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Fu W, Li L, Zhang S, Liu S, Liu W. Effects of CPAP and Mandibular Advancement Devices on depressive symptoms in patients with obstructive sleep apnea: a meta-analysis of randomized controlled trials. Sleep Breath 2023; 27:2123-2137. [PMID: 37119355 DOI: 10.1007/s11325-023-02829-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2023] [Revised: 03/25/2023] [Accepted: 04/07/2023] [Indexed: 05/01/2023]
Abstract
PURPOSE Studies show that patients with obstructive sleep apnea (OSA) are more likely than the general population to have psychological disorders such as depression. However, it is less clear how OSA treatment affects this association. This meta-analysis aimed to assess whether or not continuous positive airway pressure (CPAP) and mandibular advancement devices (MADs) reduce depression symptoms in patients with OSA. METHODS We searched Pubmed, Embase, Web of Science, and Cochrane Library from creating the databases until November 2022. Our analysis included RCTs that examined CPAP and MAD treatment effectiveness for depression in patients with OSA. RESULTS We identified 17 CPAP studies comprising 1,931 patients for inclusion in the meta-analysis. The results of the meta-analysis using a fixed effects model found that CPAP improved depressed mood in patients with OSA relative to controls (SMD = 0.27;95% CI:0.18,0.36), with small heterogeneity among trials (I2 = 8.1% < 50%, P = 0.359). We performed subgroup analyses on three factors: the length of trial follow-up, patient adherence data, and depression assessment scales. The meta-analysis also identified six MAD studies involving 315 patients. According to this analysis, there was no heterogeneity between studies (I2 = 0%, P = 0.748). MADs did not significantly improve depression symptoms compared to controls, indicating a combined effect of SMD = 0.07 (95% CI: - 0.15,0.29), P > 0.05. CONCLUSION The present findings confirm that CPAP may improve depressive symptoms in patients with OSA. However, the review results suggest that MADs have no significant effect on depressive symptoms in patients with OSA, a finding that is different from the results of previous meta-analyses.
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Affiliation(s)
- Wenli Fu
- The First Clinical Medical College of Lanzhou University, Lanzhou, 730000, China
| | - Leping Li
- The First Clinical Medical College of Lanzhou University, Lanzhou, 730000, China
| | - Sha Zhang
- The First Clinical Medical College of Lanzhou University, Lanzhou, 730000, China
| | - Shengfei Liu
- The First Clinical Medical College of Lanzhou University, Lanzhou, 730000, China
| | - Weiying Liu
- Department of Respiratory and Critical Care Medicine, The First Hospital of Lanzhou University, Lanzhou, 730000, China.
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2
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Short term impact of antidepressants on the cardinal symptoms of depression in OSA patients with comorbid MDD who are APAP-adherent: A retrospective study in a veteran population. JOURNAL OF AFFECTIVE DISORDERS REPORTS 2021. [DOI: 10.1016/j.jadr.2021.100236] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
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The relationships between obstructive sleep apnea and psychiatric disorders: a narrative review. CURRENT PROBLEMS OF PSYCHIATRY 2021. [DOI: 10.2478/cpp-2021-0005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Abstract
Introduction: Obstructive sleep apnea (OSA) is the most common sleep-related breathing disorder. Its prevalence tends to increase worldwide. Untreated sleep apnea is associated with a higher risk of metabolic diseases, cardiovascular diseases, stroke, road accidents, and death, but also it is suggested that it increases the risk of mental disorders.
Method: The literature review was based on a search of articles on Medline, Pubmed, and Google Scholar from 2003 to 2021 using the keywords: obstructive sleep apnea; mental disorders; cognitive functions; affective disorders; depression; bipolar disorder; schizophrenia; psychotic disorders. The analysis included original studies, meta-analysis, and review articles.
Discussion: The result obtained from researches published so far does not allow for drawing unequivocal conclusions. There is a lot of bias present in study protocols and inclusion/exclusion criteria. Nonetheless, it seems that some disorders have a better proven correlation with OSA. Cognitive impairment, depression, and anxiety disorders are linked to OSA not only in terms of the overlapping of symptoms but also of a causal relationship. Psychotic disorders and bipolar disorders connections with OSA are confirmed, but they are not yet well understood. All correlations are found to be possibly bidirectional.
Conclusion: 1. Multiple lines of evidence increasingly point towards a bidirectional connection between OSA and mental disorders, and the cause and effect relationship between these two groups of disorders requires further research.
2. Due to reports of an increased risk of OSA with antipsychotic drugs, caution should be exercised when initiating therapy with this type of drug in patients with known risk factors for it.
3. Screening for OSA in psychiatric patients should be introduced as OSA can increase cognitive impairment, affective, and psychotic symptoms.
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4
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Aftab Z, Anthony AT, Rahmat S, Sangle P, Khan S. An Updated Review on the Relationship of Depressive Symptoms in Obstructive Sleep Apnea and Continuous Positive Airway Pressure. Cureus 2021; 13:e15907. [PMID: 34336419 PMCID: PMC8312772 DOI: 10.7759/cureus.15907] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2021] [Accepted: 06/24/2021] [Indexed: 11/17/2022] Open
Abstract
Obstructive sleep apnea (OSA) is a common sleep disorder occurring across all age groups, gender, and is multifactorial. The episodic decrease in airflow during sleep results in hypoxia and hypercapnia over time, resulting in morning headache, systemic and pulmonary hypertension, and polycythemia. Fragmentation of sleep at night-time cause daytime somnolence, fatigue, memory problems, and mood symptoms such as depression and anxiety. These secondary mood symptoms could be easily missed by healthcare providers as the primary disorder resulting in unnecessary anti-depressants' prescription. This study investigates the effect of continuous airway pressure (CPAP) on depressive symptoms of OSA. We used PubMed, PubMed Central (PMC), and MEDLINE for data collection. We used OSA, depression, anxiety, mood symptoms, psychological symptoms, and CPAP as the keywords, both alone and in combination. The search ended on November 5, 2020, and it was limited to the year 2010 until the day of the search. However, a few of the papers published earlier than 2010 were also included to have better insight into some aspects of the topic. We included articles measuring the impact of CPAP on mood symptoms using any one of the validated scales, such as the Beck Depression Inventory (BDI), the State-Trait Anxiety Inventory (STAI), Hospital Anxiety and Depression Scale (HADS), or Hamilton Depression Scale (HAM-D). Our initial searches yielded 131 articles. Twenty-one of the 131 papers satisfied the review's criteria. Four studies out of 21 revealed no improvement in OSA-related mood symptoms with CPAP therapy, whereas the others reported beneficial effects on mood, daytime sleepiness, cognition, and patient quality of life.
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Affiliation(s)
- Zarmeena Aftab
- Family Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Adarsh Thomas Anthony
- Family Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Shermeen Rahmat
- Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Prerna Sangle
- Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Safeera Khan
- Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
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5
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Walker A, Naughton MT, Shaw L, Jeklin AT, Martin C, Dabscheck E. Depression scores improve with continuous positive airway pressure in specialized sleep clinics: real-world data. J Clin Sleep Med 2021; 17:1201-1209. [PMID: 33590822 DOI: 10.5664/jcsm.9164] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
STUDY OBJECTIVES To assess changes in Hospital Anxiety and Depression Scale (HADS) scores after continuous positive airway pressure (CPAP) in patients with obstructive sleep apnea. METHODS Consecutive patients attending the Alfred Health sleep clinic, diagnosed with obstructive sleep apnea, and prescribed CPAP were recruited. The primary outcome was a change in the HADS depression (HADS-D) and anxiety (HADS-A) subscales from the time of diagnosis to follow-up. Secondary analysis compared high (> 4 hours) and low (< 4 hours) CPAP adherence groups and change in depression cases, defined by HADS-D ≥ 8, and anxiety cases, defined by HADS-A ≥ 11. RESULTS We included 108 participants in the final analysis. Adherence groups were well matched in baseline mood, sleepiness, and apnea variables. Overall age (mean ± standard deviation) was 56.1 ± 12.8 years, and there was a median (interquartile ratio) apnea-hypopnea-index of 42.7 (27.5-58.1) or median (interquartile ratio) oxygen-desaturation-index of 43.0 (26.0-74.0). The median duration of CPAP therapy was 1.3 years. The HADS-D decreased after CPAP by -1.4 (adjusted 95% confidence interval, -2.1 to -0.6; P = .001). Patients with high-CPAP adherence (n = 84) had a tendency towards a greater reduction in HADS-D (-1.5) compared with those with low-CPAP adherence (n = 24; -0.3; adjusted P = .19). Depression cases (HADS-D ≥ 8) decreased by 13.1% in the high-CPAP-adherence group (P = .03) and increased by 4.1% in the low-CPAP-adherence group (P = .71). The HADS-A decreased after CPAP by -1.8 (adjusted 95% confidence interval, -1.8 to -0.4; P = .004). There was no significant difference between adherence groups or anxiety cases (HADS-A > 11). CONCLUSIONS Specialized obstructive sleep apnea treatment with CPAP reduces depression scores, with a trend toward greater reduction in those with high CPAP adherence.
