treated with a custom-made, two-piece, adjustable MAD and a second group treated with CPAP for 8 weeks. Before the initiation of the treatment, all patients assigned to MAD underwent drug-induced sleep endoscopy (DISE), and all CPAP group patients underwent manual titration of CPAP after PSG. Objective (PSG) and self-reported (Epworth Sleepiness Scale [ESS] and Short Form Health Survey [SF-36]) data were used to assess outcomes. Collected data included apnea-hypopnea index (AHI), mean capillary oxygen saturation (SpO2), oxygen desaturation index (ODI), arousal index (AI), degree of daytime sleepiness, and quality of life. A PSG follow-up after 8 weeks with MAD in situ, and data from the CPAP data card were used to assess the effect of the two treatments.

RESULTS

A total of 59 patients included 30 treated with MAD and 29 treated with CPAP. Between baseline and the 8-week follow-up, the mean AHI score decreased significantly from 35.1 to 6.8 episodes/h (p < 0.001) in patients treated with MAD and from 35.2 to 3.0 episodes/h (p < 0.001) in patients treated with CPAP. The mean AHI score at the 8-week follow-up was significantly lower in CPAP group than in MAD group (p = 0.003). The two groups did not differ significantly at follow-up regarding SpO2 (p = 0.571), ODI (p = 0.273), AI (p = 0.100), ESS score (p = 0.648), and SF-36 score (p = 0.237).

CONCLUSION

In the short term, patients on CPAP attained better PSG outcomes in terms of AHI reduction. Both MAD after DISE evaluation and CPAP resulted in similar improvements in clinical symptoms and health-related quality of life, even in patients with severe OSA.

[Relationship between obstructive sleep apnea and type 2 diabetes mellitus]

INTRODUCTION

The association between obstructive sleep apnea (OSA) and glucose metabolism remains controversial. This study investigates the relationship between OSA and incident type 2 diabetes (DM) and prediabetes (preDM), as well as the effect of long-term CPAP (continuous positive airway pressure) treatment.

METHODS

Follow-up study in a retrospective clinical cohort of patients with OSA and randomly selected controls. Data on incident DM and preDM as well as CPAP were obtained from hospital records. The relationship between baseline OSA and incident DM was examined using COX regression models.

RESULTS

Three hundred and fifty-six patients, 169 with OSA and 187 controls were followed for a median of 98 months; 47 patients (13.2%) developed DM and 43 (12.1%) developed preDM. The 5-year cumulative incidence of DM was 10.7% (6.5-13.9%). 87% of subjects with preDM in the baseline sample progressed to incident DM. It is shown that body mass index (BMI), nocturnal hypoxia and apnea hypopnea index (AHI) are risk factors for the development of DM and that CPAP reduces this risk.

CONCLUSIONS

Patients with OSA have a higher risk of developing DM. The risk factors involved are BMI, nocturnal hypoxia and AHI. Regular long-term CPAP use was associated with a decreased risk.

[Home Respiratory Therapies: SEPAR Technical Document for Institutional Decision Support]

Home Respiratory Therapies (HRT) encompass a variety of treatments for patients with chronic respiratory diseases, administered at home over extended periods. The Service Providers of HRT (SPHRT) collaborate with hospital resources to address chronic respiratory diseases, acting as strategic partners. The contracting of HRT in the public health system involves contests where the SPHRT present technical and economic offers. The purpose of this document is to provide a technical basis that can assist professionals, SPHRT, and the administration in making decisions when calling for, evaluating, and deciding on such contests.

Dysregulation in CD39/CD73 Axis May Trigger the Upsurge of the Immune Suppressive Agent Adenosine in OSA Patients

INTRODUCTION

Although higher incidence of cancer represents a major burden for obstructive sleep apnea (OSA) patients, the molecular pathways driving this association are not completely understood. Interestingly, adenosinergic signaling has emerged as a powerful immune checkpoint driving tumor development and progression.

METHODS

Here, we explored the expression of the adenosinergic ecto-enzymes CD39 and CD73 in T-lymphocytes of OSA patients without any evidence of cancer, as well as their soluble forms in plasma (sCD39 and sCD73), along with adenosine. In addition, we explored the role of intermittent hypoxia (IH) in this context by in vitro models.

RESULTS

Our results showed that CD39 is upregulated while CD73 is downregulated in OSA T-cells' membrane. Moreover, our findings suggest that IH, through HIF-1, mediates the upregulation of both CD39 and CD73; and that CD73 downregulation could be mediated by a higher release of sCD73 by OSA T-lymphocytes. Importantly, we found that both sCD39 and sCD73 are upregulated in OSA plasma, suggesting T-lymphocytes as a potential source for plasmatic sCD73. Finally, our data propose the alterations in CD39/CD73 axis could underlie the upsurge of adenosine levels in the plasma of OSA patients.

CONCLUSION

Our study reveals a hypoxia-mediated alteration of the CD39/CD73 axis in OSA patients, which could trigger ADO upregulation, thus potentially contributing to the immune suppressive environment and ultimately facilitating tumor development and progression. Therefore, our data highlights the need for new longitudinal studies evaluating CD39 and/or CD73 as potential cancer-risk prognostic biomarkers in OSA patients.

Correlation between polysomnographic parameters and volumetric changes generated by maxillomandibular advancement surgery in patients with obstructive sleep apnea: a fluid dynamics study

STUDY OBJECTIVES

Maxillomandibular advancement surgery (MMA) is a therapeutic option for obstructive sleep apnea (OSA). The main objective of this study was to determine the impact of MMA on the physical and airflow characteristics of the upper airway based on data obtained by computational fluid dynamics (CFD) and to correlate these data with polysomnography parameters. Other objectives included the identification of presurgical variables that could help avoid surgeries likely to have a low success rate.

