Positive Airway Pressure Therapy for Obstructive Sleep Apnea

Cannabinoids for obstructive sleep apnea: A systematic review

Cannabinoids have emerged as a potential treatment for obstructive sleep apnea (OSA). This systematic review aimed to summarize the efficacy and safety of cannabinoids to treat OSA. Databases including Ovid MEDLINE, EMBASE, Scopus, PsycINFO, and International Pharmaceutical Abstracts were searched; experimental and observational studies were eligible for inclusion. One-hundred seventy unique records were screened, and nine studies included: five full-text studies and four published abstracts. The five full-text studies were judged for quality appraisal: two studies deemed at low risk for bias, one study deemed to have some concerns for bias, and two studies deemed to have high risk for bias. Seven of nine total studies were experimental designs and evaluated dronabinol, and the other two studies were observational designs evaluating cannabis. The range of cannabinoid therapy duration spanned from 1 to 6 weeks, and the median duration was 3 weeks. Eight of nine total studies reported statistically significant, positive OSA outcomes due to cannabinoid therapy including reductions in the apnea hypopnea index and improvements in patient-reported daytime sleepiness scales. Between 70% and 80% of study participants reported neuropsychiatric and gastrointestinal adverse events attributable to cannabinoids. The American Academy of Sleep Medicine does not recommend using cannabinoids to treat OSA due to a lack of long-term safety and efficacy data. This systematic review found similar limitations, with the median cannabinoid treatment duration being only 3 weeks. Adequately powered experimental trials over longer time frames are necessary to more completely assess the long-term efficacy and safety of cannabinoids in the treatment of OSA and its effects on common comorbid conditions, such as obesity and cardiovascular disease.

Effectiveness of Continuous Positive Airway Pressure in Treating Hypertension in Obstructive Sleep Apnea: A Traditional Review

Almost one billion individuals worldwide suffer from obstructive sleep apnea (OSA). The most widely used treatment for OSA has been continuous positive airway pressure (CPAP), but its effect on blood pressure (BP) has been challenged. Our review aims to evaluate the effects of treating OSA with CPAP on BP and BP-related morbidities in adult hypertensive patients. Medical subject headings (MeSH) terminology was used to search the PubMed Central, MEDLINE, and PubMed databases for articles on the use of CPAP in OSA patients with hypertension. We selected various forms of academic writing, encompassing complete texts that were published in the English language. The study included a total of 21 papers. OSA is a serious health concern associated with a higher risk of cardiovascular disease, kidney disease, pulmonary hypertension, and aortic stiffness, which is brought on by the periodic hypoxia caused by nocturnal respiratory episodes. For individuals with moderate-to-severe OSA, CPAP therapy has been shown to have a considerable long-term benefit with a median drop of 11 mm Hg, and high adherence results in a decrease in diastolic BP. CPAP therapy directly lowers BP in OSA patients with a body mass index (BMI) of more than 30 kg/m2 and has also demonstrated improvement in early signs of atherosclerosis with lower nocturnal systolic BP levels. OSA patients with resistant hypertension also experienced lower BP after using CPAP for a year. Therefore, our findings suggest that obesity, hypersomnolence, high nocturnal BP, prolonged CPAP usage, and resistant hypertension may all have a major impact on the BP response to CPAP therapy in individuals with severe OSA.

Immediate and Medium-Term Follow-Up of Patients with Obstructive Sleep Apnea Undergoing Pharyngeal and Nasal Surgery: A Pilot Study

Objectives  To evaluate the evolution of obstructive sleep apnea (OSA), comparing data from preoperative, immediate postoperative and late postoperative, in patients undergoing pharyngeal surgery associated with nasal surgery, and to compare the findings of arterial tonometry and type 1 polysomnography in the late postoperative period. Methods  Seventeen adults with moderate or severe OSA were included in the study. They underwent clinical evaluation, surgical intervention, and sleep study preoperatively, on the 1 ^st night after surgery, and after a minimum period of 3 months. The data for the three moments were compared. Results  The mean age was 38.1 ± 12.5 years old (22 to 59 years old), and 82.3% were male. Body mass index (BMI) ranged from 25.6 to 45.1 kg/m2 (mean = 33.1 ± 5.8 kg/m ² ). Fifteen patients (88.2%) were diagnosed with severe OSA. There was a progressive improvement, with a decrease in the indexes (AHI and RDI) and in the percentage of time with peripheral oxyhemoglobin saturation below 90% (tSpO < 90%), and an increase in nadir of SpO2. In the comparison between the 2 methods used in the late postoperative period - arterial tonometry and polysomnography - there was no difference in the indexes and in the tSpO < 90%. Discussion  There was a progressive and favorable impact of pharyngeal surgery on the improvement of polysomnographic and clinical respiratory parameters; however, many patients maintained residual OSA, suggesting the need for a new sleep study in the postoperative period. The arterial tonometry showed similar findings to polysomnography, which can be considered as an option in postoperative follow-up of patients.