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Affiliation(s)
- Anne Walker
- Department of Thoracic Medicine, Royal Adelaide Hospital, Central Adelaide Local Health Network, Adelaide, Australia.,University of Adelaide, Adelaide, Australia
| | - Matthew T Naughton
- Department of Respiratory Medicine, Alfred Health, Melbourne, Australia.,School of Medicine, Monash University, Victoria, Melbourne, Australia
| | - Lachlan Shaw
- School of Medicine, Monash University, Victoria, Melbourne, Australia
| | - Andrew T Jeklin
- School of Medicine, Monash University, Victoria, Melbourne, Australia
| | - Catherine Martin
- Department of Epidemiology and Preventative Medicine, Monash University, Melbourne, Australia
| | - Eli Dabscheck
- Department of Respiratory Medicine, Alfred Health, Melbourne, Australia.,School of Medicine, Monash University, Victoria, Melbourne, Australia
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Jackson ML, Tolson J, Schembri R, Bartlett D, Rayner G, Lee VV, Barnes M. Does continuous positive airways pressure treatment improve clinical depression in obstructive sleep apnea? A randomized wait-list controlled study. Depress Anxiety 2021; 38:498-507. [PMID: 33368782 DOI: 10.1002/da.23131] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2020] [Revised: 11/12/2020] [Accepted: 11/14/2020] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Obstructive sleep apnea (OSA) is a highly prevalent sleep disorder that is associated with a range of adverse daytime sequelae, including significantly higher rates of clinical depression than is seen in the general community. Improvements in depressive symptoms occur after treatment of the primary sleep disorder, suggesting that comorbid depression might be an intrinsic feature of OSA. However, there are limited data on whether treatment for OSA in patients diagnosed with clinical depression improves mood symptoms meaningfully enough to lead to the remission of the psychiatric diagnosis. METHODS N = 121 untreated OSA patients were randomized to either continuous positive airway pressure (CPAP) treatment or waitlist control, and depressive symptoms, sleepiness and clinical depression (using a structured clinical interview) were assessed at baseline and 4 months. Linear and logistic regression analyses were conducted, controlling for baseline scores, stratification factors and antidepressant use. RESULTS Depressive symptoms (odds ratio [OR] = -4.19; 95% confidence interval [CI] = -7.25, -1.13; p = .008) and sleepiness (OR = -4.71; 95% CI = -6.26, -3.17; p < .001) were significantly lower at 4 months in the CPAP group compared to waitlist. At 4 months, there was a significant reduction in the proportion of participants in the CPAP group meeting criteria for clinical depression, compared to the waitlist controls (OR = 0.06, 95% CI = 0.01, 0.37; p = .002). CONCLUSION Treatment of OSA may be a novel approach for the management and treatment of clinical depression in those with comorbid sleep disordered breathing. Larger trials of individuals with clinical depression and comorbid OSA are needed.
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Affiliation(s)
- Melinda L Jackson
- Turner Institute for Brain and Mental Health, Monash University, Clayton, Australia.,Institute for Breathing and Sleep, Austin Health, Heidelberg, Melbourne, Australia
| | - Julie Tolson
- Institute for Breathing and Sleep, Austin Health, Heidelberg, Melbourne, Australia.,Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Melbourne, Australia
| | - Rachel Schembri
- Clinical Epidemiology and Biostatistics Unit, Murdoch Children's Research Institute, Melbourne, Australia
| | - Delwyn Bartlett
- CIRUS Centre for Sleep and Chronobiology - NHMRC Centre of Research Excellence, Woolcock Institute of Medical Research, University of Sydney, Sydney, Australia
| | - Genevieve Rayner
- Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Melbourne, Australia
| | - V Vien Lee
- Institute for Breathing and Sleep, Austin Health, Heidelberg, Melbourne, Australia
| | - Maree Barnes
- Institute for Breathing and Sleep, Austin Health, Heidelberg, Melbourne, Australia.,Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Melbourne, Australia
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The impact of sleep disorders on microvascular complications in patients with type 2 diabetes (SLEEP T2D): the protocol of a cohort study and feasibility randomised control trial. Pilot Feasibility Stud 2021; 7:80. [PMID: 33752759 PMCID: PMC7982768 DOI: 10.1186/s40814-021-00817-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Accepted: 03/09/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Obstructive sleep apnoea (OSA) is very common in patients with type 2 diabetes (T2D). We and others have shown that OSA was associated with diabetes-related microvascular complications in patients with T2D in cross-sectional and longitudinal studies and that compliance with continuous positive airway pressure (CPAP) reduced the progression of microvascular complications. Hence, we hypothesised that adequate CPAP reduces the development of microvascular complication in patients with T2D. METHODS SLEEP T2D is a cohort study with embedded feasibility, open-label, parallel-arm, randomised control trial (RCT) over 2 years. The primary aim is the feasibility of conducting a definitive RCT assessing the impact of CPAP on chronic kidney disease and other microvascular complications in patients with T2D. The main parameters are to assess willingness of participants to be randomised, follow-up rates, CPAP adherence/compliance, to optimise the choice of outcome measures for a substantive trial, and to identify the parameters for sample size calculations. The secondary aims of the study are related to the impact of CPAP, sleep-related disorders, and sleep chronotype on a variety of diabetes-related end points. The study participants were recruited from the T2D services in multiple NHS trusts across England. The main exclusion criteria for the cohort study are as follows: T1D, eGFR < 15 mL/min/1.73 m2, known OSA, active malignancy or chronic kidney disease from reasons other than diabetes, pregnancy, professional drivers, and a history of falling asleep whilst driving within last 2 years. The main exclusion criteria from the RCT were as follows: Apnoea-Hypopnoea Index < 10 and Epworth Sleepiness Score ≥ 11. Study participants were extensively phenotyped clinically and biochemically. The OSA diagnosis was based on multichannel portable device (ApneaLink AirTM, Resmed). DISCUSSION The feasibility RCT will help us design the future RCT to assess the impact of CPAP on diabetes-related microvascular complications. The cohort study will generate preliminary data regarding the impact of sleep quality, duration, and chronotype on diabetes-related outcomes which could lead to further mechanistic and interventional studies. TRIAL REGISTRATION ISRCTN, ISRCTN12361838 . Registered 04 April 2018, Protocol version: v5.0 02.12.19.
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8
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Oh A, Grivell N, Chai-Coetzer CL. What is a Clinically Meaningful Target for Positive Airway Pressure Adherence? Sleep Med Clin 2021; 16:1-10. [PMID: 33485522 DOI: 10.1016/j.jsmc.2020.10.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Although good adherence to continuous positive airway pressure (PAP) traditionally is defined as greater than or equal to 4 hours/night, the origins and rationale for this remain unclear. Research studies report variation in optimal duration of PAP adherence, depending on outcome of interest. Evidence demonstrates benefit with PAP for daytime sleepiness, quality of life, neurocognitive outcomes, depression, and hypertension, predominantly in symptomatic, moderate-severe obstructive sleep apnea. Recent randomized controlled trials, however, have failed to demonstrate a reduction in cardiovascular and mortality risks. This review explores the question of what can be considered a clinically meaningful outcome for PAP adherence.
