Frequency and outcomes of primary central sleep apnea in a population-based study

The enigma of sleep: Implications of sleep neuroscience for the dental clinician and patient

BACKGROUND

Sleep disturbances have been shown to result in considerable morbidity and mortality. It is important for dental clinicians to understand the neuroscience behind sleep disorders.

TYPES OF STUDIES REVIEWED

The authors conducted a search of the literature published from January 1990 through March 2024 of sleep medicine-related articles, with a focus on neuroscience. The authors prioritized articles about the science of sleep as related to dental medicine.

RESULTS

The authors found a proliferation of articles related to sleep neuroscience along with its implications in dental medicine. The authors also found that the intricate neuroscientific principles of sleep medicine are being investigated robustly. The salient features of, and the differences between, central and obstructive sleep apneas have been elucidated. Sleep genes, such as CRY, PER1, PER2, and CLOCK, and their relationship to cancer and neurodegeneration are also additions to this rapidly developing science.

CONCLUSIONS AND PRACTICAL IMPLICATIONS

The dental clinician has the potential to be the first to screen patients for possible sleep disorders and make prompt referrals to the appropriate medical professionals. This can be lifesaving as well as minimize potential future morbidity for the patient.

Predictors of Initial CPAP Prescription and Subsequent Course with CPAP in Patients with Central Sleep Apneas at a Single Center

PURPOSE

Guidelines recommend considering an initial trial of continuous positive airway pressure (CPAP) to treat central sleep apnea (CSA). However, practice patterns vary widely. This study investigated predictors for an initial trial of CPAP in patients with central apneas and whether those factors predict adequate treatment response in patients receiving an initial CPAP trial.

METHODS

Charts of patients receiving a diagnostic code for CSA following a sleep study during 2016-2018 at a single center were reviewed. Patient factors, initial treatment prescriptions, and subsequent changes to therapy were extracted from electronic health records. Regression models were used to estimate factors associated with an initial CPAP prescription and the likelihood of an adequate CPAP response (no subsequent therapy change and no discontinuation of therapy) among patients prescribed CPAP.

RESULTS

429/588 (73%) patients with central apneas received an initial trial of CPAP. Younger age, diagnosis by home sleep testing, non-opiate etiology of central apneas, and a lower proportion of central apneas at diagnosis were independently associated with a higher likelihood of an initial CPAP trial. A lower proportion of central apneas was associated with a higher probability of adequate response, while current smoking and opiate-related central apneas predicted an unsuccessful CPAP trial. A new finding was that older age predicted a lower likelihood of an initial CPAP prescription but did not predict an unsatisfactory response to CPAP.

CONCLUSION

Clinicians may incorrectly weigh certain clinical and sleep study characteristics when deciding whether to trial CPAP for patients with central apneas.

Contribution of central sleep apnea to severe sleep apnea hypopnea syndrome

PURPOSE

Central sleep apnea (CSA) is usually distinguished from obstructive sleep apnea (OSA). In fact, CSA is often a component of severe sleep apnea hypopnea syndrome (SAHS), rather than occurring alone. We investigated the clinical characteristics and polysomnography (PSG) parameters of CSA components in patients with severe SAHS.

METHODS

The clinical characteristics and PSG parameters were retrospectively analyzed.

RESULTS

Pure or dominant CSA was rare (5% of all patients). Of all patients with CSA, 72% also exhibited other apnea subtypes that contributed to severe SAHS. Among patients with severe SAHS, those with CSA were more likely than others to be older; thinner; exhibit higher prevalences of comorbid coronary heart disease, arrhythmia, and heart failure; a higher apnea/hypopnea index (AHI); mixed apnea index (MAI); an elevated oxygen desaturation index (ODI); and more nighttime oxygen saturation levels < 90%. Multivariate logistic regression analysis revealed that older age, comorbid arrhythmia or heart failure, and an elevated ODI were independently associated with CSA.