METHODS

This was a retrospective observational study of 18 patients with moderate-severe OSA who underwent MMA. Polysomnography and computed axial tomography imaging were performed before and after the surgery. Three-dimensional models for CFD study were made based on the images obtained.

RESULTS

MMA achieved an average increase in airway volume of 43.75%, with a mean decrease in the maximum airway velocity of 40.3%. We found significant correlations between improved apnea-hypopnea index values and both the increase in airway volume and decrease in maximum airway speed. Patients with a maximum velocity of less than 7.2 m/s before the intervention had a high rate of surgical failure (43%).

CONCLUSIONS

MMA generates a significant increase in the volume of the upper airway, which was associated with improved flow conditions in the CFD simulation. These findings also correlated with improved polysomnography parameters. Thus, CFD simulation on three-dimensional anatomical models of patients with OSA could contribute to the better selection of candidates for MMA.

CITATION

Furundarena-Padrones L, Cabriada-Nuño V, Brunsó-Casellas J, et al. Correlation between polysomnographic parameters and volumetric changes generated by maxillomandibular advancement surgery in patients with obstructive sleep apnea: a fluid dynamics study. J Clin Sleep Med. 2024;20(3):371-379.

Modifications in Upper Airway Collapsibility during Sleep Endoscopy with a Mandibular Positioner: Study in Snorers and Obstructive Sleep Apnea Patients

BACKGROUND

Mandibular advancement devices (MADs) are an effective treatment for patients with sleep-related breathing disorders, with variable response. Increasingly more research points to the predictive value of Drug-Induced Sleep Endoscopy (DISE) in patient selection. This study aims to analyze the changes in upper airway collapsibility using a titratable MAD simulator during DISE.

METHODS

This study included 104 patients with simple snoring and obstructive sleep apnea (OSA). The VOTE scale was used to assess the presence of collapses during the DISE both without and with the MAD simulator.

RESULTS

In snorers, there was a decrease in collapses at the level of the soft palate and oropharynx when the advancement was achieved. Patients with mild OSA also showed a decrease in collapses at the base of the tongue. Patients with moderate/severe OSA exhibited significant amelioration at all levels. The levels at which there were residual collapses despite the maneuver were, in order, the velopharynx, oropharynx, epiglottis, and tongue.

CONCLUSIONS

The MAD simulator reduces collapsibility at all levels and in all severity groups. Residual collapses suitable for combined treatments were able to be identified. This highlights the need for individualized patient selection, as upper airway collapsibility exhibits variable improvement or worsening with the MAD simulator regardless of the severity of the condition.

Use of Ultrasound to Verify the Impact of Telemedicine Myofunctional Therapy on Sleep Apnea Syndrome: Study Protocol Proposal

The anatomy of the upper airways influences the risk of obstructive sleep apnea (OSA). The size of soft tissue structures, such as the tongue, soft palate, and lateral walls of the pharynx, contributes to the pathogenesis of OSA. New lines of treatment for sleep apnea, such as myofunctional therapy (MT), aim to strengthen the oropharyngeal musculature to improve the defining parameters of apnea. The present protocol uses ultrasound imaging to measure the size of the lingual musculature non-invasively and cost-effectively and evaluates the changes in its morphology. Eligible patients include those with OSA who have undergone submental cervical ultrasound and drug-induced sleep endoscopy before starting MT with the AirwayGym app. Follow-up evaluations are conducted at 3 months after beginning treatment. Patients diagnosed with OSA via questionnaires and polysomnography or respiratory polygraphy are evaluated anatomically and functionally using the Iowa Oral Performance Instrument, a tongue digital spoon, somnoscopy, and submental cervical ultrasound to assess their responses to the AirwayGym app. The lingual thickness (mm) and volume (cm3) and the distance between both lingual arteries (mm) are measured. The AirwayGym app helps users and therapists monitor the patient performance of MT. Incorporating submental ultrasound can be a useful non-invasive tool to evaluate OSA and MT.

[Diabetes and obstructive sleep apnoea: A case-control study]

INTRODUCTION

Obstructive sleep apnoea (OSA) and diabetes mellitus (DM) are very prevalent diseases frequently associated. Their coexistence is independently associated with an increased prevalence of cardiovascular comorbidities. As this association is underdiagnosed, it is necessary to optimise clinical suspicion by studying independent predictors of DM or prediabetes (preDM) in patients with OSA.

METHOD

A simple randomised case-control study, matched for sex, body mass index (BMI) and age, aimed to study the association of OSA with DM and preDM and to identify independent predictors for both diseases in people with OSA.

RESULTS

We included 208 cases with OSA and 208 controls without OSA. In the former, 18.8% had DM compared to only 10.1% in the latter (P=.00). Prevalence of preDM was 41.8% vs. 10.6%, respectively (P=.00). One hundred and twenty-four cases (59.6%) reported excessive daytime sleepiness (EDS) (Epworth scale, 10.5±3.1) vs. 24.5% of the control group (Epworth scale, 6.6±2.9). Apnoea-hypopnoea index (AHI) and O2 desaturation indices (IDO, CT90 and CT80) were significantly higher in the case group. The risk of MD was related to age, nocturnal hypoxaemia and EDS. The risk of pre-MD was related to BMI and AHI.

CONCLUSIONS

OSA is associated with DM and preDM. Age, nocturnal hypoxaemia and EDS are predictors of DM. BMI and AHI are predictors of pre-MD.