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Affiliation(s)
- Aaron Oh
- College of Medicine and Public Health, Flinders University, Sturt Road, Bedford Park, South Australia 5042, Australia
| | - Nicole Grivell
- Adelaide Institute for Sleep Health, College of Medicine and Public Health, Flinders University, Mark Oliphant Building, 5 Laffer Drive, Bedford Park, South Australia 5042, Australia
| | - Ching Li Chai-Coetzer
- Adelaide Institute for Sleep Health, College of Medicine and Public Health, Flinders University, Mark Oliphant Building, 5 Laffer Drive, Bedford Park, South Australia 5042, Australia; Respiratory and Sleep Service, Southern Adelaide Local Health Network, SA Health, Flinders Drive, Bedford Park, South Australia 5042, Australia.
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9
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Yang X, Yang J, Yang C, Niu L, Song F, Wang L. Continuous positive airway pressure can improve depression in patients with obstructive sleep apnoea syndrome: a meta-analysis based on randomized controlled trials. J Int Med Res 2020; 48:300060519895096. [PMID: 32208858 PMCID: PMC7370809 DOI: 10.1177/0300060519895096] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2019] [Accepted: 11/25/2019] [Indexed: 11/28/2022] Open
Abstract
Objective Substantial research indicates a clear relationship between obstructive sleep apnoea syndrome (OSAS) and depression. The study aim was to quantitatively evaluate whether continuous positive airway pressure (CPAP) therapy improves mood symptoms in OSAS patients. Methods PubMed and Embase databases were systematically searched up to 2017 for publications on the impact of CPAP on mood symptoms in OSAS patients. Results For the final analysis, nine randomized controlled trials comprising 1,052 patients were selected. The pooled standard mean difference (SMD) of the effect of CPAP on depression was 0.31 (95% confidence interval 0.18, 0.43). A subgroup analysis showed that when CPAP use was greater than 4 hours per night, it tended to be effective in improving patients’ mood symptoms (SMD = 0.38; confidence interval 0.23, 0.54). Analysis of publication bias using Egger’s test found no evidence of publication bias. Conclusion CPAP treatment can improve depression in OSAS patients.
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Affiliation(s)
- Xiangli Yang
- Department of Otolaryngology Head and Neck Surgery, Tianjin Union Medical Center, Tianjin, China
| | - Jun Yang
- Department of Otolaryngology Head and Neck Surgery, Tianjin HaiBin People’s Hospital, Tianjin, China
| | - Chunwei Yang
- Department of Otolaryngology Head and Neck Surgery, Tianjin Union Medical Center, Tianjin, China
| | - Lin Niu
- Department of Otolaryngology Head and Neck Surgery, Tianjin Union Medical Center, Tianjin, China
| | - Fucun Song
- Department of Otolaryngology Head and Neck Surgery, Tianjin Union Medical Center, Tianjin, China
| | - Lin Wang
- Department of Otolaryngology Head and Neck Surgery, Tianjin Union Medical Center, Tianjin, China
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Garbarino S, Bardwell WA, Guglielmi O, Chiorri C, Bonanni E, Magnavita N. Association of Anxiety and Depression in Obstructive Sleep Apnea Patients: A Systematic Review and Meta-Analysis. Behav Sleep Med 2020; 18:35-57. [PMID: 30453780 DOI: 10.1080/15402002.2018.1545649] [Citation(s) in RCA: 110] [Impact Index Per Article: 27.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Background: Obstructive sleep apnea (OSA) has been associated with mental disorders, but the strength of this association is unknown. The aim of our study was to investigate the association among OSA, depression, and anxiety in adults and to quantitatively summarize the results. Methods: A literature search in Medline, PubMed, PsycInfo, Scopus, and Web of Science was conducted. Seventy-three articles were selected for study. Results: The pooled prevalence of depressive and anxious symptoms in OSA patients was 35% (95% CI, 28-41%) and 32% (95% CI, 22-42%), respectively. Conclusions: The association between OSA, anxiety, and depression indicates the value of an early diagnosis and personalized treatment of OSA to improve mental disorders conditioning compliance to therapy. These conditions share a probably bidirectional relationship.
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Affiliation(s)
- Sergio Garbarino
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, and Maternal/Child Sciences (DINOGMI), University of Genoa, Genoa, Italy.,Department of Health Sciences, University of Genoa, Genoa, Italy
| | - Wayne A Bardwell
- Department of Psychiatry, University of California San Diego, San Diego, California
| | - Ottavia Guglielmi
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, and Maternal/Child Sciences (DINOGMI), University of Genoa, Genoa, Italy
| | - Carlo Chiorri
- Department of Educational Sciences, University of Genoa, Genoa, Italy
| | - Enrica Bonanni
- Center of Sleep Medicine, Neurology Unit, Azienda Ospedaliero-Universitaria Pisana, Pisa, Italy
| | - Nicola Magnavita
- Institute of Public Health, Università Cattolica del Sacro Cuore, Rome, Italy
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Zheng D, Xu Y, You S, Hackett ML, Woodman RJ, Li Q, Woodward M, Loffler KA, Rodgers A, Drager LF, Lorenzi-Filho G, Wang X, Quan WW, Tripathi M, Mediano O, Ou Q, Chen R, Liu Z, Zhang X, Luo Y, McArdle N, Mukherjee S, McEvoy RD, Anderson CS. Effects of continuous positive airway pressure on depression and anxiety symptoms in patients with obstructive sleep apnoea: results from the sleep apnoea cardiovascular Endpoint randomised trial and meta-analysis. EClinicalMedicine 2019; 11:89-96. [PMID: 31312807 PMCID: PMC6610775 DOI: 10.1016/j.eclinm.2019.05.012] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2019] [Revised: 05/23/2019] [Accepted: 05/28/2019] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Whether continuous positive airway pressure (CPAP) treatment can improve depression or anxiety symptoms in obstructive sleep apnoea (OSA) patients remains uncertain. METHODS Secondary analysis of the Sleep Apnea Cardiovascular Endpoints (SAVE) trial, combined with a systematic review of randomised evidence. The SAVE secondary analyses involved 2410 patients with co-existing moderate-severe OSA and established cardiovascular disease randomly allocated to CPAP treatment plus usual care or usual care alone and followed up for 3·7 (SD 1·6) years. We evaluated the effect of CPAP treatment on depression and anxiety caseness (scores ≥ 8 on the Hospital Anxiety and Depression Scale depression and anxiety subscales [HADS-D and HADS-A]) for OSA patients. FINDINGS CPAP treatment was associated with reduced odds of depression caseness (adjusted odds ratio [OR] 0·80, 95% confidence interval [CI] 0·65-0·98, P = 0·031) compared to usual care in the SAVE trial and the treatment effect was greater in those with pre-existing depression symptoms. A systematic review of 20 randomised trials including 4255 participants confirmed a benefit of CPAP in reducing depression symptoms in OSA patients: the overall effect (standardised mean difference) was - 0·18 (95% CI - 0·24 to - 0·12). No effect of CPAP treatment on anxiety caseness was found both in patients of the SAVE study (adjusted OR 0·98, 95% CI 0·78-1·24, P = 0·89) and the systematic review. INTERPRETATION CPAP reduces depression symptoms in patients with co-existing OSA and CVD independently of improvements in sleepiness.
