Continuous positive airway pressure with good adherence can reduce risk of stroke in patients with moderate to severe obstructive sleep apnea: An updated systematic review and meta-analysis

Hypoglossal Nerve Stimulation Therapy in a Belgian Cohort of Obstructive Sleep Apnea Patients

Hypoglossal nerve stimulation (HGNS) has emerged as a widespread and innovative treatment option for selected moderate-to-severe obstructive sleep apnea (OSA) patients who cannot be treated effectively with traditional treatment modalities. In this observational cohort study, the objective and subjective outcomes of Belgian OSA patients treated with HGNS therapy were analyzed at 6 and 12 months post-implantation. Thirty-nine patients implanted with a respiration-synchronized HGNS device at the Antwerp University Hospital w ere included in this study. Patients underwent baseline in-laboratory polysomnography and a follow-up sleep study 6 and 12 months post-implantation. Questionnaires on patient experience and daytime sleepiness were filled out and data on objective therapy usage were collected. All 39 patients completed the 6-month follow-up and 21 patients (54%) completed the 12-month follow-up. Median AHI decreased from 33.8 [26.1;45.0] to 10.2 [4.8;16.4] at the 6-month follow-up, and to 9.6 [4.1;16.4] at the 12-month follow-up (p < 0.001). The surgical success rate, according to the Sher20 criteria, was 80% and 76% at the 6- and 12-month follow-ups, respectively. Median ESS improved from 12.0 [7.0;18.0] at baseline to 6.0 [2.5;11.0] at 6 months (p < 0.001) and to 6.5 [2.8;11.5] at 12 months (p = 0.012). Objective therapy usage was 7.4 [6.6;8.0] and 7.0 [5.9:8.2] h/night at the 6- and 12-month follow-ups, respectively. A high overall clinical effectiveness of HGNS therapy, as shown by a mean disease alleviation of 58%, was demonstrated at 12 months post-implantation. Overall, HGNS therapy using respiration-synchronized neurostimulation of the XII cranial nerve resulted in a significant improvement in both objective and subjective OSA outcomes, with a high level of patient satisfaction and high treatment adherence.

Understanding adherence to continuous positive airway pressure in patients with obstructive sleep apnea post-stroke: A prospective study based on the Andersen model

Adherence to continuous positive airway pressure (CPAP) in patients with obstructive sleep apnea (OSA) post-stroke is often problematic, despite potential benefits. This study aimed to evaluate CPAP adherence in patients with OSA post-stroke based on the Andersen behavioral model of health services utilization. A total of 227 eligible participants were recruited from a Chinese hospital. After baseline assessment, participants were followed for 6 months to determine short-term CPAP adherence. Those with good short-term adherence were followed for an additional 6 months to explore long-term adherence and influencing factors. Short-term CPAP adherence rate was 33%. Being married or living with a partner, having an associate degree or baccalaureate degree or higher, and stronger health beliefs independently predicted short-term CPAP adherence. Only 25% of participants from the adherent group showed good long-term adherence. The factor associated with long-term CPAP adherence was participants not using alcohol. Adherence to CPAP is suboptimal among patients having OSA post-stroke. Addressing unfavorable predisposing factors and modifying health beliefs are suggested.

Pre-morbid sleep disturbance and its association with stroke severity: results from the international INTERSTROKE study

BACKGROUND AND PURPOSE

Whilst sleep disturbances are associated with stroke, their association with stroke severity is less certain. In the INTERSTROKE study, the association of pre-morbid sleep disturbance with stroke severity and functional outcome following stroke was evaluated.

METHODS

INTERSTROKE is an international case-control study of first acute stroke. This analysis included cases who completed a standardized questionnaire concerning nine symptoms of sleep disturbance (sleep onset latency, duration, quality, nocturnal awakening, napping duration, whether a nap was planned, snoring, snorting and breathing cessation) in the month prior to stroke (n = 2361). Two indices were derived representing sleep disturbance (range 0-9) and obstructive sleep apnoea (range 0-3) symptoms. Logistic regression was used to estimate the magnitude of association between symptoms and stroke severity defined by the modified Rankin Score.