Sleep apnoea increases biomarkers of immune evasion, lymphangiogenesis and tumour cell aggressiveness in high-risk patients and those with established lung cancer

Background

Intermittent hypoxaemia and obstructive sleep apnoea (OSA) have been linked to lung cancer through as yet unidentified pathophysiological mechanisms. This study evaluates the effect of OSA on serum levels of biomarkers of immunosurveillance, lymphangiogenesis and intrinsic tumour cell aggressiveness in high-risk individuals screened for lung cancer and patients with established lung cancer.

Methods

Serum samples from individuals participating in a lung cancer screening cohort (SAILS study) or with newly diagnosed lung cancer (SAIL study) were analysed. All patients underwent home sleep apnoea testing. Soluble levels of programmed cell death-1 (PD-1), programmed cell death ligand-1 (PD-L1), cytotoxic T-lymphocyte antigen-4, midkine (MDK), paraspeckle component-1 (PSPC1), transforming growth factor-β1 (TGF-β1), SMAD3, matrix metalloproteinase-2 and co-stimulus receptor of the tumour necrosis factor family of receptors (CD137) were determined by ELISA.

Results

The presence of moderate-to-severe OSA was associated with increased levels of PSPC1, MDK, PD-L1 and PD-1 in screened individuals, and with higher values of PSPC1, TGF-β1, PD-L1 and PD-1 in patients with established lung cancer. The findings correlated with nocturnal intermittent hypoxaemia indices.

Conclusion

Moderate-to-severe OSA is associated with increased expression of serum biomarkers of immune evasion, lymphangiogenesis and tumour cell aggressiveness in high-risk individuals screened for lung cancer and those with established disease.

Application study of apnea-hypopnea duration for assessing adult obstructive sleep apnea

BACKGROUND

Obstructive sleep apnea (OSA) is a common sleep disordered breathing disorder, which can cause serious damage to multiple human systems. Although polysomnography (PSG) is the current gold standard for diagnosis, it is complex and expensive. Therefore, it is of great significance to find a simple, economical and rapid primary screening and diagnosis method to replace PSG for the diagnosis of OSA.

OBJECTIVE

The purpose of this study is to propose a new method for the diagnosis and classification of OSA, which is used to automatically detect the duration of sleep apnea hypopnea events (AHE), so as to estimate the ratio(S) of the total duration of all-night AHE to the total sleep time only based on the sound signal of sleep respiration, and to identify OSA.

METHODS

We performed PSG tests on participants and extracted relevant sleep breathing sound signal data. This study is carried out in two stages. In the first stage, the relevant PSG report data of eligible subjects were recorded, the total duration of AHE in each subject's data was extracted, and the S value was calculated to evaluate the severity of OSA. In the second stage, only the sleep breath sound signal data of the same batch of subjects were used for automatic detection, and the S value in the sleep breath sound signal was extracted, and the S value was compared with the PSG diagnosis results to calculate the accuracy of the experimental method.

RESULTS

Among 225 subjects. Using PSG as the reference standard, the S value extracted from the PSG diagnostic data report can accurately diagnose OSA(accuracy rate 99.56%) and distinguish its severity (accuracy rate 95.11%). The accuracy of the S value detected in the sleep breathing sound signal in the diagnosis of severe OSA reached 100%.

CONCLUSION

The results show that the experimental parameter S value is feasible in OSA diagnosis and classification. OSA can be identified and evaluated only by sleep breathing sounds. This method helps to simplify the diagnostic grading of traditional OSA and lays a foundation for the subsequent development of simple diagnostic grading equipment.

Asthma and obstructive sleep apnea: Unveiling correlations and treatable traits for comprehensive care

Asthma and obstructive sleep apnea (OSA) are common respiratory disorders. They share characteristics such as airway obstruction, poor sleep quality, and low quality of life. They are often present as comorbidities, along with obesity, gastroesophageal reflux disease (GERD), and allergic rhinitis (AR), which impacts the disease's control. In recent years, there has been discussion about the association between these conditions and their pathophysiological and clinical consequences, resulting in worse health outcomes, increased healthcare resource consumption, prolonged hospital stays, and increased morbidity and mortality. Some studies demonstrate that treatment with continuous positive airway pressure (CPAP) can have a beneficial effect on both pathologies. This review summarizes the existing evidence of the association between asthma and OSA at their pathophysiological, epidemiological, clinical, and therapeutic levels. It intends to raise awareness among healthcare professionals about these conditions and the need for further research.

Role of Sleep Apnea and Long-Term CPAP Treatment in the Prognosis of Patients With Melanoma: A Prospective Multicenter Study of 443 Patients

BACKGROUND

OSA has been associated with increased incidence and aggressiveness of melanoma. However, the long-term impact of OSA and CPAP treatment on the prognosis of melanoma remains unexplored.

RESEARCH QUESTION

Are OSA and CPAP treatment associated independently with a poor prognosis for cutaneous melanoma?

STUDY DESIGN AND METHODS

Four hundred forty-three patients with a diagnosis of cutaneous melanoma (2012-2015) underwent a sleep study within 6 months of diagnosis. The main 5-year outcome of the study was a composite of melanoma recurrence, metastasis, or mortality. Patients were divided into four groups: baseline apnea-hypopnea index (AHI) of fewer than 10 events/h (no OSA; control group), OSA treated with CPAP and good adherence, untreated or poor CPAP adherence in moderate (AHI, 10-29 events/h), and severe OSA (AHI, ≥ 30 events/h). Survival analysis was used to determine the independent role of OSA and CPAP treatment on melanoma composite outcome.