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Affiliation(s)
- Danni Zheng
- Centre for Big Data Research in Health, University of New South Wales, Sydney, NSW, Australia
- The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, NSW, Australia
| | - Ying Xu
- The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, NSW, Australia
- Sydney Medical School, University of Sydney, Sydney, NSW, Australia
| | - Shoujiang You
- Department of Neurology, The Second Affiliated Hospital of Soochow University, Suzhou, Jiangsu, PR China
| | - Maree L. Hackett
- The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, NSW, Australia
- Faculty of Health and Wellbeing, The University of Central Lancashire, Preston, Lancashire, UK
| | - Richard J. Woodman
- Flinders Centre for Epidemiology and Biostatistics, College of Medicine and Public Health, Flinders University, Adelaide, SA, Australia
| | - Qiang Li
- The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, NSW, Australia
| | - Mark Woodward
- The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, NSW, Australia
- The George Institute for Global Health, University of Oxford, Oxford, Oxfordshire, UK
- Department of Epidemiology, Johns Hopkins University, Baltimore, MD, USA
| | - Kelly A. Loffler
- Adelaide Institute for Sleep Health, Flinders University, Adelaide, SA, Australia
| | - Anthony Rodgers
- The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, NSW, Australia
| | - Luciano F. Drager
- Hypertension Unit, Heart Institute (InCor), University of Sao Paulo Medical School, Sao Paulo, Brazil
- Hypertension Unit, Renal Division, University of Sao Paulo Medical School, Sao Paulo, Brazil
| | - Geraldo Lorenzi-Filho
- Sleep Laboratory, Pulmonary Division, University of Sao Paulo Medical School, Sao Paulo, Brazil
| | - Xia Wang
- The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, NSW, Australia
| | - Wei Wei Quan
- Department of Cardiology, Rui Jin Hospital and Institute of Cardiovascular Diseases, Shanghai Jiao Tong University School of Medicine, Shanghai, PR China
| | - Manjari Tripathi
- Department of Neurology, All India Institute of Medical Sciences, Delhi, India
| | - Olga Mediano
- Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Madrid, Spain
- Respiratory Department, Hospital Universitario de Guadalajara, Universidad de Alcalá, Madrid, Spain
| | - Qiong Ou
- Sleep Center, Respiratory and Critical Medical Department, Guangdong Institute of Geriatrics, Guangdong Academy of Medical Sciences, Guangdong Provincial People's Hospital, Guangzhou 510000, Guangdong PR, PR China
| | - Rui Chen
- The Second Affiliated Hospital of Soochow University, Suzhou, Jiangsu, PR China
| | - Zhihong Liu
- Department of Cardiology, Fuwai Hospital, Beijing, PR China
| | - Xilong Zhang
- The First Affiliated Hospital of Nanjing Medical University, Nanjing, PR China
| | - Yuanming Luo
- The First Affiliated Hospital of Guangzhou Medical University, State Key Laboratory of Respiratory Disease, Guangzhou, PR China
| | - Nigel McArdle
- West Australian Sleep Disorders Research Institute, Department of Pulmonary Physiology and Sleep Medicine, Sir Charles Gairdner Hospital, Nedlands, WA, Australia
| | - Sutapa Mukherjee
- Adelaide Institute for Sleep Health, Flinders University, Adelaide, SA, Australia
- West Australian Sleep Disorders Research Institute, Department of Pulmonary Physiology and Sleep Medicine, Sir Charles Gairdner Hospital, Nedlands, WA, Australia
- Sleep Health Service, Respiratory and Sleep Services, Southern Adelaide Local Health Network, Flinders Medical Centre, Adelaide, SA, Australia
| | - R. Douglas McEvoy
- Adelaide Institute for Sleep Health, Flinders University, Adelaide, SA, Australia
- Sleep Health Service, Respiratory and Sleep Services, Southern Adelaide Local Health Network, Flinders Medical Centre, Adelaide, SA, Australia
| | - Craig S. Anderson
- The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, NSW, Australia
- Neurology Department, Royal Prince Alfred Hospital, Sydney Health Partners, Sydney, NSW, Australia
- The George Institute for Global Health China at Peking University Health Science Center, Beijing, PR China
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Abstract
PURPOSE OF REVIEW To summarize recent research investigating the interaction between obstructive sleep apnea (OSA) and anxiety, and contextualize their bidirectional relationship. RECENT FINDINGS Recent investigations corroborate the bidirectional relationship between sleep-disordered breathing (SDB) and anxiety, evaluate the etiological and clinical manifestations through different mechanisms, and provide insight into clinical implications of this interaction. Much of the literature about anxiety as it relates to SDB is from small samples, using different tools of symptom measurement that are often subjectively quantified. The objective severity of OSA does not appear to be associated with subjectively reported sleepiness and fatigue, whereas physiological manifestations of anxiety are associated with the severity of subjective symptoms reported. Recent findings support that women are more likely to have comorbid SDB and anxiety than men. SDB may precipitate and perpetuate anxiety, whereas anxiety in OSA negatively impacts quality-of-life. Treating SDB may improve anxiety symptoms, whereas anxiety symptoms can be an obstacle and deterrent to appropriate treatment. SUMMARY The interaction between anxiety and SDB is still poorly elucidated. Being aware of the clinical associations, risk factors, and treatment implications for SDB as related to anxiety disorders in different populations can help clinicians with the diagnosis and management of both SDB and anxiety.
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Liu T, Li W, Zhou H, Wang Z. Verifying the Relative Efficacy between Continuous Positive Airway Pressure Therapy and Its Alternatives for Obstructive Sleep Apnea: A Network Meta-analysis. Front Neurol 2017; 8:289. [PMID: 28701992 PMCID: PMC5487413 DOI: 10.3389/fneur.2017.00289] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2017] [Accepted: 06/06/2017] [Indexed: 12/21/2022] Open
Abstract
Obstructive sleep apnea (OSA) is a common breathing disorder, and continuous positive airway pressure (CPAP) therapy together with its alternatives has been developed to treat this disease. This network meta-analysis (NMA) was aimed to compare the efficacy of treatments for OSA. Cochrane Library, MEDLINE, and Embase were searched for eligible studies. A conventional and NMA was carried out to compare all therapies. Sleeping characteristics, including Apnea–Hypopnea Index (AHI), Epworth Sleepiness Scale (ESS), arterial oxygen saturation, and arousal index (AI), and changes of blood pressure were selected as outcomes. A total of 84 studies were finally included after rigorous screenings. For the primary outcomes of AHI and ESS, the value of auto-adjusting positive airway pressure (APAP), CPAP, and oral appliance (OA) all showed statistically reduction compared with inactive control (IC). Similar observation was obtained in AI, with treatments of the three active interventions. A lower effect of IC in SaO2 was exhibited when compared with APAP, CPAP, and OA. Similar statistically significant results were presented in 24 h systolic blood pressure and 24 h DBP when comparing with CPAP. Our NMA identified CPAP as the most efficacious treatment for OSA patients after the evaluation of sleeping characteristics and blood pressures. In addition, more clinical trials are needed for further investigation due to the existence of inconsistency observed in this study.
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Affiliation(s)
- Tingwei Liu
- Department of Respiratory Medicine, First Affiliated Hospital of China Medical University, Shenyang, China
| | - Wenyang Li
- Department of Respiratory Medicine, First Affiliated Hospital of China Medical University, Shenyang, China
| | - Hui Zhou
- Department of Respiratory Medicine, First Affiliated Hospital of China Medical University, Shenyang, China
| | - Zanfeng Wang
- Department of Respiratory Medicine, First Affiliated Hospital of China Medical University, Shenyang, China
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Wang Y, Ai L, Luo J, Li R, Chai Y, He X, Cao Y, Li Y. Effect of adherence on daytime sleepiness, fatigue, depression and sleep quality in the obstructive sleep apnea/hypopnea syndrome patients undertaking nasal continuous positive airway pressure therapy. Patient Prefer Adherence 2017; 11:769-779. [PMID: 28442894 PMCID: PMC5396979 DOI: 10.2147/ppa.s128217] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
OBJECTIVES The aims of this study were to describe changes in day- and nighttime symptoms and the adherence to nasal continuous positive airway pressure (nCPAP) during the first 3-month nCPAP therapy among newly diagnosed patients with obstructive sleep apnea/hypopnea syndrome (OSAS) and to identify the effect of adherence on the changes in day- and nighttime symptoms during the first 3 months. METHODS Newly diagnosed OSAS patients were consecutively recruited from March to August 2013. Baseline clinical information and measures of the Epworth Sleepiness Scale (ESS), Fatigue Severity Scale (FSS), Zung's Self-Rating Depression Scale (SDS) and the Pittsburgh Sleep Quality Index (PSQI) at baseline and the end of 3rd, 6th, 9th and 12th week of therapy were collected. Twelve weeks' adherence was calculated as the average of each 3-week period. Mixed model was used to explore the effect of adherence to nCPAP therapy on ESS, FSS, SDS and PSQI in each 3-week phase. RESULTS Seventy-six patients completed the 12-week follow-up. The mixed-effects models showed that under the control of therapy phase adherence in the range of <4 hours per night, using nCPAP could independently improve daytime sleepiness, in terms of ESS (coefficient, [95% confidence interval] unit; -4.49 [-5.62, -3.36]). Adherence at 4-6 hours per night could independently improve all variables of day- and nighttime symptoms included in this study, namely ESS -6.69 (-7.40, -5.99), FSS -6.02 (-7.14, -4.91), SDS -2.40 (-2.95, -1.85) and PSQI -0.20 (-0.52, -0.12). Further improvement in symptoms could be achieved at ≥6 hours per night using nCPAP, which was ESS -8.35 (-9.26, -7.44), FSS -10.30 (-11.78, -8.83), SDS -4.42 (-5.15, -3.68) and PSQI -0.40 (-0.82, -0.02). The interaction between adherence level and therapy phase was not significant in day- and nighttime symptoms. CONCLUSION The effect of adherence on the above-mentioned symptoms is stable through the first 3 months. Under the control of therapy phase, the nCPAP therapy effectively improves day- and nighttime symptoms with ≥4 hours adherence, and the patients can achieve a further improvement with ≥6 hours adherence.