CONCLUSION

Patients who complain of snoring or apnea may be better evaluated by comprehensive PSG prior to treatment if they are old, show greater hypoxia, or suffer from arrhythmia and/or heart failure, because such patients are more likely than others to exhibit CSA.

Predictors of Initial CPAP Prescription and Subsequent Course with CPAP in Patients with Central Sleep Apneas

Purpose

Guidelines recommend considering an initial trial of continuous positive airway pressure (CPAP) to treat central sleep apnea (CSA). However, practice patterns vary widely. This study investigated predictors for an initial trial of CPAP in patients with central apneas and whether those factors predict adequate treatment response in patients receiving an initial CPAP trial.

Methods

Charts of patients receiving a diagnostic code for CSA following a sleep study during 2016-2018 at a single center were reviewed. Patient factors, initial treatment prescriptions, and subsequent changes to therapy were extracted from electronic health records. Regression models were used to estimate factors associated with an initial CPAP prescription and the likelihood of an adequate CPAP response (no subsequent therapy change or nonadherence) among patients prescribed CPAP.

Results

429/588 (73%) patients with central apneas received an initial trial of CPAP. Younger age, diagnosis by home sleep testing, non-opiate etiology of central apneas, and a lower proportion of central apneas at diagnosis were independently associated with a higher likelihood of an initial CPAP trial. A lower proportion of central apneas was associated with a higher probability of adequate response, while current smoking and opiate-related central apneas predicted an unsuccessful CPAP trial. A new finding was that older age predicted a lower likelihood of an initial CPAP prescription but did not predict a suboptimal response to CPAP.

Conclusion

Clinicians may incorrectly weigh certain clinical and sleep study characteristics when deciding whether to trial CPAP for patients with central apneas.

A Novel Portable Real-Time Low-Cost Sleep Apnea Monitoring System based on the Global System for Mobile Communications (GSM) Network

Background and objective

Continuous monitoring of breathing activity plays a vital role in the detection of respiratory-based diseases (SA, COPD, etc.). Sleep Apnea (SA) is characterized by recurrent upper airway obstruction during sleep associated with arterial blood desaturation, sympathetic nervous system activation, and cardiovascular impairment. Untreated patients with SA have increased mortality rates compared to the general population. This study aims to design a remote monitoring system for sleep apnea to ensure patient safety and ease the workload of doctors in the Covid-19 era.

Methods

This study aims to design a remote monitoring system for sleep apnea to ensure patient safety and ease the workload of doctors. Our study focuses on a novel portable real-time low-cost sleep apnea monitoring system utilizing the GSM network (GSM Shield Sim900a). Proposed system is a remote monitoring and patient tracking system to detect the apnea event in real time, and to provide information of the sleep position, pulse, and respiratory and oxygen saturation to the medical specialists (SpO₂) by establishing a direct contact. As soon as an abnormal condition is detected in the light of these parameters, the condition is reported (instant or in the form of short reports after sleep) to the patient relatives, the doctor’s mobile telephone or to the emergency medical centers (EMCs) through a GSM network to handle the case depending on the patient’s emergency condition.

Results

A study group was formed of six patients for monitoring apnea events (three males and three females) between the ages of 20 and 60. The patients in the study group have sleep apnea (SA) in different grades. All the apnea events were detected, and all the patients were successfully alerted. Also, the patient parameters were successfully sent to all patient relatives. Patients who could not get out of apnea were called through the CALL feature, and they were informed about their ongoing apnea event and told that intervention was necessary. The proposed system is tested on six patients. The beginning moment of apnea was successfully detected and the SMS/CALL feature was successfully activated without delay. During the testing, it has been observed that while some of the patients start breathing after the first SMS, some others needed the second or the third SMS. According to the measurement result, the maximum breathless time is 46 s among the patients, and a SMS is sent every 15 s. In addition, in cases where the patient was breathless for a long time, the CALL feature was actively sought from the relatives of the patient and enabled him to intervene. The proposed monitoring system could be used in both clinical and home settings.