RESULTS

Three hundred ninety-one patients (88.2%) were available for analysis at 5-year follow-up (mean age, 65.1 ± 15.2 years; 49% male; Breslow index, 1.7 ± 2.5 mm). One hundred thirty-nine patients had AHI of fewer than 10 events/h (control group); 78 patients with OSA were adherent to CPAP; and 124 and 50 patients had moderate and severe OSA, respectively, without CPAP treatment. Median follow-up was 60 months (interquartile range, 51-74 months). During follow-up, 32 relapses, 53 metastases, and 52 deaths occurred (116 patients showed at least one of the main composite outcomes). After adjusting for age, sex, sentinel lymph nodes affected at diagnosis, BMI, diabetes, nighttime with an oxygen saturation below 90%, Breslow index, Epworth sleepiness scale scores, and melanoma treatment, moderate (hazard ratio [HR], 2.45; 95% CI, 1.09-5.49) and severe OSA (HR, 2.96; 95% CI, 1.36-6.42) were associated with poorer prognosis of melanoma compared with the control group. However, good adherence to CPAP avoided this excess risk (HR, 1.66; 95% CI, 0.71-3.90).

INTERPRETATION

Moderate to severe untreated OSA is an independent risk factor for poor prognosis of melanoma. Treatment with CPAP is associated with improved melanoma outcomes compared with untreated moderate to severe OSA.

Seasonal influence on sleep apnoea recorded daily by pacemakers

PURPOSE

Obstructive sleep apnoea (OSA) and cardiac conduction disorders are pathologies with a rising prevalence due to increased life expectancy. Upper airway patency is affected by environmental factors that may be associated with seasonal periods. The ability to record the degree of nocturnal apnoea on a daily basis may provide a more accurate picture of seasonal variability.

METHODS

This study used an observational, cross-sectional design recruiting consecutive patients with Sorin/Livanova/Microport® pacemakers. The study assessed the seasonal influence on the daily degree of nocturnal apnoea over a minimum period of 180 days. The respiratory events were recorded using a pacemaker-integrated detection algorithm based on transthoracic impedance variation. A generalised linear repeated measure mixed model was used to study the seasonal effect.

RESULTS

A sample of 101 subjects with a mean of 227 valid nights was compiled. Summer was associated with higher RDI (respiratory disturbance index) values and winter with lower values. The mean daily RDI ratio in summer was 1.099 times higher than in winter.

CONCLUSIONS

Slight seasonal influences on the degree of nocturnal apnoea were detected through the daily observation of an unselected sample of pacemaker wearers. The degree of apnoea is higher in warmer months and lower in colder months.

Hypoxic burden to guide CPAP treatment allocation in patients with obstructive sleep apnoea: a post hoc study of the ISAACC trial

BACKGROUND

Hypoxic burden (HB) has emerged as a strong predictor of cardiovascular risk in obstructive sleep apnoea (OSA). We aimed to assess the potential of HB to predict the cardiovascular benefit of treating OSA with continuous positive airway pressure (CPAP).

METHODS

This was a post hoc analysis of the ISAACC trial (ClinicalTrials.gov: NCT01335087) including non-sleepy patients with acute coronary syndrome (ACS) diagnosed with OSA (apnoea-hypopnoea index ≥15 events·h-1) by respiratory polygraphy. Patients were randomised to CPAP or usual care and followed for a minimum of 1 year. HB was calculated as the total area under all automatically identified desaturations divided by total sleep time. Patients were categorised as having high or low baseline HB according to the median value (73.1%min·h-1). Multivariable Cox regression models were used to assess whether the effect of CPAP on the incidence of cardiovascular outcomes was dependent on the baseline HB level.

RESULTS

The population (362 patients assigned to CPAP and 365 patients assigned to usual care) was middle-aged (mean age 59.7 years), overweight/obese and mostly male (84.5%). A significant interaction was found between the treatment arm and the HB categories. In the high HB group, CPAP treatment was associated with a significant reduction in the incidence of cardiovascular events (HR 0.57, 95% CI 0.34-0.96). In the low HB group, CPAP-treated patients exhibited a trend toward a higher risk of cardiovascular outcomes than those receiving usual care (HR 1.33, 95% CI 0.79-2.25). The differential effect of the treatment depending on the baseline HB level followed a dose-response relationship.

CONCLUSION

In non-sleepy ACS patients with OSA, high HB levels were associated with a long-term protective effect of CPAP on cardiovascular prognosis.

Changes in sleep-disordered breathing from the acute to the stable phase of pulmonary embolism: The ESAET study

BACKGROUND

/Objective: Sleep-disordered breathing (SDB) may change from the acute to stable phase of some cardiovascular disorders, but little is known whether these dynamic changes also exist in pulmonary embolism (PE). This study aimed to analyze the changes in the apnea-hypopnea index (AHI) from the acute to stable phase of PE as well as the factors associated.

PATIENTS/METHODS

We conducted a prospective, longitudinal and multicenter study of consecutive adults requiring hospitalization for non-hypotensive acute PE, with a protocol including clinical, imaging (transthoracic echocardiography [TTE] and computed tomography), blood tests and a sleep study within 48 h of diagnosis of PE. After 3 months of follow-up, the sleep study was repeated. Right ventricular (RV) dysfunction was defined according to TTE criteria.