H3K23/H3K36 hypoacetylation and HDAC1 up-regulation are associated with adverse consequences in obstructive sleep apnea patients

The aim of this study is to determine the roles of global histone acetylation (Ac)/methylation (me), their modifying enzymes, and gene-specific histone enrichment in obstructive sleep apnea (OSA). Global histone modifications, and their modifying enzyme expressions were assessed in peripheral blood mononuclear cells from 56 patients with OSA and 16 matched subjects with primary snoring (PS). HIF-1α gene promoter-specific H3K36Ac enrichment was assessed in another cohort (28 OSA, 8 PS). Both global histone H3K23Ac and H3K36Ac expressions were decreased in OSA patients versus PS subjects. H3K23Ac expressions were further decreased in OSA patients with prevalent hypertension. HDAC1 expressions were higher in OSA patients, especially in those with excessive daytime sleepiness, and reduced after more than 6 months of continuous positive airway pressure treatment. H3K79me3 expression was increased in those with high C-reactive protein levels. Decreased KDM6B protein expressions were noted in those with a high hypoxic load, and associated with a higher risk for incident cardiovascular events or hypertension. HIF-1α gene promoter-specific H3K36Ac enrichment was decreased in OSA patients versus PS subjects. In vitro intermittent hypoxia with re-oxygenation stimuli resulted in HDAC1 over-expression and HIF-1α gene promoter-specific H3K36Ac under-expression, while HDAC1 inhibitor, SAHA, reversed oxidative stress through inhibiting NOX1. In conclusions, H3K23/H3K36 hypoacetylation is associated with the development of hypertension and disease severity in sleep-disordered breathing patients, probably through up-regulation of HDAC1, while H3K79 hypermethylation is associated with higher risk of cardiovascular diseases, probably through down-regulation of KDM6B.

Sleep in Older Adults and Its Possible Relations With COVID-19

Since the beginning of the COVID-19 pandemic, older adults have been found to be a highly vulnerable group, with a higher prevalence of severe cases and negative outcomes. Research has focused on the reasons why older adults are at greater risk; Sleep-related factors have been suggested as one possible explanation for this. An individual's sleep pattern undergoes significant changes over the course of their life. In older adults a specific sleep profile can be observed, one characterized by advanced sleep timing, a morningness preference, longer sleep-onset latency, shorter overall sleep duration, increased sleep fragmentation, reduced slow-wave sleep and, increased wake time after sleep onset. Additionally, an increased prevalence of sleep disorders can be observed, such as obstructive sleep apnea and insomnia. Previous research has already linked sleep disorders (especially sleep apnea) with COVID-19, but few studies have focused specifically on the older population. We believe that the intrinsic sleep patterns of older adults, and the prevalence of sleep disorders in this population, may be important factors that could explain why they are at a greater risk of negative COVID-19 outcomes. In this review, we discuss the relationship between sleep and COVID-19 among older adults, focusing on three different aspects: (1) Sleep-related issues that might increase the likelihood of getting infected by SARS-COV-2; (2) Sleep disturbances that might increase the predisposition to worse COVID-19 prognosis and outcomes; and (3) COVID-19-related aspects affecting community-dwelling older adults, such as social isolation, quarantine, and home confinement, among others, that might impact sleep.