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Affiliation(s)
- Yeying Wang
- Department of Respiratory Medicine, The Second Affiliated Hospital of Kunming Medical University
- Department of Epidemiology and Biostatistics, School of Public Health, Kunming Medical University, Chenggong New City, Kunming, Yunnan Province, People’s Republic of China
| | - Li Ai
- Department of Respiratory Medicine, The Second Affiliated Hospital of Kunming Medical University
| | - Jiahong Luo
- Department of Epidemiology and Biostatistics, School of Public Health, Kunming Medical University, Chenggong New City, Kunming, Yunnan Province, People’s Republic of China
| | - Ran Li
- Department of Respiratory Medicine, The Second Affiliated Hospital of Kunming Medical University
| | - Yanlin Chai
- Department of Respiratory Medicine, The Second Affiliated Hospital of Kunming Medical University
| | - Xiaojie He
- Department of Respiratory Medicine, The Second Affiliated Hospital of Kunming Medical University
| | - Yu Cao
- Department of Respiratory Medicine, The Second Affiliated Hospital of Kunming Medical University
| | - Yongxia Li
- Department of Respiratory Medicine, The Second Affiliated Hospital of Kunming Medical University
- Correspondence: Yongxia Li, Department of Respiratory Medicine, The Second Affiliated Hospital of Kunming Medical University, No 374 Dianmian Road, Kunming 650101, Yunnan Province, People’s Republic of China, Tel +86 136 5881 0805, Fax +86 871 6535 2087, Email
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Devita M, Montemurro S, Ramponi S, Marvisi M, Villani D, Raimondi MC, Rusconi ML, Mondini S. Obstructive sleep apnea and its controversial effects on cognition. J Clin Exp Neuropsychol 2016; 39:659-669. [PMID: 27845600 DOI: 10.1080/13803395.2016.1253668] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Obstructive sleep apnea syndrome is a sleep disorder that may affect many brain functions. We are interested in the cognitive consequences of the condition with regard to the quality of life of individuals with this disorder. A debate is still underway as to whether cognitive difficulties caused by obstructive sleep apnea actually induce a "pseudodementia" pattern. This work provides a brief overview of the main controversies currently surrounding this issue. We report findings and opinions on structural and cognitive brain changes in individuals affected by obstructive sleep apnea by highlighting the involvement of executive functions and the possible reversibility of signs following-treatment with continuous positive airway pressure. Much research has been done on this issue but, to the best of our knowledge, a review of the present state of the literature evaluating different points of view has not yet been carried out.
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Affiliation(s)
- Maria Devita
- a Department of Human and Social Sciences , University of Bergamo , Bergamo , Italy
| | - Sonia Montemurro
- b Department of General Psychology , University of Padua , Padua , Italy.,c Human Inspired Technology Research Centre , University of Padua , Padua , Italy
| | - Sara Ramponi
- d Internal Medicine Unit , Figlie di S. Camillo , Cremona , Italy
| | - Maurizio Marvisi
- d Internal Medicine Unit , Figlie di S. Camillo , Cremona , Italy.,e Department of Internal Medicine and Pneumology , University of Parma , Parma , Italy
| | - Daniele Villani
- f Neuromotor Rehabilitation Unit , Figlie di S. Camillo , Cremona , Italy
| | | | - Maria Luisa Rusconi
- a Department of Human and Social Sciences , University of Bergamo , Bergamo , Italy
| | - Sara Mondini
- b Department of General Psychology , University of Padua , Padua , Italy.,c Human Inspired Technology Research Centre , University of Padua , Padua , Italy
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Li YY, Mazarakis T, Shen YC, Yang MC, Chang ET, Wang HM. Anxiety and depression are improved by continuous positive airway pressure treatments in obstructive sleep apnea. Int J Psychiatry Med 2016. [PMID: 28629298 DOI: 10.1177/0091217417696737] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Background Obstructive sleep apnea involves repeated nocturnal desaturation and sleep fragmentation that leads to poor sleep quality, anxiety, and depression. This study aimed to investigate short- and long-term improvements in the anxiety and depression of patients with different obstructive sleep apnea treatments. Methods This is a prospective, non-randomized hospital-based study evaluated 55 patients (46 male, 9 female) with obstructive sleep apnea. The patients were divided into three groups based on different treatment: uvulopalatopharyngoplasty group, continuous positive airway pressure group, and no treatment group (by their own decision). They completed the Beck Depression Inventory II, Beck Anxiety Inventory, and Pittsburgh Sleep Quality Index before treatment and at one and six months after treatment. Results Compared to the no treatment group, the surgery and continuous positive airway pressure groups had higher body mass index, AHI, and Epworth sleepiness scale, but no difference in Pittsburgh Sleep Quality Index, Chinese Health Questionnaire-12, Beck Depression Inventory II, and Beck Anxiety Inventory. The continuous positive airway pressure and surgery groups still had no improvements in Pittsburgh Sleep Quality Index, Chinese Health Questionnaire-12, Beck Depression Inventory II, and Beck Anxiety Inventory scores one month after treatment. At six months after treatment, the continuous positive airway pressure group had significantly decreased Pittsburgh Sleep Quality Index, Chinese Health Questionnaire-12, Beck Depression Inventory II, and Beck Anxiety Inventory, whereas the surgery group had significant difference in Beck Anxiety Inventory only and the no treatment group still had no significant difference in any of the parameters. Conclusions Continuous positive airway pressure can improve the sleep quality, quality of life, depression, and anxiety of obstructive sleep apnea patients after six months of treatment. However, surgery can significantly improve anxiety only in the same period.