RESULTS

One hundred and eleven patients (mean age [SD]: 63 [15] years; body mass index: 28.4 [4.7] kg/m2) were included. The initial AHI was 24.4 (21.8) events/h (AHI≥5: 82.8 %; AHI≥30: 33.3 %). Seventy-seven patients (69.4 %) had RV dysfunction. In the overall cohort, the AHI decreased by 8.7 events/h from the acute to stable phase (24.4/h vs. 15.7/h; p=0.013). Patients with RV dysfunction showed a greater decrease in AHI (mean decrease 12.3/h vs. 0.43/h). In the multivariable analysis a drop of an AHI≥5 events/hour was independently associated with the presence of initial RV dysfunction (hazard ratio 3.9; 95%CI 1.3 to 12.1).

CONCLUSIONS

In hemodynamically stable patients with acute PE, there is a transient but clinically significant decrease in the AHI from the acute to stable phase, particularly when initially presenting with RV dysfunction.

Metabolipidomic Analysis in Patients with Obstructive Sleep Apnea Discloses a Circulating Metabotype of Non-Dipping Blood Pressure

A non-dipping blood pressure (BP) pattern, which is frequently present in patients with obstructive sleep apnea (OSA), confers high cardiovascular risk. The mechanisms connecting these two conditions remain unclear. In the present study we performed a comprehensive analysis of the blood metabolipidome that aims to provide new insights into the molecular link between OSA and the dysregulation of circadian BP rhythmicity. This was an observational prospective longitudinal study involving adults with suspected OSA who were subjected to full polysomnography (PSG). Patients with an apnea-hypopnea index ≥ 5 events/h were included. Fasting plasma samples were obtained the morning after PSG. Based on the dipping ratio (DR; ratio of night/day BP values) measured via 24 h ambulatory BP monitoring, two groups were established: dippers (DR ≤ 0.9) and non-dippers (DR > 0.9). Treatment recommendations for OSA followed the clinical guidelines. Untargeted metabolomic and lipidomic analyses were performed in plasma samples via liquid chromatography-tandem mass spectrometry. Non-dipper patients represented 53.7% of the cohort (88/164 patients). A set of 31 metabolic species and 13 lipidic species were differentially detected between OSA patients who present a physiologic nocturnal BP decrease and those with abnormal BP dipping. Among the 44 differentially abundant plasma compounds, 25 were putatively identified, notably glycerophospholipids, glycolipids, sterols, and fatty acid derivates. Multivariate analysis defined a specific metabotype of non-dipping BP, which showed a significant dose-response relationship with PSG parameters of OSA severity, and with BP dipping changes after 6 months of OSA treatment with continuous positive airway pressure (CPAP). Bioinformatic analyses revealed that the identified metabolipidomic profile was found to be implicated in multiple systemic biological pathways, with potential physiopathologic implications for the circadian control of BP among individuals with OSA.

A Multicenter Prospective Study on the Use of a Mandibular Advancement Device in the Treatment of Obstructive Sleep Apnea

The main objective of this prospective study was the evaluation of 1 mm step titration of mandible advancement in the success of treating obstructive sleep apnea (OSA). For that, a multicenter prospective study was designed to recruit patients with OSA who were eligible to receive a mandibular advancement device. Gradual titration of mandibular advancement (steps of 1 mm) from maximum intercuspidation was performed to determine the optimal mandibular advancement (highest reduction in the apnea-hypopnea index (AHI)). The principal variable was the percentage of patients where a reduction ≥50% of the AHI was achieved at the end of the titration phase. A total of 102 patients participated in this study. Fifty-six percent of the participants were males and 67% had a BMI ≥ 25 kg/m2. Most of the patients (79%) had an age ≥ 50 years and the majority (74%) were either non-smokers or ex-smokers. Excessive daytime sleepiness was reported by 40% of the patients. The mean AHI at baseline was 20.6 ± 12.7 events/h. The mean advancement of the mandible was 3.1 ± 1.6 mm. The device achieved a reduction in the AHI in 93% of the patients and success (≥50% reduction in the AHI) in 69% of the patients. Success was achieved in 50%, 81.6%, and 73.3% of the patients with mild, moderate, and severe OSA, respectively. Decreasing the magnitude of mandibular advancement could be possible by controlling the vertical mouth opening and step-by-step titration.

Impact of obstructive sleep apnea in cardiovascular risk in the pediatric population: A systematic review

While the association of obstructive sleep apnea (OSA) with an increased cardiovascular risk (CVR) in the adult population is well known, there is insufficient evidence to affirm something similar in the pediatric population. On the other hand, adenotonsillectomy has been shown to be an effective treatment. Our objective was to evaluate the association of sleep respiratory disorders in children with increased CVR and the impact of adenotonsillectomy in the literature. To this aim, a literature search was conducted, between 2002 to the present. After carrying out a systematic review, the following results were provided: thoracic echocardiography after surgery found improvements in terms of cardiac function and structure; blood pressure (BP) measurement, verified a tendency to higher BP values in the OSA pediatric population, which improved after surgery; different biomarkers of CVR, were increased in OSA patients and improved after treatment and finally; some studies found endothelial dysfunction in pediatric OSA, a measurement of vascular system function, was reversible with adenotonsillectomy. Increases in BP parameters, biological markers related to CVR and alterations in cardiac function structure, have been reported in pediatric patients with OSA. At least, some of these parameters would be reversible after adenotonsillectomy, reflecting a possible reduction in CVR.

Use of Telemonitoring for CPAP Therapy Control in OSA Patients: Impact on Cost and Process Improvements

Introduction

In Spain, 2 million people are treated for obstructive sleep apnoea. Continuous positive airway pressure, the gold-standard therapy, requires regular follow-up and periodic evaluation of the efficacy of the treatment via a titration examination, i.e. autoCPAP test. Telemonitoring use is increasing and this study aims to evaluate the cost impact of its use for therapy evaluation instead of the standard ambulatory autoCPAP test.