Conclusions

The monitoring of a patient in real time allows to intervene in any unexpected circumstances about the patient. The proposed work uses an acceleration sensor as a reliable method of the sleep apnea for monitoring and prevention. The developed device is more economical, comfortable, and convenient than existing systems not only for the patients but also for the doctors. The patients can easily use this device in their home environment, so which could yield a more comfortable, easy to use, cost-effective, and long-term breathing monitoring system for healthcare applications.

Graphical abstract

Optimal Noninvasive Medicare Access Promotion: Patients with Central Sleep Apnea A Technical Expert Panel Report from the American College of Chest Physicians, the American Association for Respiratory Care, the American Academy of Sleep Medicine, and the American Thoracic Society

This document summarizes suggestions of the central sleep apnea (CSA) technical expert panel (TEP) working group. This paper shares our vision for bringing the right device to the right patient at the right time. For patients with CSA, current coverage criteria do not align with guideline treatment recommendations. For example, continuous positive airway pressure (CPAP) and oxygen therapy are recommended but not covered for CSA. On the other hand, BPAP without a backup rate may be a covered therapy for OSA, but it may worsen CSA. Narrow coverage criteria that require near elimination of obstructive breathing events on CPAP or bilevel positive airway pressure in the spontaneous mode , even if at poorly tolerated pressure levels, may preclude therapy with BPAP with backup rate or adaptive servoventilation (ASV), even when those devices provide demonstrably better therapy. CSA is a dynamic disorder that may require different treatments over time, sometimes switching from one device to another, for example from BPAP with backup rate to an ASV with automatic end expiratory pressure adjustments, which may not be covered. To address these challenges we suggest several changes to the coverage determinations, including 1) a single simplified initial and continuing coverage definition of CSA that aligns with obstructive sleep apnea, 2) removal of hypoventilation terminology from coverage criteria for CSA, 3) all effective therapies for CSA should be covered, including oxygen and all PAP devices with or without backup rates or servo-mechanisms, and 4) patients shown to have a suboptimal response to one PAP device should be allowed to add oxygen or change to another PAP device with different capabilities if shown to be effective with testing.

Transvenous phrenic nerve stimulation to treat idiopathic central sleep apnea

STUDY OBJECTIVES

Idiopathic central sleep apnea (ICSA) is a rare disorder diagnosed when known causes of central sleep apnea are excluded. No established treatments exist for ICSA, and long-term studies are lacking. We assessed the long-term effectiveness and safety of transvenous phrenic nerve stimulation in patients with ICSA.

METHODS

In the remedē System Pivotal Trial, 16/151 (11%) participants with central sleep apnea were diagnosed as having ICSA. Patients were implanted and followed through 18 months of active therapy. Polysomnograms obtained at baseline and at 6, 12, and 18 months were scored by a central laboratory. Sleep metrics and patient-reported quality of life outcomes were assessed.

RESULTS

Patients experienced moderate-severe central sleep apnea. The baseline AHI, central apnea index, and arousal index were 40, 25, and 32 events/h of sleep, respectively. These metrics improved at 6, 12, and 18 months of therapy: the AHI decreased by 25, 25, and 23 events/h (P < .001 at each visit), the central apnea index by 22, 23, and 22 events/h (P < .001 at each visit), and the arousal index by 12 (P = .005), 11 (P = .035), and 13 events/h (P < .001). Quality of life instruments showed clinically meaningful improvements in daytime somnolence, fatigue, general and mental health, and social functioning. The only related serious adverse event was lead component failure in 1 patient.

CONCLUSIONS

This is the longest prospective study for the treatment of ICSA. Transvenous phrenic nerve stimulation significantly decreased sleep-disordered breathing metrics with consequent improvement in quality of life at 6 months, and all benefits were sustained through 18 months.

CLINICAL TRIAL REGISTRATION

Registry: ClinicalTrials.gov; Name: Respicardia, Inc. Pivotal Trial of the remedē System; URL: https://clinicaltrials.gov/ct2/show/NCT01816776; Identifier: NCT01816776.