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Affiliation(s)
- Yu-Ying Li
- 1 Department of Counseling and Clinical Psychology, National Dong Hwa University, Hualien, Taiwan
| | - Thodoris Mazarakis
- 1 Department of Counseling and Clinical Psychology, National Dong Hwa University, Hualien, Taiwan
| | - Yu-Chih Shen
- 2 Department of Psychiatry, Buddhist Tzu Chi General Hospital, Hualien, Taiwan.,3 School of Medicine, Tzu Chi University, Hualien, Taiwan
| | - Miao-Chun Yang
- 4 Department of Otolaryngology, Buddhist Tzu Chi General Hospital, Hualien, Taiwan
| | - En-Ting Chang
- 3 School of Medicine, Tzu Chi University, Hualien, Taiwan.,5 Division of Chest Medicine, Department of Internal Medicine, Buddhist Tzu Chi General Hospital, Hualien, Taiwan
| | - Hsiu-Mei Wang
- 5 Division of Chest Medicine, Department of Internal Medicine, Buddhist Tzu Chi General Hospital, Hualien, Taiwan
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17
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The effect of treating obstructive sleep apnea with positive airway pressure on depression and other subjective symptoms: A systematic review and meta-analysis. Sleep Med Rev 2016; 28:55-68. [DOI: 10.1016/j.smrv.2015.07.002] [Citation(s) in RCA: 77] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2015] [Revised: 06/26/2015] [Accepted: 07/13/2015] [Indexed: 01/18/2023]
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19
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Iftikhar IH, Bittencourt L, Youngstedt SD, Ayas N, Cistulli P, Schwab R, Durkin MW, Magalang UJ. Comparative efficacy of CPAP, MADs, exercise-training, and dietary weight loss for sleep apnea: a network meta-analysis. Sleep Med 2016; 30:7-14. [PMID: 28215266 DOI: 10.1016/j.sleep.2016.06.001] [Citation(s) in RCA: 79] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2016] [Revised: 05/30/2016] [Accepted: 06/13/2016] [Indexed: 01/18/2023]
Abstract
STUDY OBJECTIVE To synthesize evidence from available studies on the relative efficacies of continuous positive airway pressure (CPAP), mandibular advancement device (MAD), supervised aerobic exercise training, and dietary weight loss in patients with obstructive sleep apnea (OSA). DESIGN Network meta-analysis of 80 randomized controlled trials (RCTs) short-listed from PubMed, SCOPUS, Web of science, and Cochrane register (inception - September 8, 2015). PATIENTS Individuals with OSA. INTERVENTIONS CPAP, MADs, exercise training, and dietary weight loss. RESULTS CPAP decreased apnea-hypopnea index (AHI) the most [by 25.27 events/hour (22.03-28.52)] followed by exercise training, MADs, and dietary weight loss. While the difference between exercise training and CPAP was non-significant [-8.04 (-17.00 to 0.92), a significant difference was found between CPAP and MADs on AHI and oxygen desaturation index (ODI) [-10.06 (-14.21 to -5.91) and -7.82 (-13.04 to -2.59), respectively]. Exercise training significantly improved Epworth sleepiness scores (ESS) [by 3.08 (0.68-5.48)], albeit with a non-significant difference compared to MADs and CPAP. CONCLUSIONS CPAP is the most efficacious in complete resolution of sleep apnea and in improving the indices of saturation during sleep. While MADs offer a reasonable alternative to CPAP, exercise training which significantly improved daytime sleepiness (ESS) could be used as adjunctive to the former two.
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Affiliation(s)
- Imran H Iftikhar
- Division of Pulmonary, Allergy, Critical Care & Sleep Medicine, Emory University, Atlanta, GA, USA.
| | - Lia Bittencourt
- Departmento de Psicobiologia, Universidade Federal de São Paulo (UNIFESP), São Paulo, SP, Brazil
| | - Shawn D Youngstedt
- College of Nursing and Health Innovation, Arizona State University, Phoenix, AZ, USA
| | - Najib Ayas
- Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Peter Cistulli
- Department of Respiratory and Sleep Medicine, Royal North Shore Hospital, and Sydney Medical School, University of Sydney, Australia
| | - Richard Schwab
- Department of Medicine, Division of Sleep Medicine, Pulmonary, Allergy and Critical Care, University of Pennsylvania Medical Center, Philadelphia, PA, USA
| | - Martin W Durkin
- Department of Clinical Research, Palmetto Health Richland, Columbia, SC, USA
| | - Ulysses J Magalang
- Division of Pulmonary, Allergy, Critical care & Sleep Medicine, The Ohio State University Wexner Medical Center, Columbus, OH, USA
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Sharples LD, Clutterbuck-James AL, Glover MJ, Bennett MS, Chadwick R, Pittman MA, Quinnell TG. Meta-analysis of randomised controlled trials of oral mandibular advancement devices and continuous positive airway pressure for obstructive sleep apnoea-hypopnoea. Sleep Med Rev 2016; 27:108-24. [PMID: 26163056 PMCID: PMC5378304 DOI: 10.1016/j.smrv.2015.05.003] [Citation(s) in RCA: 133] [Impact Index Per Article: 16.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2014] [Revised: 04/17/2015] [Accepted: 05/15/2015] [Indexed: 02/01/2023]
Abstract
Obstructive sleep apnoea-hypopnoea (OSAH) causes excessive daytime sleepiness, impairs quality-of-life, and increases cardiovascular disease and road traffic accident risks. Continuous positive airway pressure (CPAP) treatment and mandibular advancement devices (MAD) have been shown to be effective in individual trials but their effectiveness particularly relative to disease severity is unclear. A MEDLINE, Embase and Science Citation Index search updating two systematic reviews to August 2013 identified 77 RCTs in adult OSAH patients comparing: MAD with conservative management (CM); MAD with CPAP; or CPAP with CM. Overall MAD and CPAP significantly improved apnoea-hypopnoea index (AHI) (MAD -9.3/hr (p < 0.001), CPAP -25.4 (p < 0.001)). In direct comparisons mean AHI and Epworth sleepiness scale score were lower (7.0/hr (p < 0.001) and 0.67 (p = 0.093) respectively) for CPAP. There were no CPAP vs. MAD trials in mild OSAH but in comparisons with CM, MAD and CPAP reduced ESS similarly (MAD 2.01 (p < 0.001); CPAP 1.23 (p = 0.012). Both MAD and CPAP are clinically effective in the treatment of OSAH. Although CPAP has a greater treatment effect, MAD is an appropriate treatment for patients who are intolerant of CPAP and may be comparable to CPAP in mild disease.
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Affiliation(s)
- Linda D Sharples
- University of Leeds Clinical Trials Research Unit, Leeds, United Kingdom; Medical Research Council Biostatistics Unit, Cambridge, United Kingdom.
| | | | - Matthew J Glover
- Health Economics Research Unit, Brunel University, Uxbridge, Middlesex, United Kingdom
| | - Maxine S Bennett
- Medical Research Council Biostatistics Unit, Cambridge, United Kingdom
| | - Rebecca Chadwick
- University Hospitals Coventry and Warwickshire NHS Trust, Coventry, United Kingdom
| | - Marcus A Pittman
- Papworth Hospital NHS Foundation Trust, Papworth Everard, Cambridge, United Kingdom
| | - Timothy G Quinnell
- Papworth Hospital NHS Foundation Trust, Papworth Everard, Cambridge, United Kingdom
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Kerner NA, Roose SP. Obstructive Sleep Apnea is Linked to Depression and Cognitive Impairment: Evidence and Potential Mechanisms. Am J Geriatr Psychiatry 2016; 24:496-508. [PMID: 27139243 PMCID: PMC5381386 DOI: 10.1016/j.jagp.2016.01.134] [Citation(s) in RCA: 160] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2015] [Revised: 11/17/2015] [Accepted: 01/12/2016] [Indexed: 12/19/2022]
Abstract
Obstructive sleep apnea (OSA) is highly prevalent but very frequently undiagnosed. OSA is an independent risk factor for depression and cognitive impairment/dementia. Herein the authors review studies in the literature pertinent to the effects of OSA on the cerebral microvascular and neurovascular systems and present a model to describe the key pathophysiologic mechanisms that may underlie the associations, including hypoperfusion, endothelial dysfunction, and neuroinflammation. Intermittent hypoxia plays a critical role in initiating and amplifying these pathologic processes. Hypoperfusion and impaired cerebral vasomotor reactivity lead to the development or progression of cerebral small vessel disease (C-SVD). Hypoxemia exacerbates these processes, resulting in white matter lesions, white matter integrity abnormalities, and gray matter loss. Blood-brain barrier (BBB) hyperpermeability and neuroinflammation lead to altered synaptic plasticity, neuronal damage, and worsening C-SVD. Thus, OSA may initiate or amplify the pathologic processes of C-SVD and BBB dysfunction, resulting in the development or exacerbation of depressive symptoms and cognitive deficits. Given the evidence that adequate treatment of OSA with continuous positive airway pressure improves depression and neurocognitive functions, it is important to identify OSA when assessing patients with depression or cognitive impairment. Whether treatment of OSA changes the deteriorating trajectory of elderly patients with already-diagnosed vascular depression and cognitive impairment/dementia remains to be determined in randomized controlled trials.