Methods

This prospective observational study includes 100 OSA patients under CPAP therapy who volunteered to test telemonitoring as an alternative therapy control tool. Costs for both the patients and the Sleep Unit were calculated and compared for the standard of care (ambulatory autoCPAP (SoC)), vs alternative telemonitoring option (TM).

Results

More than half (54%) of the patients preferred the TM option vs only 47.5% of the SoC patients. Patients inclining towards telemonitoring option were mainly reported to be more than 10 years youngers, mainly active workers (63%), travelling more distance to the Sleep Unit (16 vs 8 km) and spending more expenses in travel than those who preferred SoC (median 30€). 29% of active workers left their jobs to attend the SoC. The costs related to the use of the Sleep Unit resources were found to be lower in the TM option compared to the SoC option (0.47 vs 3.09 euros per patient attended).

Conclusions

The use of TM for follow-up CPAP therapy enables the patient to save travel costs and to reduce absenteeism but also to save assistential burden and therefore to reduce the Sleep Unit workload and optimize the care activity.

Improved Quality of Life After Mandibular Advancement by Bilateral Internal Ramus Distraction

BACKGROUND

Obstructive Sleep Apnea (OSA) is a significant health issue due to noncompliance with continuous positive airway pressure treatment. Therefore, evaluating alternative treatments is crucial.

PURPOSE

Analyze the impact of maxillomandibular advancement using bilateral internal ramus distraction (BIRD) on quality of life (QOL) in OSA patients.

STUDY DESIGN, SETTING, AND SAMPLE

A prospective cohort study was conducted at the Oral and Maxillofacial Surgery Department of the University Hospital "La Princesa." The study included patients with moderate to severe OSA who were treated with the BIRD approach.

PREDICTOR VARIABLE

Changes in measured variables were analyzed at three time points: before surgery (T1), after mandibular advancement (T2), and after maxillary advancement (T3).

MAIN OUTCOME VARIABLE(S)

QOL changes measured by Quebec Sleep Questionnaire and the Epworth Sleepiness Scale. Secondary outcomes included: apnea-hypopnea index (AHI), oxygen desaturation index, and percentage of time with saturation below 90%.

COVARIATES

Age, sex, continuous positive airway pressure treatment, cephalometric variables and cardiovascular risk parameters were considered.

ANALYSES

Statistical analysis employed the Friedman test and χ2 test, with a significance level of P ≤ .05.

RESULTS

The study included 32 patients (22% with moderate OSA, 78% with severe OSA). Epworth Sleepiness Scale scores significantly decreased between T1 (13.4 ± 4.4) and T2 (5.8 ± 3.6) and T3 (1.9 ± 1.8) (P < .001). QOL improvements were observed in all domains: daytime sleepiness T1 (3.0 ± 1.3) T2 (5.4 ± 1.4) T3 (6.3 ± 1.0); diurnal symptoms T1 (2.5 ± 1.4) T2 (5.2 ± 1.3) T3 (6.2 ± 1.1); nocturnal symptoms T1 (2.5 ± 1.1) T2 (5.6 ± 1.1) T3 (6.5 ± 0.8); emotions T1 (2.6 ± 1.6) T2 (5.3 ± 1.4) T3 (6.5 ± 0.9); and social interaction T1 (2.5 ± 1.6) T2 (5.4 ± 1.6) T3 (6.3 ± 1.2) (P < .001). AHI decreased between T1 (47.9 ± 23.1) and T2 (14.4 ± 14.3) and T3 (4.7 ± 5.6) h-1 (P < .001), with a final cure rate of 81.2% (defined as final AHI<5 h-1). Oxygen desaturation index and percentage of time with saturation below 90% also showed significant reductions (P < .001).

CONCLUSIONS AND RELEVANCE

BIRD approach for OSA demonstrated a high cure rate and significant QOL improvements. It shows promise as an effective surgical option. Further research and long-term follow-up are needed.

Proposal of a diagnostic algorithm based on the use of pulse oximetry in obstructive sleep apnea

PURPOSE

The aims of this study were to assess the cut-off values for oxygen desaturation index ≥ 3% (ODI3) to confirm obstructive sleep apnea (OSA) in subjects undergoing polysomnography (PSG) and home-based respiratory polygraphy (RP), and to propose an algorithm based on pulse oximetry (PO) for initial management of patients with suspected OSA.

METHODS

This was an observational, cross-sectional, retrospective study. ODI3 was used to classify subjects as healthy (no OSA = AHI < 5 or < 15 events/h) or unhealthy (OSA = AHI ≥ 5 or ≥ 15 events/h). On the PSG or experimental group (Exp-G), we determined ODI3 cut-off values with 100% specificity (Sp) for both OSA definitions. ODI3 values without false positives in the Exp-G were applied to a validation group (Val-G) to assess their performance. A strategy based on PO was proposed in patients with suspected OSA.

RESULTS

In Exp-G (PSG) 1141 patients and in Val-G (RP) 1141 patients were included. In Exp-G, ODI3 > 12 (OSA = AHI ≥ 5) had a sensitivity of 69.5% (CI95% 66.1-72.7) and Sp of 100% (CI95% 99-100), while an ODI3 ≥ 26 had a 53.8% sensitivity (CI95% 49.3-58.2) and Sp of 100% (CI95% 99.4-100) for AHI ≥ 15. A high pretest probability for OSA by Berlin questionaire (≥ 2 categories) had a lower diagnostic performance than by STOP-BANG questionnaire ≥ 5 points (AHI ≥ 5: 0.856 vs. 0.899, p < 0.001; AHI ≥ 15: 0.783 vs. 0.807, p 0.026).