RESULTS

The mean age of participants was 62.9 years, and 42% were female. On multivariable analysis, there was a graded association between increasing number of sleep disturbance symptoms and initially severe stroke (2-3, odds ratio [OR] 1.44, 95% confidence interval [CI] 1.07-1.94; 4-5, OR 1.66, 95% CI 1.23-2.25; >5, OR 2.58, 95% CI 1.83-3.66). Having >5 sleep disturbance symptoms was associated with significantly increased odds of functional deterioration at 1 month (OR 1.54, 95% CI 1.01-2.34). A higher obstructive sleep apnoea score was also associated with significantly increased odds of initially severe stroke (2-3, OR 1.48; 95% CI 1.20-1.83) but not functional deterioration at 1 month (OR 1.19, 95% CI 0.93-1.52).

CONCLUSIONS

Sleep disturbance symptoms were common and associated with an increased odds of severe stroke and functional deterioration. Interventions to modify sleep disturbance may help prevent disabling stroke/improve functional outcomes and should be the subject of future research.

Obstructive Sleep Apnea and Stroke: Determining the Mechanisms Behind their Association and Treatment Options

Sleep-disordered breathing (SDB) can be a sequela of stroke caused by vascular injury to vital respiratory centers, cerebral edema, and increased intracranial pressure of space-occupying lesions. Likewise, obstructive sleep apnea (OSA) contributes to increased stroke risk through local mechanisms such as impaired ischemic cerebrovascular response and systemic effects such as promoting atherosclerosis, hypercoagulability, cardiac arrhythmias, vascular-endothelial dysfunction, and metabolic syndrome. The impact of OSA on stroke outcomes has been established, yet it receives less attention in national guidelines on stroke management than hyperglycemia and blood pressure dysregulation. Furthermore, whether untreated OSA worsens stroke outcomes is not well-described in the literature. This scoping review provides an updated investigation of the correlation between OSA and stroke, including inter-relational pathophysiology. This review also highlights the importance of OSA treatment and its role in stroke outcomes. Knowledge of pathophysiology, the inter-relationship between these common disorders, and the impact of OSA therapy on outcomes affect the clinical management of patients with acute ischemic stroke. In addition, understanding the relationship between stroke outcomes and pre-existing OSA will allow clinicians to predict outcomes while treating acute stroke.

Impact of Sleep Disorders and Disturbed Sleep on Brain Health: A Scientific Statement From the American Heart Association

Accumulating evidence supports a link between sleep disorders, disturbed sleep, and adverse brain health, ranging from stroke to subclinical cerebrovascular disease to cognitive outcomes, including the development of Alzheimer disease and Alzheimer disease-related dementias. Sleep disorders such as sleep-disordered breathing (eg, obstructive sleep apnea), and other sleep disturbances, as well, some of which are also considered sleep disorders (eg, insomnia, sleep fragmentation, circadian rhythm disorders, and extreme sleep duration), have been associated with adverse brain health. Understanding the causal role of sleep disorders and disturbances in the development of adverse brain health is complicated by the common development of sleep disorders among individuals with neurodegenerative disease. In addition to the role of sleep disorders in stroke and cerebrovascular injury, mechanistic hypotheses linking sleep with brain health and biomarker data (blood-based, cerebrospinal fluid-based, and imaging) suggest direct links to Alzheimer disease-specific pathology. These potential mechanisms and the increasing understanding of the "glymphatic system," and the recognition of the importance of sleep in poststroke recovery, as well, support a biological basis for the indirect (through the worsening of vascular disease) and direct (through specific effects on neuropathology) connections between sleep disorders and brain health. Given promising evidence for the benefits of treatment and prevention, sleep disorders and disturbances represent potential targets for early treatment that may improve brain health more broadly. In this scientific statement, we discuss the evidence supporting an association between sleep disorders and disturbances and poor brain health ranging from stroke to dementia and opportunities for prevention and early treatment.