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Sforza E, Saint Martin M, Barthélémy JC, Roche F. Mood disorders in healthy elderly with obstructive sleep apnea: a gender effect. Sleep Med 2016; 19:57-62. [DOI: 10.1016/j.sleep.2015.11.007] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2015] [Revised: 10/16/2015] [Accepted: 11/04/2015] [Indexed: 11/25/2022]
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Sharples L, Glover M, Clutterbuck-James A, Bennett M, Jordan J, Chadwick R, Pittman M, East C, Cameron M, Davies M, Oscroft N, Smith I, Morrell M, Fox-Rushby J, Quinnell T. Clinical effectiveness and cost-effectiveness results from the randomised controlled Trial of Oral Mandibular Advancement Devices for Obstructive sleep apnoea-hypopnoea (TOMADO) and long-term economic analysis of oral devices and continuous positive airway pressure. Health Technol Assess 2015; 18:1-296. [PMID: 25359435 DOI: 10.3310/hta18670] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Obstructive sleep apnoea-hypopnoea (OSAH) causes excessive daytime sleepiness (EDS), impairs quality of life (QoL) and increases cardiovascular disease and road traffic accident risks. Continuous positive airway pressure (CPAP) treatment is clinically effective but undermined by intolerance, and its cost-effectiveness is borderline in milder cases. Mandibular advancement devices (MADs) are another option, but evidence is lacking regarding their clinical effectiveness and cost-effectiveness in milder disease. OBJECTIVES (1) Conduct a randomised controlled trial (RCT) examining the clinical effectiveness and cost-effectiveness of MADs against no treatment in mild to moderate OSAH. (2) Update systematic reviews and an existing health economic decision model with data from the Trial of Oral Mandibular Advancement Devices for Obstructive sleep apnoea-hypopnoea (TOMADO) and newly published results to better inform long-term clinical effectiveness and cost-effectiveness of MADs and CPAP in mild to moderate OSAH. TOMADO A crossover RCT comparing clinical effectiveness and cost-effectiveness of three MADs: self-moulded [SleepPro 1™ (SP1); Meditas Ltd, Winchester, UK]; semibespoke [SleepPro 2™ (SP2); Meditas Ltd, Winchester, UK]; and fully bespoke [bespoke MAD (bMAD); NHS Oral-Maxillofacial Laboratory, Addenbrooke's Hospital, Cambridge, UK] against no treatment, in 90 adults with mild to moderate OSAH. All devices improved primary outcome [apnoea-hypopnoea index (AHI)] compared with no treatment: relative risk 0.74 [95% confidence interval (CI) 0.62 to 0.89] for SP1; relative risk 0.67 (95% CI 0.59 to 0.76) for SP2; and relative risk 0.64 (95% CI 0.55 to 0.76) for bMAD (p < 0.001). Differences between MADs were not significant. Sleepiness [as measured by the Epworth Sleepiness Scale (ESS)] was scored 1.51 [95% CI 0.73 to 2.29 (SP1)] to 2.37 [95% CI 1.53 to 3.22 (bMAD)] lower than no treatment (p < 0.001), with SP2 and bMAD significantly better than SP1. All MADs improved disease-specific QoL. Compliance was lower for SP1, which was unpopular at trial exit. At 4 weeks, all devices were cost-effective at £20,000/quality-adjusted life-year (QALY), with SP2 the best value below £39,800/QALY. META-ANALYSIS A MEDLINE, EMBASE and Science Citation Index search updating two existing systematic reviews (one from November 2006 and the other from June 2008) to August 2013 identified 77 RCTs in adult OSAH patients comparing MAD with conservative management (CM), MADs with CPAP or CPAP with CM. MADs and CPAP significantly improved AHI [MAD -9.3/hour (p < 0.001); CPAP -25.4/hour (p < 0.001)]. Effect difference between CPAP and MADs was 7.0/hour (p < 0.001), favouring CPAP. No trials compared CPAP with MADs in mild OSAH. MAD and CPAP reduced the ESS score similarly [MAD 1.6 (p < 0.001); CPAP 1.6 (p < 0.001)]. LONG-TERM COST-EFFECTIVENESS An existing model assessed lifetime cost-utility of MAD and CPAP in mild to moderate OSAH, using the revised meta-analysis to update input values. The TOMADO provided utility estimates, mapping ESS score to European Quality of Life-5 Dimensions three-level version for device cost-utility. Using SP2 as the standard device, MADs produced higher mean costs and mean QALYs than CM [incremental cost-effectiveness ratio (ICER) £6687/QALY]. From a willingness to pay (WTP) of £15,367/QALY, CPAP is cost-effective, although the likelihood of MADs (p = 0.48) and CPAP (p = 0.49) being cost-effective is very similar. Both were better than CM, but there was much uncertainty in the choice between CPAP and MAD (at a WTP £20,000/QALY, the probability of being the most cost-effective was 47% for MAD and 52% for CPAP). When SP2 lifespan increased to 18 months, the ICER for CPAP compared with MAD became £44,066. The ICER for SP1 compared with CM was £1552, and for bMAD compared with CM the ICER was £13,836. The ICER for CPAP compared with SP1 was £89,182, but CPAP produced lower mean costs and higher mean QALYs than bMAD. Differential compliance rates for CPAP reduces cost-effectiveness so MADs become less costly and more clinically effective with CPAP compliance 90% of SP2. CONCLUSIONS Mandibular advancement devices are clinically effective and cost-effective in mild to moderate OSAH. A semi-bespoke MAD is the appropriate first choice in most patients in the short term. Future work should explore whether or not adjustable MADs give additional clinical and cost benefits. Further data on longer-term cardiovascular risk and its risk factors would reduce uncertainty in the health economic model and improve precision of effectiveness estimates. TRIAL REGISTRATION This trial is registered as ISRCTN02309506. FUNDING This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 18, No. 67. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Linda Sharples
- University of Leeds Clinical Trials Research Unit, Leeds, UK
| | - Matthew Glover
- Health Economics Research Unit, Brunel University, Uxbridge, UK
| | | | - Maxine Bennett
- Medical Research Council Biostatistics Unit, Cambridge, UK
| | - Jake Jordan
- Health Economics Research Unit, Brunel University, Uxbridge, UK
| | - Rebecca Chadwick
- Papworth Hospital NHS Foundation Trust, Papworth Everard, Cambridge, UK
| | - Marcus Pittman
- Papworth Hospital NHS Foundation Trust, Papworth Everard, Cambridge, UK
| | - Clare East
- Papworth Hospital NHS Foundation Trust, Papworth Everard, Cambridge, UK
| | - Malcolm Cameron
- Maxillofacial Unit, Addenbrooke's NHS Foundation Trust, Cambridge, UK
| | - Mike Davies
- Papworth Hospital NHS Foundation Trust, Papworth Everard, Cambridge, UK
| | - Nick Oscroft
- Papworth Hospital NHS Foundation Trust, Papworth Everard, Cambridge, UK
| | - Ian Smith
- Papworth Hospital NHS Foundation Trust, Papworth Everard, Cambridge, UK
| | - Mary Morrell
- National Heart and Lung Institute, Imperial College London, London, UK
| | | | - Timothy Quinnell
- Papworth Hospital NHS Foundation Trust, Papworth Everard, Cambridge, UK
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Abstract
Sleep-disordered breathing, the commonest form of which is obstructive sleep apnoea (OSA) is increasingly recognised as a treatable cause of morbidity. It shares many risk factors with psychiatric disorders including behaviours such as smoking and physical comorbidity. Many symptoms of the two overlap, leaving OSA often undetected and undertreated. In the few studies that assess the two, OSA is commonly comorbid with depression (17-45%) and schizophrenia (up to 55%) and possibly bipolar. There is some limited evidence that treating OSA can ameliorate psychiatric symptoms. Some psychotropics, such as narcotics, cause sleep-disordered breathing (SDB), whilst weight-inducing neuroleptics may exacerbate it. An extreme form of SDB, sudden infant death syndrome (SIDS), is a risk in mothers with substance abuse. Being aware of these common comorbidities may help improve psychiatric patient's treatment and quality of life.
