Residual Daytime Sleepiness in Obstructive Sleep Apnea After Continuous Positive Airway Pressure Optimization

Match and Mismatch between Lived Experiences of Daytime Sleepiness and Diagnostic Instruments: A Qualitative Study amongst Patients with Sleep Disorders

Excessive daytime sleepiness is a common symptom of sleep disorders. Despite its prevalence, it remains difficult to define, detect, and address. The difficulties surrounding sleepiness have been linked to an ambiguous conceptualization, a large variety of scales and measures, and the overlap with other constructs, such as fatigue. The present study aims to investigate patients' descriptions of sleepiness-related daytime complaints and their phenomenology. We performed semi-directed interviews with patients diagnosed with obstructive sleep apnea (N = 15) or narcolepsy (N = 5). The interviewers took care of utilizing the participants' terminology when describing daytime complaints related to their sleep disorder. Various aspects of the daytime complaints were investigated, such as their description and temporality. The transcribed content was thematically analyzed using an eclectic coding system, yielding five themes. The participants used different interchangeable descriptors (tired, sleepy, fatigued, exhausted) to express their daytime complaints. They enriched their description with indexes of magnitude (ranging from 'not especially' to 'most gigantic, extreme'), oppositions to other states (using antipodes like energy, alertness, wakefulness, or rest), and indications of fluctuations over the day. Interestingly, the participants often used metaphors to express their experiences and their struggles. The lived experiences of the patients were found to not always align with common self-reported monitoring tools of sleepiness and to relate only in part with current conceptions. In practice, it is important to probe daytime complaints, such as daytime sleepiness, with a broader consideration, for example, by exploring antipodes, consequences, and time-of-day fluctuations.

Solriamfetol enhances wakefulness and improves cognition and anxiety in a murine model of OSA

BACKGROUND

Obstructive sleep apnea (OSA) is a chronic condition characterized by intermittent hypoxia (IH). Excessive daytime sleepiness (EDS) is a common consequence of OSA and is associated with cognitive deficits and anxiety. Modafinil (MOD) and Solriamfetol (SOL) are potent wake-promoting agents clinically used to improve wakefulness in OSA patients with EDS.

METHODS

Male C57Bl/6J mice were exposed to either IH or room air (RA) controls during the light phase for 16 weeks. Both groups were then randomly assigned to receive once-daily intraperitoneal injections of SOL (200 mg/kg), MOD (200 mg/kg) or vehicle (VEH) for 9 days while continuing IH exposures. Sleep/wake activity was assessed during the dark (active) phase. Novel object recognition (NOR), elevated-plus maze test (EPMT), and forced swim test (FST) were performed before and after drug treatment.

RESULTS

IH exposure increased dark phase sleep percentage and reduced wake bouts lengths and induced cognitive deficits and anxiogenic effects. Both SOL and MOD treatments decreased sleep propensity under IH conditions, but only SOL promoted improvements in NOR performance (explicit memory) and reduced anxiety-like behaviors.

CONCLUSION

Chronic IH, a hallmark feature of OSA, induces EDS in young adult mice that is ameliorated by both SOL and MOD. SOL, but not MOD, significantly improves IH-induced cognitive deficits and promotes anxiolytic effects. Thus, SOL could potentially benefit OSA patients beyond EDS management.

Solriamfetol improves chronic sleep fragmentation-induced increases in sleep propensity and ameliorates explicit memory in male mice