Inflammatory Markers and Sleep Architecture in Sleep Bruxism-A Case-Control Study

Background: Sleep bruxism (SB) is a common sleep-related movement behavior with a multifaceted etiology and a deficiently understood pathophysiology. A recent hypothesis suggests a link between SB and systemic inflammation. The scope of the study was to determine whether bruxers have altered sleep structure and different levels of inflammatory parameters compared to nonbruxers. Methods: A total of 83 adults underwent full-night polysomnography. The polysomnograms were evaluated using the American Academy of Sleep Medicine (AASM) guidelines. Then, the blood samples were obtained from the participants by venipuncture and the analyses were performed. The study group was divided based on bruxism episode index (BEI) into two groups: BEI ≤ 4 and BEI > 4. Results: In comparison with nonbruxers, the oxygen desaturation index (ODI) was significantly higher in severe bruxers (7.5 ± 11.08 vs. 3.33 ± 5.75, p < 0.005), as well as the arousal parameters (7.77 ± 4.68 vs. 4.03 ± 2.97, p < 0.001), and the mean oxygen desaturation (3.49 ± 0.69 vs. 3.01 ± 0.67, p < 0.05). Moreover, the differences in sleep architecture and deprivation of the deep sleep phase were observed, the non-REM sleep stage 3 was significantly shorter in severe bruxers (p < 0.03). Differences were also noted in non-REM sleep stage 1 and REM sleep phase. In the investigated group, there were no statistical differences in inflammatory cytokines levels between bruxers and nonbruxers. Conclusions: Sleep bruxism is associated with sleep structure alterations and may be associated with deep sleep phase deprivation. The inflammatory markers are not linearly correlated with the severity of sleep bruxism expressed as BEI.

Long non-coding RNA FKSG29 regulates oxidative stress and endothelial dysfunction in obstructive sleep apnea

Altered expressions of pro-/anti-oxidant genes are known to regulate the pathophysiology of obstructive sleep apnea (OSA).We aim to explore the role of a novel long non-coding (lnc) RNA FKSG29 in the development of intermittent hypoxia with re-oxygenation (IHR)-induced endothelial dysfunction in OSA. Gene expression levels of key pro-/anti-oxidant genes, vasoactive genes, and the FKSG29 were measured in peripheral blood mononuclear cells from 12 subjects with primary snoring (PS) and 36 OSA patients. Human monocytic THP-1 cells and human umbilical vein endothelial cells (HUVEC) were used for gene knockout and double luciferase under IHR exposure. Gene expression levels of the FKSG29 lncRNA, NOX2, NOX5, and VEGFA genes were increased in OSA patients versus PS subjects, while SOD2 and VEGFB gene expressions were decreased. Subgroup analysis showed that gene expression of the miR-23a-3p, an endogenous competitive microRNA of the FKSG29, was decreased in sleep-disordered breathing patients with hypertension versus those without hypertension. In vitro IHR experiments showed that knock-down of the FKSG29 reversed IHR-induced ROS overt production, early apoptosis, up-regulations of the HIF1A/HIF2A/NOX2/NOX4/NOX5/VEGFA/VEGFB genes, and down-regulations of the VEGFB/SOD2 genes, while the protective effects of FKSG29 knock-down were abolished by miR-23a-3p knock-down. Dual-luciferase reporter assays confirmed that FKSG29 was a sponge of miR-23a-3p, which regulated IL6R directly. Immunofluorescence stain further demonstrated that FKSGH29 knock-down decreased IHR-induced uptake of oxidized low density lipoprotein and reversed IHR-induced IL6R/STAT3/GATA6/ICAM1/VCAM1 up-regulations. The findings indicate that the combined RNA interference may be a novel therapy for OSA-related endothelial dysfunction via regulating pro-/anti-oxidant imbalance or targeting miR-23a-IL6R-ICAM1/VCAM1 signaling.