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Effect of treatment of obstructive sleep apnea on depressive symptoms: systematic review and meta-analysis. PLoS Med 2014; 11:e1001762. [PMID: 25423175 PMCID: PMC4244041 DOI: 10.1371/journal.pmed.1001762] [Citation(s) in RCA: 94] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2014] [Accepted: 10/17/2014] [Indexed: 01/06/2023] Open
Abstract
BACKGROUND Obstructive sleep apnea (OSA) is associated with increased morbidity and mortality, and decreased quality of life. Treatment with continuous positive airway pressure (CPAP) or mandibular advancement devices (MADs) is effective for many symptoms of OSA. However, it remains controversial whether treatment with CPAP or MAD also improves depressive symptoms. METHODS AND FINDINGS We performed a systematic review and meta-analysis of randomized controlled trials that examined the effect of CPAP or MADs on depressive symptoms in patients with OSA. We searched Medline, EMBASE, the Cochrane Central Registry of Controlled Trials, and PsycINFO from the inception of the databases until August 15, 2014, for relevant articles. In a random effects meta-analysis of 19 identified trials, CPAP treatment resulted in an improvement in depressive symptoms compared to control, but with significant heterogeneity between trials (Q statistic, p<0.001; I(2) = 71.3%, 95% CI: 54%, 82%). CPAP treatment resulted in significantly greater improvement in depressive symptoms in the two trials with a higher burden of depression at baseline (meta-regression, p<0.001). The pooled standardized mean difference (SMD) in depressive symptoms with CPAP treatment in these two trial populations with baseline depression was 2.004 (95% CI: 1.387, 2.621), compared to 0.197 (95% CI: 0.059, 0.334) for 15 trials of populations without depression at baseline. Pooled estimates of the treatment effect of CPAP were greater in parallel arm trials than in crossover trials (meta-regression, p = 0.076). Random effects meta-analysis of five trials of MADs showed a significant improvement in depressive symptoms with MADs versus controls: SMD = 0.214 (95% CI: 0.026, 0.401) without significant heterogeneity (I(2) = 0%, 95% CI: 0%, 79%). Studies were limited by the use of depressive symptom scales that have not been validated specifically in people with OSA. CONCLUSIONS CPAP and MADs may be useful components of treatment of depressive symptoms in individuals with OSA and depression. The efficacy of CPAP and MADs compared to standard therapies for depression is unknown. Please see later in the article for the Editors' Summary.
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Gagnadoux F, Le Vaillant M, Goupil F, Pigeanne T, Chollet S, Masson P, Bizieux-Thaminy A, Humeau MP, Meslier N. Depressive Symptoms Before and After Long-term CPAP Therapy in Patients With Sleep Apnea. Chest 2014; 145:1025-1031. [DOI: 10.1378/chest.13-2373] [Citation(s) in RCA: 56] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
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Carissimi A, Martinez D, Kim LJ, Fiori CZ. Factors influencing the response of psychological symptoms to continuous positive airway pressure therapy. Sleep Breath 2013; 18:499-507. [DOI: 10.1007/s11325-013-0911-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2013] [Revised: 10/03/2013] [Accepted: 11/04/2013] [Indexed: 11/25/2022]
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Yilmaz E, Sedky K, Bennett DS. The relationship between depressive symptoms and obstructive sleep apnea in pediatric populations: a meta-analysis. J Clin Sleep Med 2013; 9:1213-20. [PMID: 24235907 DOI: 10.5664/jcsm.3178] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND A higher incidence of depressive disorders and symptoms has been suggested among children suffering from obstructive sleep apnea (OSA). Yet, the extent to which OSA is related to increased depression is unclear. OBJECTIVES To evaluate (a) the relationship between depressive symptoms and OSA in pediatric populations, and (b) the efficacy of adenotonsillectomy (AT) for decreasing depressive symptoms among children with OSA. METHODS A meta-analysis was conducted to assess the relationship between depressive symptoms and OSA, and the efficacy of AT for decreasing depressive symptoms. Studies reporting depressive symptoms of children with OSA through January 2013 were included. RESULTS Eleven studies assessed depressive symptoms in both children diagnosed with OSA (n = 894) and a comparison group (n = 1,096). A medium relationship was found between depressive symptoms and OSA (Hedges' g = 0.43, 95% CI: 0.22-0.64; p = 0.0005). Addressing the second question, 9 studies (n = 379 children) examined depressive symptoms pre- and post-AT. A medium improvement in depressive symptoms was found at follow-up (Hedge's g = 0.41, 95% CI: 0.20-0.62; p ≤ 0.001). CONCLUSION Our findings suggest that depressive symptoms are higher among children with OSA. Therefore, patients with depressive symptomatology should receive screening for sleep disordered breathing. Treatment of OSA with AT might decrease clinical symptoms of depression, reduce pharmacotherapy, improve sleep patterns, and promote better health.
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Affiliation(s)
- Elif Yilmaz
- Department of Child and Adolescent Psychiatry, Drexel University College of Medicine, Philadelphia, PA
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Abstract
This article analyzes late-life depression, looking carefully at what defines a person as elderly, the incidence of late-life depression, complications and differences in symptoms between young and old patients with depression, subsyndromal depression, bipolar depression in the elderly, the relationship between grief and depression, along with sleep disturbances and suicidal ideation.
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Affiliation(s)
- Zahinoor Ismail
- Hotchkiss Brain Institute, University of Calgary, 1402 29 St NW, Calgary, Alberta, Canada T2N 2T9; University of Toronto, Toronto, Ontario, Canada.
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Perioperative Auto-titrated Continuous Positive Airway Pressure Treatment in Surgical Patients with Obstructive Sleep Apnea. Anesthesiology 2013; 119:837-47. [DOI: 10.1097/aln.0b013e318297d89a] [Citation(s) in RCA: 76] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Abstract
Background:
Obstructive sleep apnea (OSA) may worsen postoperatively. The objective of this randomized open-label trial is to determine whether perioperative auto-titrated continuous positive airway pressure (APAP) treatment decreases postoperative apnea hypopnea index (AHI) and improves oxygenation in patients with moderate and severe OSA.
Methods:
The consented patients with AHI of more than 15 events/h on preoperative polysomnography were randomized into the APAP or control group (receiving routine care). The APAP patients received APAP for 2 or 3 preoperative, and 5 postoperative nights. All patients were monitored with oximetry for 7 to 8 nights (N) and underwent polysomnography on postoperative N3. The primary outcome was AHI on the postoperative N3.
Results:
One hundred seventy-seven OSA patients undergoing orthopedic and other surgeries were enrolled (APAP: 87 and control: 90). There was no difference between the two groups in baseline data. One hundred six patients (APAP: 40 and control: 66) did polysomnography on postoperative N3, and 100 patients (APAP: 39 and control: 61) completed the study. The compliance rate of APAP was 45%. The APAP usage was 2.4–4.6 h/night. In the APAP group, AHI decreased from preoperative baseline: 30.1 (22.1, 42.5) events/h (median [25th, 75th percentile]) to 3.0 (1.0, 12.5) events/h on postoperative N3 (P < 0.001), whereas, in the control group, AHI increased from 30.4 (23.2, 41.9) events/h to 31.9 (13.5, 50.2) events/h, P = 0.302. No significant change occurred in the central apnea index.
Conclusions:
The trial showed the feasibility of perioperative APAP for OSA patients. Perioperative APAP treatment significantly reduced postoperative AHI and improved oxygen saturation in the patients with moderate and severe OSA.
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Comments on “Effect of three weeks of continuous airway pressure treatment on mood in patients with obstructive sleep apnoea: A randomized placebo-controlled trial”. Sleep Med 2012; 13:965-6; author reply 966-7. [DOI: 10.1016/j.sleep.2012.05.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2012] [Accepted: 05/08/2012] [Indexed: 11/24/2022]
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Lee IS, Dimsdale JE. Response from authors. Sleep Med 2012. [DOI: 10.1016/j.sleep.2012.05.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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