Obstructive sleep apnea (OSA) is a highly prevalent condition characterized by episodes of partial or complete breath cessation during sleep that induces sleep fragmentation (SF). One of the frequent manifestations of OSA is the presence of excessive daytime sleepiness (EDS) associated with cognitive deficits. Solriamfetol (SOL) and modafinil (MOD) are wake-promoting agents commonly prescribed to improve wakefulness in OSA patients with EDS. This study aimed to assess the effects of SOL and MOD in a murine model of OSA characterized by periodic SF. Male C57Bl/6J mice were exposed to either control sleep (SC) or SF (mimicking OSA) during the light period (06:00 h to 18:00 h) for 4 weeks, which consistently induces sustained excessive sleepiness during the dark phase. Both groups were then randomly assigned to receive once-daily intraperitoneal injections of SOL (200 mg/kg), MOD (200 mg/kg), or vehicle for 1 week while continuing exposures to SF or SC. Sleep/wake activity and sleep propensity were assessed during the dark phase. Novel Object Recognition test, Elevated-Plus Maze Test, and Forced Swim Test were performed before and after treatment. SOL or MOD decreased sleep propensity in SF, but only SOL induced improvements in explicit memory, while MOD exhibited increased anxiety behaviors. Chronic SF, a major hallmark of OSA, induces EDS in young adult mice that is mitigated by both SOL and MOD. SOL, but not MOD, significantly improves SF-induced cognitive deficits. Increased anxiety behaviors are apparent in MOD-treated mice. Further studies aiming to elucidate the beneficial cognitive effects of SOL are warranted.

Brazilian Thoracic Association Consensus on Sleep-disordered Breathing

Sleep is essential for the proper functioning of all individuals. Sleep-disordered breathing can occur at any age and is a common reason for medical visits. The objective of this consensus is to update knowledge about the main causes of sleep-disordered breathing in adult and pediatric populations, with an emphasis on obstructive sleep apnea. Obstructive sleep apnea is an extremely prevalent but often underdiagnosed disease. It is often accompanied by comorbidities, notably cardiovascular, metabolic, and neurocognitive disorders, which have a significant impact on quality of life and mortality rates. Therefore, to create this consensus, the Sleep-Disordered Breathing Department of the Brazilian Thoracic Association brought together 14 experts with recognized, proven experience in sleep-disordered breathing.

Residual sleepiness in veterans with post-traumatic stress disorder and obstructive sleep apnea

PURPOSE

The causes of residual excessive sleepiness (RES) in patients with post-traumatic stress disorder (PTSD) and obstructive sleep apnea (OSA) are multifactorial and modulated by comorbid conditions. The aim of the present study was to elucidate clinical and polysomnographic determinants of RES in continuous positive airway pressure (CPAP)-adherent OSA veterans with PTSD.

METHODS

The study protocol consisted of a retrospective analysis of consecutive cases of patients with PTSD who presented to the Veterans Affairs sleep clinics with adequately treated OSA between June 1, 2017 and October 15, 2021. Based on the Epworth Sleepiness Scale (ESS), patients were categorized into RES (ESS ≥ 11) and no RES (ESS < 11) groups. Demographic and PSG data were subjected to univariate and multivariate analyses to ascertain predictive factors of RES.

RESULTS

Out of 171 veterans with PTSD who were adherent to CPAP, 59 (35%) continued to experience RES. The RES group had a decrease in mean ESS score of 1.2 ± 4.5 after CPAP treatment compared with 4.6 ± 4.9 for the no RES group (< 0.001). A dose-response was observed between CPAP use and RES (p = 0.003). Multivariate regression analysis identified higher baseline ESS (OR 1.30; 95% CI 1.16-1.44), greater percentage of time spent in REM sleep (OR 0.91; 95% CI 0.85-0.96), CPAP use less than 6 h (OR 2.82; 95% CI 1.13-7.01), and a positive screen for depression (OR 1.69; 95% CI 1.03-4.72) as independent predictors of RES in patients with PTSD and OSA.

CONCLUSION

RES is highly prevalent in patients with PTSD and OSA despite adherence to CPAP and is independently associated with percentage time spent in REM, duration of CPAP utilization, and symptoms of depression.

In-office communication about excessive daytime sleepiness associated with treated obstructive sleep apnea: insights from an ethnographic study of physician-patient visits

Background

Excessive daytime sleepiness (EDS), a primary symptom of obstructive sleep apnea (OSA), negatively affects functioning and quality of life (QoL). EDS can persist despite primary airway therapy, and often remains unmanaged, potentially due to inadequate provider-patient communication. Ethnographic research was conducted to assess provider-patient communication about EDS.