Sleep-Disordered Breathing and Prognosis after Ischemic Stroke: It Is Not Apnea-Hypopnea Index That Matters

BACKGROUND

Sleep-disordered breathing (SDB) is highly prevalent after stroke and is considered to be a risk factor for poor post-stroke outcomes. The aim of this observational study was to evaluate the effect of nocturnal respiratory-related indices based on nocturnal respiratory polygraphy on clinical outcomes (including mortality and non-fatal events) in patients with ischemic stroke.

METHODS

A total of 328 consecutive patients (181 (55%) males, mean age 65.8 ± 11.2 years old) with confirmed ischemic stroke admitted to a stroke unit within 24 h after stroke onset were included in the analysis. All patients underwent standard diagnostic and treatment procedures, and sleep polygraphy was performed within the clinical routine in the first 72 h after admission. The long-term outcomes were assessed by cumulative endpoint (death of any cause, new non-fatal myocardial infarction, new non-fatal stroke/transient ischemic attack, emergency revascularization, emergency hospitalization due to the worsening of cardiovascular disease). A Cox-regression analysis was applied to evaluate the effects of nocturnal respiratory indices on survival.

RESULTS

The mean follow-up period comprised 12 months (maximal-48 months). Patients with unfavourable outcomes demonstrated a higher obstructive apnea-hypopnea index, a higher hypoxemia burden assessed as a percent of the time with SpO₂ < 90%, a higher average desaturation drop, and a higher respiratory rate at night. Survival time was significantly lower (30.6 (26.5; 34.7) versus 37.9 (34.2; 41.6) months (Log Rank 6.857, p = 0.009)) in patients with higher hypoxemia burden (SpO₂ < 90% during ≥2.1% versus <2.1% of total analyzed time). However, survival time did not differ depending on the SDB presence assessed by AHI thresholds (either ≥5 or ≥15/h). The multivariable Cox proportional hazards regression (backward stepwise analysis) model demonstrated that the parameters of hypoxemia burden were significantly associated with survival time, independent of age, stroke severity, stroke-related medical interventions, comorbidities, and laboratory tests.

CONCLUSION

Our study demonstrates that the indices of hypoxemia burden have additional independent predictive value for long-term outcomes (mortality and non-fatal cardiovascular events) after ischemic stroke.

Sleep-Disordered Breathing in Acute Stroke: A Single-Center, Prospective, Longitudinal Study

BACKGROUND

Sleep-disordered breathing (SDB) is common among acute stroke patients. We sought to investigate the prevalence, severity and type of SDB in consecutive acute stroke patients. Moreover, we aimed to identify independent predictors of SDB in the acute stroke setting and investigate potential associations between SDB and functional outcomes at three months.

METHODS

We prospectively studied consecutive acute stroke patients, who underwent overnight polysomnography within 72 h from symptom onset. Demographics, clinical and imaging characteristics were documented. Daytime sleepiness preceding the stroke, stroke severity on admission and functional outcome at three months were evaluated using the Epworth-Sleepiness Scale (ESS), National Institute of Health Stroke Scale (NIHSS) and modified Rankin Scale (mRS), respectively. SDB was documented using standard polysomnography criteria.

RESULTS

A total of 130 consecutive acute stroke patients were prospectively evaluated [110 with ischemic stroke and 20 with intracerebral hemorrhage, mean age 60.5 ± 10.9 years, 77% men, median NIHSS score on admission: 3 (IQR: 2-17)]. The rate of SDB detection on polysomnography recordings was 79% (95% CI: 71-86). Three variables were independently associated with the likelihood of SDB detection in multivariable analyses adjusting for potential confounders: age (OR per 10-year-increase: 2.318, 95% CI: 1.327-4.391, p = 0.005), male sex (OR: 7.901, 95% CI: 2.349-30.855, p = 0.001) and abnormal ESS-score (OR: 6.064, 95% CI: 1.560-32.283, p = 0.017). Among patients with SDB, congestive heart failure was independently associated with the likelihood of central apnea detection (OR: 18.295, 95% CI: 4.464-19.105, p < 0.001). Among all patients, increasing NIHSS score on admission (OR: 0.817, 95% CI: 0.737-0.891, p < 0.001) and Apnea-Hypopnea Index (OR: 0.979, 95% CI: 0.962-0.996, p = 0.020) emerged as independent predictors of excellent functional outcome at 3 months (mRS-scores 0-1).