CONCLUSION

We propose the initial use of PO at home in cases of moderate-to-high pretest probability of OSA. This algorithm considers PO as well as RP and PSG for more challenging cases or in case of doubt.

Adipokines and Inflammatory Markers in Acute Myocardial Infarction Patients with and without Obstructive Sleep Apnea: A Comparative Analysis

An association has been suggested between acute myocardial infarction (AMI) and obstructive sleep apnea (OSA). Considering the role of adipose-tissue-derived inflammatory mediators (adipokines) and the shared risk factor of obesity in OSA and AMI, this study aimed to investigate the involvement of adipokines in AMI patients with and without OSA. Serum levels of adipokines and inflammatory mediators were quantified, and home respiratory polygraphy was conducted. A total of 30 AMI patients and 25 controls were included. Patients with AMI exhibited elevated levels of resistin (7.4 vs. 3.7 ng/mL), interleukin-6 (8.8 vs. 1.3 pg/mL), and endothelin-1 (3.31 vs. 1.8 pg/mL). Remarkably, AMI patients with concomitant OSA exhibited higher levels of resistin (7.1 vs. 3.7 ng/mL), interleukin-6 (8.9 vs. 1.3 pg/mL), endothelin-1 (3.2 vs. 1.8 pg/mL), creatin kinase (1430 vs. 377 U/L), creatine kinase-MB (64.6 vs. 9.7 ng/mL), and troponin T (2298 vs. 356 pg/mL) than their non-OSA counterparts. Leptin showed a correlation with OSA severity markers. OSA was associated with greater cardiac damage in AMI patients. Our findings underscore that adipokines alone are not sufficient to discriminate the risk of AMI in the presence of OSA. Further research is necessary to determine the potential mechanisms contributing to exacerbated cardiac damage in patients with both conditions.

The Cervical Fat Tissue Volume is a Predictor for Moderate to Severe OSA

Objective  Obstructive sleep apnea (OSA) is a disorder characterized by recurrent pharyngeal obstruction during sleep, in which upper airway anatomy plays a key role in its pathogenesis. The aim of this study was to describe whether the quantification of cervical fat tissue volume (CFTV) obtained by Computed Tomography (CT)cephalometry is related to the severity of OSA. Methods  Retrospective study between 2018 and 2020 in those patients > 18 years old, with diagnosis of OSA who performed a volumetric cephalometric imaging. Three-dimensional reconstruction of the images was performed and CFTV was measured. Results  91 patients were included in this study of which: without OSA (n: 7), mild (n: 19), moderate (n: 39) and severe OSA (n: 26). We observed a progressive increase of CFTV related to OSA severity has been observed (without OSA: 58.9 ml (47.9-87.5), mild: 59.1ml (48.4-78.3), moderate: 71 ml (42.6-127.1) and severe OSA 103.6 ml (81-153); p < 0.01); nevertheless, no differences were found in the airway volume and neck area. It was showed a significant correlation between CFTV and OSA indicators: AHI, ODI and T90 (Sp r: 0.48; 0.38 and 0.36; p < 0.01 respectively). CFTV cut-off value to discriminate AHI >15 ev/h with best sensitivity-specificity relationship was 64.1 ml with an area under the curve of 0.6 ± 0.06. Multivariate analysis showed that CFTV is a predictor for moderate to severe OSA (OR:3.05, IC95%: 1.14-8.17). Conclusion  Cervical fat quantification by CT cephalometry correlates with OSA severity in adults. Fat volume > 64.1 ml increased more than three times the risk of OSA moderate to severe.

Validity and reliability of the Berlin questionnaire for the detection of moderate or severe obstructive sleep apnea in patients aged 40 years or older detected from primary care

Background

The obstructive sleep apnea syndrome (OSA) is a highly prevalent condition. In Spain and other countries, only 5%-9% of patients with OSA have been diagnosed and treated. The lack of accessibility to diagnosis is considered the main cause of this situation through easy-to-use screening instruments, it is necessary to check their validity and reliability in the context where they are to be used.

Objective

To validate the Spanish translation of the Berlin questionnaire for screening for moderate or severe OSA in patients aged 40 years or more detected in primary care.

Methods

A descriptive observational study, with a first qualitative phase of transcultural adaptation to Spanish using the translation-back-translation method. Setting: primary care level of the Spanish National Health System. A total of 255 patients recruited from 7 healthcare centers completed the study. The Berlin questionnaire was administered to the recruited patients, and subsequently, a respiratory polygraphy was performed to confirm the diagnosis of OSA. The concurrent criterion validity of the questionnaire and its reliability in terms of internal consistency and reproducibility (intra-observer agreement) were analyzed.

Results

The patients' mean age was 54.76 years (SD: 6.57; 95% CI: 53.53-54.99), and 54.12% were men (95% CI: 47.96-60.27). We found that 61.57% (95% CI: 55.57-67.57) presented OSA (apnea-hypopnea index-AHI >5), and 45.5% (95% CI: 17.05-57.92) presented moderate or severe (AHI >15) OSA. The Berlin questionnaire, with a cut-off point of 4.5, showed a sensitivity of 76.77% (95% CI: 67.94-85.59), a specificity of 74.49% (95% CI: 65.35-83.63), a positive predictive value of 75.25% (95% CI: 66.34-84.16), a negative predictive value of 76.04% (95% CI: 66.98-85.10), and an area under the curve of 0.786 (95% CI: 0.721-0.851). Cronbach's alpha coefficient was 0.730 (95% CI: 0.668-0.784), and the Kappa index was 0.739 (95% CI, 0.384-1.000).