Methods

Participating physicians (primary care n = 5; pulmonologists n = 5; sleep specialists n = 3) identified adult patients (n = 33) diagnosed with OSA who were prescribed positive airway pressure (PAP) therapy ≥6 months prior and previously reported EDS. Visits and post-visit interviews were video-recorded and analyzed using standardized, validated sociolinguistic techniques.

Results

Despite 55% of patients (18/33) reporting QoL impacts post-visit, this was discussed during 28% (5/18) of visits. Epworth Sleepiness Scale was administered during 27% (9/33) of visits. Many patients (58% [19/33]) attributed EDS to factors other than OSA. Physicians provided EDS education during 24% of visits (8/33). Prior to the visit, 30% (10/33) of patients were prescribed EDS medication, of which 70% (7/10) reported currently experiencing EDS symptoms.

Conclusions

EDS was minimally discussed and rarely reassessed or treated after PAP therapy initiation in this study. Patients often attributed EDS to factors other than OSA. The findings suggest physicians and patients may benefit from dialogue tools, routine use of screening tools, and patient education.

Development and Comparison of Predictive Models Based on Different Types of Influencing Factors to Select the Best One for the Prediction of OSAHS Prevalence

OBJECTIVE

This study aims to retrospectively analyze numerous related clinical data to identify three types of potential influencing factors of obstructive sleep apnea-hypopnea syndrome (OSAHS) for establishing three predictive nomograms, respectively. The best performing one was screened to guide further clinical decision-making.

METHODS

Correlation, difference and univariate logistic regression analysis were used to identify the influencing factors of OSAHS. Then these factors are divided into three different types according to the characteristics of the data. Lasso regression was used to filter out three types of factors to construct three nomograms, respectively. Compare the performance of the three nomograms evaluated by C-index, ROC curve and Decision Curve Analysis to select the best one. Two queues were obtained by randomly splitting the whole queue, and similar methods are used to verify the performance of the best nomogram.

RESULTS

In total, 8 influencing factors of OSAHS have been identified and divided into three types. Lasso regression finally determined 6, 3 and 4 factors to construct mixed factors nomogram (MFN), baseline factors nomogram (BAFN) and blood factors nomogram (BLFN), respectively. MFN performed best among the three and also performed well in multiple queues.

CONCLUSION

Compared with BAFN and BLFN constructed by single-type factors, MFN constructed by six mixed-type factors shows better performance in predicting the risk of OSAHS.

Different components of excessive daytime sleepiness and the change with positive airway pressure treatment in patients with obstructive sleep apnea: Results from the Icelandic Sleep Apnea Cohort (ISAC)

Excessive daytime sleepiness includes both an inability to stay awake during the day and a general feeling of sleepiness. We describe different dimensions of daytime sleepiness in adults with moderate-severe obstructive sleep apnea (OSA) before and after 2 years of positive airway pressure (PAP) treatment. Using the Epworth Sleepiness Scale (score >10 defined as "risk of dozing") and Basic Nordic Sleep Questionnaire (feeling sleepy ≥3 times/week defined as "feeling sleepy"), participants were categorised into sleepiness phenotypes labelled non-sleepy, risk of dozing only, feeling sleepy only, or both symptoms. Participants repeated baseline assessments and PAP adherence was evaluated after 2 years. PAP-adherent subjects with sleepiness symptoms at both baseline and follow-up were considered persistently sleepy. Of the 810 participants, 722 (89%) returned for follow-up. At baseline, 17.7% were non-sleepy, 7.7% were at risk of dozing only, 24.7% were feeling sleepy only, and 49.9% had both symptoms. PAP adherence did not differ by baseline sleepiness phenotype. Patients with risk of dozing demonstrated greater PAP benefits for sleepiness symptoms than non-sleepy and feeling sleepy only phenotypes. Using these phenotypes, 42.3% of PAP users had persistent sleepiness; they had less severe OSA (p < 0.001), more persistent OSA symptoms and more often had symptoms of insomnia than patients in whom sleepiness resolved. Our present results, therefore, suggest that measuring the risk of dozing and the feeling of sleepiness reflect different sleepiness components and may respond differently to PAP. Patients feeling sleepy without risk of dozing may need more thorough evaluation for factors contributing to sleepiness before initiating treatment.