Treatment with CPAP in Elderly Patients with Obstructive Sleep Apnoea

The population pyramid is changing as a result of the ever-increasing life expectancy, which makes it crucial to acquire an in-depth understanding of the diseases that most often affect the elderly. Obstructive sleep apnoea (OSA) affects 15%-20% of the population aged over 65 years. Despite this prevalence, there have been very few specific studies on the management of OSA in this age group, even though over 60% of the patients aged over 65-70 years who attend sleep units with suspicion of OSA receive treatment with continuous positive airway pressure (CPAP), on the basis of an extrapolation of the positive results achieved by CPAP in clinical trials involving middle-aged males. However, the latter's form of presentation, evolution and, probably, prognosis comparing with OSA are not the same as those of elderly patients. Recent clinical trials performed on an exclusive series of elderly patients have shed light on the possible role of CPAP treatment in elderly patients with OSA, but there are still many questions that need to be answered. The physiological increase in the number of sleep-related disorders with the passing of years, and the lack of validated diagnostic and therapeutic tools for this age group are probably the greatest obstacles to define, diagnose and treat OSA in the elderly.

Association of Positive Airway Pressure Use With Acute Care Utilization and Costs

STUDY OBJECTIVES

The current value-based medical climate has led to scrutiny of all medical costs. Given the relationship between obstructive sleep apnea (OSA) and many significant comorbid medical conditions, treating patients with OSA via positive airway pressure (PAP) therapy might reduce health care expenditures. Our goal was to determine the relationship between PAP use and acute care utilization and costs.

METHODS

This was a retrospective cohort study of adult patients who initiated PAP therapy after a diagnosis of moderate-severe OSA at a large integrated health system during 2014-2016.

RESULTS

The study consisted of 1,098 patients, of which 60% were on PAP > 4 h/night for ≥ 70% of the nights. The average h/night were 5.3 (standard deviation 2.4). Increasing PAP usage was associated with reduced inpatient (rate ratio [RR] 0.92, 95% confidence interval [CI] 0.86-0.98) and overall acute care visits (RR 0.96, 95% CI 0.92-0.99). The linear relationships were supported by the threshold effects identified in the categorical adherence measures. No linear association was identified with emergency department visits and inpatient stays. However, lower number of emergency department visits (RR 0.78, 95% CI 0.62-0.98) and inpatient stays (RR 0.56, 95% CI 0.35-0.91) were observed among adherent (> 4 h/night for ≥ 70% of the nights) patients.

CONCLUSIONS

PAP usage was linearly associated with reduced number of inpatient and overall acute care visits, and lower likelihood of having positive costs from these visits. PAP usage was also associated with less emergency department visits and inpatient stays when comparing adherent patients to less adherent patients.

CITATION

Kirsch DB, Yang H, Maslow AL, Stolzenbach M, McCall A. Association of positive airway pressure use with acute care utilization and costs. J Clin Sleep Med. 2019;15(9):1243-1250.

Tooth Movement Associated With CPAP Therapy

ABSTRACT

We report on a rarely documented side effect-tooth movement-associated with positive airway pressure therapy. A 64-year-old woman presented to an orthodontic practice for evaluation of unexplained tooth movement and spaces opening between her anterior teeth. The patient recently received a diagnosis of mild obstructive sleep apnea, for which she had been using continuous positive airway pressure (CPAP) delivered by a nasal pillows interface for the past 18 months. Follow-up questioning revealed that shifting of the teeth was first noticed in the months following the initiation of CPAP and the result of forward thrusting of the tongue during use. Following 12 months of orthodontic treatment, the malocclusion was corrected and teeth returned to their pretreatment positions. Unwanted tooth movement, although a minor sequela, can have a meaningful effect on quality of life. With improved awareness of this issue, the patient experience and ultimately adherence with CPAP treatment can be improved.

Adherence to positive airway pressure treatment among minority populations in the US: A scoping review

Minority individuals in the United States (US) have an increased prevalence of obstructive sleep apnea (OSA) compared to their white/Caucasian counterparts. In general, adherence to positive airway pressure (PAP) therapy is poor and some studies suggest that PAP use among minority individuals is inferior to that of whites. However, there has not been a review of the evidence that addresses racial-ethnic disparities for PAP adherence in the treatment of OSA, and no review has systematically examined the contributing factors to poor adherence among minority individuals compared to whites. We searched the literature for studies published between January 1990 to July 2016 that included objective PAP use comparisons between adult US minority individuals and whites. Twenty-two studies met the inclusion criteria. All studies compared the PAP adherence of blacks to whites. Seven studies compared the PAP adherence of additional minority groups to that of whites. Sixteen of the 22 studies (73%) showed worse PAP adherence in blacks compared to whites. Four studies found equivalent PAP use in US Hispanics compared to whites. Little is known about the PAP adherence of other US minority groups. We present a framework and research agenda for understanding PAP use barriers among US minority individuals.