Conclusion

The Spanish adaptation of the Berlin questionnaire has good validity and reliability as a test for the diagnostic screening of moderate or severe OSA in patients aged 40 years or older. The findings of our study confirm that primary care physicians should use such screening tools to predict OSA.

Inflammation biomarkers in OSA, chronic obstructive pulmonary disease, and chronic obstructive pulmonary disease/OSA overlap syndrome

STUDY OBJECTIVES

The coexistence of obstructive sleep apnea (OSA) and chronic obstructive pulmonary disease (COPD) in a single individual, also known as overlap syndrome (OVS), is associated with higher cardiovascular risk and mortality than either OSA or COPD alone. However, the underlying mechanisms remain unclear. We hypothesized that patients with OVS have elevated systemic inflammatory biomarkers relative to patients with either disease alone, which could explain greater cardiovascular risk observed in OVS.

METHODS

We included 255 participants in the study, 55 with COPD alone, 100 with OSA alone, 50 with OVS, and 50 healthy controls. All participants underwent a home sleep study, spirometry, and a blood draw for high-sensitivity C-reactive protein and total blood count analysis. In a randomly selected subset of 186 participants, inflammatory protein profiling was performed using Bio-Rad Bio-Plex Pro Human Cytokine 27-Plex Assays. Biomarker level differences across groups were identified using a mixed linear model.

RESULTS

Levels of interleukin 6 (IL-6), high-sensitivity C-reactive protein (hs-CRP), and granulocyte colony stimulating factor (G-CSF) were higher in participants with OVS and COPD compared with healthy controls and participants with OSA. Furthermore, participants with OVS had higher circulating levels of leukocytes and neutrophils than those with COPD, OSA, and controls.

CONCLUSIONS

COPD and OVS are associated with higher systemic inflammation relative to OSA and healthy controls. This work proposes the potential utilization of interleukin 6, granulocyte colony stimulating factor, and high-sensitivity C-reactive protein as screening biomarkers for COPD in patients with OSA. Inflammatory pathways may not fully explain the higher cardiovascular risk observed in OVS, indicating the need for further investigation.

CITATION

Sanchez-Azofra A, Gu W, Masso-Silva JA, et al. Inflammation biomarkers in OSA, chronic obstructive pulmonary disease, and chronic obstructive pulmonary disease/OSA overlap syndrome. J Clin Sleep Med. 2023;19(8):1447-1456.

Diagnosis and Treatment of Sleep Apnea in Children: A Future Perspective Is Needed

Obstructive sleep apnea (OSA) in children is a prevalent, but still, today, underdiagnosed illness, which consists of repetitive episodes of upper airway obstruction during sleep with important repercussions for sleep quality. OSA has relevant consequences in the pediatric population, mainly in the metabolic, cardiovascular (CV), and neurological spheres. However, contrary to adults, advances in diagnostic and therapeutic management have been scarce in the last few years despite the increasing scientific evidence of the deleterious consequences of pediatric OSA. The problem of underdiagnosis and the lack of response to treatment in some groups make an update to the management of OSA in children necessary. Probably, the heterogeneity of OSA is not well represented by the classical clinical presentation and severity parameters (apnea/hypopnea index (AHI)), and new strategies are required. A specific and consensus definition should be established. Additionally, the role of simplified methods in the diagnosis algorithm should be considered. Finally, the search for new biomarkers for risk stratification is needed in this population. In conclusion, new paradigms based on personalized medicine should be implemented in this population.

Is it Mandatory to do a 24 hour ABPM in all Patients with Moderate to Severe Obstructive Sleep Apnoea?

Background  Obstructive sleep apnoea (OSA) has been described as a risk factor for arterial hypertension (HT). One of the proposed mechanisms linking these conditions is non dipping (ND) pattern in nocturnal blood pressure, however evidence is variable and based on specific populations with underlying conditions. Data for OSA and ND in subjects residing at high altitude are currently unavailable. Objective  Identify the prevalence and association of moderate to severe OSA with HT and ND pattern in hypertensive and non-hypertensive otherwise healthy middle-aged individuals in residing at high altitude (Bogotá:2640 mt) Methods  Adult individuals with diagnosis of moderate to severe OSA underwent 24 hour- ambulatory blood pressure monitoring (ABPM) between 2015 and 2017. Univariable and multivariable logistic regression analysis were performed to identify predictors of HT and ND pattern. Results  Ninety-three (93) individuals (male 62.4% and median age 55) were included in the final analysis. Overall, 30.1% showed a ND pattern in ABPM and 14.9% had diurnal and nocturnal hypertension. Severe OSA (higher apnea-hiponea index [AHI]) was associated with HT (p = 0.006), but not with ND patterns (p = 0.54) in multivariable regression. Smoking status and lowest oxygen saturation during respiratory events where independently associated with ND pattern (p = 0.04), whereas age (p = 0.001) was associated with HT. Conclusions  In our sample, one in three individuals with moderate to severe OSA have non dipping patterns suggesting lack of straight association between OSA and ND. Older individuals who have higher AHI are more likely to have HT, and those who smoke have a higher risk of ND. These findings add aditional information to the multiple mechanisms involved in the relationship between OSA and ND pattern, and questions the routine use of 24-hour ABPM, particullary in our region, with limited resources and healthcare acces. However, further work with more robust methodology is needed to draw conclusions.