Residual excessive daytime sleepiness in patients treated for obstructive sleep apnea: guidance for assessment, diagnosis, and management

Excessive daytime sleepiness (EDS) affects approximately half of patients with obstructive sleep apnea (OSA) and can persist in some despite normalization of breathing, oxygenation, and sleep quality with primary OSA therapy, such as continuous positive airway pressure (CPAP). EDS is often overlooked and under discussed in the primary care setting and in the follow-up of CPAP-treated patients due to difficult assessment of such a multi-dimensional symptom. This review aims to provide suggestions for procedures that can be implemented into routine clinical practice to identify, evaluate, and manage EDS in patients treated for OSA, including how to appropriately use various self-report and objective assessments along the clinical pathway and options for pharmacotherapy. In addition, examples of when it is appropriate to refer a patient to a sleep specialist for evaluation are discussed.

Prevalence of sleepiness and associations with quality of life in patients with sleep apnea in an online cohort

STUDY OBJECTIVES

Excessive daytime sleepiness (EDS) is a treatment target for many patients with obstructive sleep apnea (OSA). We aimed to understand the prevalence, risk factors and quality of life associated with EDS in a non-clinical, "real world" sample of patients with OSA.

METHODS

Cross-sectional survey of patients with OSA participating in an online peer support community, assessing demographics, comorbidities, treatment, and quality of life. Differences in those with and without EDS (Epworth Sleepiness Scale [ESS] > and ≤ 10) were assessed.

RESULTS

The sample (n=422) was 54.2% male, 65.9% were ≥ 55 years, and 43.3% reported sleeping ≤ 6 hours/night. EDS was identified among 31.0% of respondents and 51.7% reported sleepiness as a precipitating factor for seeking initial OSA treatment. EDS was more prevalent in individuals reporting asthma, insomnia symptoms, positive airway pressures (PAP) use less than 6 hours/night on ≥ 5 nights/week, or sleep duration < 6 hours/night. After adjusting for demographics and comorbidities, patients with EDS reported poorer mental and physical health and well-being, lower disease-specific functional status, more activity and work impairment, and more driving impairment (p values < 0.05). In the sub-sample (n=265) with high PAP adherence, 26.0% reported EDS, and similar associations between EDS and outcomes were observed.

CONCLUSIONS

These "real-world" data suggest that patients seeking online OSA support experience a high prevalence of EDS, which was associated with poorer quality of life and worse functional status. Associations persisted among respondents with high self-reported PAP-adherence, potentially driving these individuals to seek online support for sleepiness-related symptoms.

Sleep disordered breathing from preschool to early adult age and its neurocognitive complications: A preliminary report

Objective

The onset and development of sleep disordered breathing (SDB) remains unclear in an age - dependent manner. Despite treatment, persistent symptoms such as snoring and excessive daytime sleepiness, as well as cognitive impairment may be present. The aim of the research was to determine the prevalence of residual symptoms of SDB in adolescence and early adulthood, the predisposing factors and its neurocognitive complications.

Methods

In the present pilot study-cohort, a questionnaire was utilized to 154 people (average age: 17.9 ± 3), who as children (mean age: 5.3 ± 1.4) had AHI ≥2.5 episodes/h. They were divided into two groups based on AHI = 5 episodes/h. Depending on the results, they were invited to undergo a repeated polysomnography (PSG) and complete the Montreal Cognitive Assessment (MoCA) test. Statistical analysis was made with IBM SPSS software.

Results

Out of the total, 35.7% claimed to still snore. AHI was negatively correlated to the severity of residual symptoms (Mann-Witney U test, p <0.005). According to repeated PSGs, 9/17 met the criteria for OSAS, while high BMI was associated with the severity of new AHI (chi squared test, p<0.005). Additionally, 7/16 scored below the MoCA baseline (<26/30). The characteristics of cognitive declines were mapped, with most prominent having been visuospatial, short - term memory and naming/language deficits.

Discussion

A significant percentage of children with sleep breathing disorder present with residual symptoms during their transition to early adulthood, as well as undiagnosed neurocognitive complications. Clinicians suspicion for the underlying neurocognitive complications is required, even in young adults, while guidelines on monitoring pediatric OSAS patients after treatment should be addressed.

Pitolisant for Residual Excessive Daytime Sleepiness in OSA Patients Adhering to CPAP: A Randomized Trial

BACKGROUND

Excessive daytime sleepiness (EDS) in individuals with OSA syndrome persisting despite good adherence to CPAP is a disabling condition. Pitolisant is a selective histamine H3-receptor antagonist with wake-promoting effects.

RESEARCH QUESTION

Is pitolisant effective and safe for reducing daytime sleepiness in individuals with moderate to severe OSA adhering to CPAP treatment but experiencing residual EDS?

STUDY DESIGN AND METHODS

In a multicenter, double-blind, randomized (3:1), placebo-controlled, parallel-design trial, pitolisant was titrated individually at up to 20 mg/day and taken over 12 weeks. The primary end point was change in the Epworth Sleepiness Scale (ESS) score in the intention-to-treat population. Key secondary end points were maintenance of wakefulness assessed by the Oxford Sleep Resistance Test, Clinical Global Impressions scale of severity, the patient's global opinion, EuroQoL quality-of-life questionnaire score, Pichot fatigue questionnaire score, and safety.

RESULTS

Two hundred forty-four OSA participants (82.8% men; mean age, 53.1 years; mean Apnea Hypopnea Index with CPAP, 4.2/h; baseline ESS score, 14.7) were randomized to pitolisant (n = 183) or placebo (n = 61). ESS significantly decreased with pitolisant compared with placebo (-2.6; 95% CI, -3.9 to -1.4; P < .001), and the rate of responders to therapy (ESS ≤ 10 or change in ESS ≥ 3) was significantly higher with pitolisant (71.0% vs 54.1%; P = .013). Adverse event occurrence (mainly headache and insomnia) was higher in the pitolisant group compared with the placebo group (47.0% and 32.8%, respectively; P = .03). No cardiovascular or other significant safety concerns were reported.

INTERPRETATION

Pitolisant used as adjunct to CPAP therapy for OSA with residual sleepiness despite good CPAP adherence significantly reduced subjective and objective sleepiness and improved participant-reported outcomes and physician-reported disease severity.

TRIAL REGISTRY

ClinicalTrials.gov; No.: NCT01071876; URL: www.clinicaltrials.gov; EudraCT N°: 2009-017248-14; URL: eudract.ema.europa.eu.

Therapeutic Approaches for the Management of Sleep Disorders in Geriatric Population

OBJECTIVE

Aging is a natural biological phenomenon that occurs in human beings. With increasing of age, there is an appearance of deleterious changes related to progression onto pathological conditions, including hypertension, heart disease, diabetes, hearing and vision impairments, as well as sleep disorders. It is important to recognize that some sleep disturbances reported by aged subjects include insomnia, obstructive sleep apnea, restless legs syndrome, among others. Moreover, accumulating evidence indicates that coexistence of medical issues with sleep disorders constitutes clinical challenges for treatment of comorbidities in elderly. Here, we have attempted to review and summarize the available literature that assesses the sleep disturbances in aging. In addition, we highlight the management of sleep disorders associated with aging. Due to the particular health condition of aged adults, the development of effective pharmacological interventions for sleep disorders treatment in aging is warranted.

METHODS

Review of studies retrieved from the PubMed.

RESULTS

The sleep-wake cycle includes abnormalities classified as sleep disorders. Comorbidity between sleep disturbances and aging-related health issues will represent a public health challenge to be addressed in the near future. Moreover, this scenario will suggest an area that requires further drug investigation and design of new pharmacological and pharmaceutical strategies to treat sleep disorders in the elderly population.

CONCLUSION

The review highlights the sleep disturbances in aging. We focus on current knowledge in medicinal chemistry and further design of new treatments tools for managing sleep disturbances in the aged population.

Redesigning Care for OSA

Constrained by a limited supply of specialized personnel, health systems face a challenge in caring for the large number of patients with OSA. The complexity of this challenge is heightened by the varied clinical presentations of OSA and the diversity of treatment approaches. Innovations such as simplified home-based care models and the incorporation of nonspecialist providers have shown promise in the management of uncomplicated patients, producing comparable outcomes to the resource-intensive traditional approach. However, it is unclear if these innovations can meet the needs of all patients with OSA, including those with mild disease, atypical presentations, and certain comorbid medical and mental health conditions. This review discusses the diversity of needs in OSA care, the evidence base behind recent care innovations, and the potential limitations of each innovation in meeting the diversity of care needs. We propose how these innovations can fit within the stepped care and hub and spoke models in a way that addresses the full spectrum of OSA, and we discuss future research directions to assess the deployment of these innovations.

Sleepiness and Driving: Benefits of Treatment

Drowsy driving is common and causes 21% of fatal crashes. Individuals at risk include young men, shift workers, older adults, and people with chronic short sleep duration, untreated obstructive sleep apnea (OSA), and narcolepsy. Untreated OSA is a particular concern in commercial drivers, who are at higher risk for the disorder. Treatment for sleep problems such as sleep extension for chronic short sleep, positive airway pressure (PAP) for OSA, pharmacologic treatments, and drowsy driving countermeasures may reduce the risk of crashes. Implementing screening measures to identify common sleep problems contributing to drowsy driving continues to be of high importance.

Management Of Excessive Sleepiness In Patients With Narcolepsy And OSA: Current Challenges And Future Prospects

Excessive daytime sleepiness (EDS) can be caused by insufficient sleep but is also a manifestation of medical or sleep disorders and a side effect of medications. It impacts quality of life and creates safety concerns in the home, at work, and on the roads. Screening questionnaires can be used to estimate EDS, but further evaluation is necessary. EDS is a common symptom of both narcolepsy and obstructive sleep apnea (OSA). Polysomnography and multiple sleep latency testing are used to diagnose these disorders. However, isolating the primary etiology of EDS can be challenging and may be multifactorial. Untreated OSA can show polysomnographic findings that are similar to narcolepsy. The effects of sleep deprivation and certain medications can also affect the polysomnographic results. These challenges can lead to misdiagnosis. In addition, narcolepsy and OSA can occur as comorbid disorders. If EDS persists despite adequate treatment for either disorder, a comorbid diagnosis should be sought. Thus, despite advances in clinical practice, appropriate management of these patients can be challenging. This review is focused on EDS due to OSA and narcolepsy and addresses some of the challenges with managing this patient population.

Characterization of the Neurochemical and Behavioral Effects of Solriamfetol (JZP-110), a Selective Dopamine and Norepinephrine Reuptake Inhibitor

Excessive sleepiness (ES) is associated with several sleep disorders, including narcolepsy and obstructive sleep apnea (OSA). A role for monoaminergic systems in treating these conditions is highlighted by the clinical use of US Food and Drug Administration-approved drugs that act on these systems, such as dextroamphetamine, methylphenidate, modafinil, and armodafinil. Solriamfetol (JZP-110) is a wake-promoting agent that is currently being evaluated to treat ES in patients with narcolepsy or OSA. Clinical and preclinical data suggest that the wake-promoting effects of solriamfetol differ from medications such as modafinil and amphetamine. The goal of the current studies was to characterize the mechanism of action of solriamfetol at monoamine transporters using in vitro and in vivo assays. Results indicate that solriamfetol has dual reuptake inhibition activity at dopamine (DA; IC₅₀ = 2.9 μM) and norepinephrine (NE; IC₅₀ = 4.4 μM) transporters, and this activity is associated in vivo with increased extracellular concentration of DA and NE as measured by microdialysis. Solriamfetol has negligible functional activity at the serotonin transporter (IC₅₀ > 100 μM). Moreover, the wake-promoting effects of solriamfetol are probably owing to activity at DA and NE transporters rather than other neurotransmitter systems, such as histamine or orexin. The dual activity of solriamfetol at DA and NE transporters and the lack of significant monoamine-releasing properties of solriamfetol might explain the differences in the in vivo effects of solriamfetol compared with modafinil or amphetamine. Taken together, these data suggest that solriamfetol may offer an important advancement in the treatment of ES in patients with narcolepsy or OSA.

[Sleepiness, continuous positive airway pressure and the obstructive sleep apnea hypopnea syndrome]

Excessive daytime sleepiness is a major symptom in cases of the obstructive sleep apnea-hypopnea syndrome. Most often, it is vastly improved by treatment with continuous positive airway pressure (CPAP). The most effective way to confirm its disappearance is through wakefulness maintenance testing. If residual sleepiness remains, despite CPAP, further diagnostic investigation must be carried out. Firstly, it must be assessed whether the treatment is fully effective (apnea hypopnea index<10/h) by examining flow limitations under treatment (polysomnography) and whether it is sufficiently used (>6h/night). If this is the case, the possibility of other situations responsible for excessive daytime sleepiness must be reviewed and eliminated, whether they are depression, sleep insufficiency, use of intoxicants, obesity, restless legs syndrome, or circadian sleep-wake cycle disorder. If not, the multiple sleep latency tests make it possible to assess sleepiness (latency<8min) and can lead to a diagnosis of central hypersomnia (narcolepsy, idiopathic hypersomnia, hypersomnia due to a medical pathology). In some rare cases (about 6% of patients) investigations will reveal central hypersomnia due to the obstructive sleep apnea-hypopnea syndrome or "lesional" hypersomnia due to intermittent hypoxia. Since 2011, medications treating excessive sleepiness have had marketing authorization only for narcolepsy in France. However, they can be administered by way of derogation to other neurological hypersomnias on prescription by a reference centre or a centre with expertise in hypersomnia.

Effect of transoral endoscopic adenoidectomy on peripheral blood T-lymphocyte subsets in children with obstructive sleep apnea-hypopnea syndrome and its treatment strategy

The objective of the present study was to investigate the effect of transoral endoscopic adenoidectomy on peripheral blood T lymphocyte subsets in pediatric patients with obstructive sleep apnea-hypopnea syndrome (OSAHS) and its treatment strategy. Ninety-eight pediatric patients with adenoidal hypertrophy associated with OSAHS admitted to the Department of Otolaryngology, Xuzhou Children's Hospital were selected. After admission, patients received perfected 24 h polysomnogram monitoring, routine blood examination, fasting blood biochemistry examination, T-lymphocyte subset count, 24 h ambulatory blood pressure monitoring, and nasopharyngeal computed tomography. After patients were diagnosed with adenoidal hypertrophy associated with OSAHS, they underwent transoral endoscopic adenoidectomy with a power microdebrider. Patients were evaluated at 3-, 6- and 12-week follow-up visits. The CD3⁺, CD4⁺, and CD8⁺ T-cell counts, CD4⁺/CD8⁺ T lymphocyte ratio, and changes of 24 h ambulatory blood pressure before and after surgery were recorded. After the 6-week follow-up visit, the mean CD4⁺ T lymphocyte count in patients was increased significantly compared with that before surgery, the CD4⁺/CD8⁺ T lymphocyte ratio increased gradually, and the differences were statistically significant (P<0.05). The frequency of nocturnal awakening of patients was decreased significantly after surgery and the duration of nocturnal sleep was extended significantly (P<0.05). Through analysis of the preoperative and postoperative clinical data of pediatric patients, the CD4⁺/CD8⁺ T lymphocyte ratio was negatively correlated with mean arterial pressure (MAP) (r=-1.06, P=0.003). In conclusion, adenoidectomy can significantly decrease the MAP in pediatric patients with OSAHS and increase the duration of nocturnal sleep. The peripheral blood CD4⁺/CD8⁺ T lymphocyte ratio in pediatric patients was significantly negatively correlated with MAP.