CONCLUSION

The high prevalence and severity of SDB in acute stroke patients and its negative impact on functional outcome indicate the importance of polysomnography implementation in everyday clinical practice of acute stroke work-up and management.

Lighter sleep is associated with higher enlarged perivascular spaces burden in middle-aged and elderly individuals

BACKGROUND

While healthy sleep is suggested to promote glymphatic clearance in the brain, poorer sleep may be associated with higher enlarged perivascular spaces (ePVS) burden, potentially representing impaired perivascular drainage. This study aims to evaluate the association between ePVS burden and polysomnographic sleep characteristics in a large community-based sample.

METHODS

552 dementia and stroke-free Framingham Heart Study participants (age: 58.6 ± 8.9 years; 50.4% men) underwent a full-night in-home polysomnography. Three years later on average, participants underwent a brain MRI. ePVS were rated in the basal ganglia and centrum semiovale, and dichotomized as low burden (<20 counts, grades 1 and 2) or high burden (>20 counts, grades 3 and 4). Logistic regression analyses relating sleep variables to subsequent ePVS burden were used, adjusted for age, sex, time interval between polysomnography and MRI, ApoE ε4 allele carrier status, hypertension, and smoking.

RESULTS

Longer N1 sleep and shorter N3 sleep duration were associated with higher ePVS burden in the centrum semiovale. When stratifying these associations by subpopulations, longer N1 sleep duration with ePVS burden was observed especially in older individuals and hypertensive participants. Associations between ePVS burden and other sleep characteristics such as total sleep time and REM sleep duration varied according to ApoE ε4 allele carrier status.

CONCLUSIONS

Lighter sleep, as characterized by longer N1 sleep and shorter slow-wave sleep, is associated with higher ePVS burden. These findings suggest that sleep architecture may be involved in glymphatic clearance and cerebral small vessel disease, which could be an important biological link between sleep and dementia risk.

Influence of continuous positive airway pressure on lipid profiles of obstructive sleep apnea: A systematic review and meta-analysis

BACKGROUND

To investigate the influence of continuous positive airway pressure (CPAP) on lipid profiles of the patients with obstructive sleep apnea (OSA) in this meta-analysis.

METHODS

Relevant studies reporting the correlation between CPAP and lipid profiles of OSA patients were searched in Pubmed, Cochrane Library and Embase before January 1, 2021. Data of eligible studies were extracted and analyzed using the fixed-effect or random-effect model. Standard mean difference (SMD) and 95% confidence interval (95% CI) were calculated to assess such influence. Subgroup analysis based on CPAP duration was further performed. STATA 12.0 was used in this meta-analysis.

RESULTS

A total of 12 independent randomized controlled studies involved 1129 OSA patients were recruited in this meta-analysis. The analyzed lipid profiles included total cholesterol (TC), triglyceride (TG), low density lipoprotein (LDL) and high density lipoprotein (HDL). CPAP was not correlated to TC (SMD = -0.07, 95% CI = -0.33 to 0.19), TG (SMD = -0.01, 95% CI = -0.19 to 0.17), LDL (SMD = -0.01, 95% CI = -0.23 to 0.21) and HDL (SMD = 0.10, 95% CI = -0.03 to 0.22) in OSA patients. Moreover, CPAP duration (=12 weeks; >12 weeks; <12 weeks) also did not influence lipid profiles of OSA patients as well.

CONCLUSIONS

Regardless of the treatment in CPAP duration, it doses does not influence lipid profiles of OSA patients, including TC, TG, LDL and HDL. The results are inconsistent with previous findings, which should be further validated in the multi-center, long-term randomized controlled trials.

Low Arousal Threshold Estimation Predicts Failure of Mandibular Advancement Devices in Obstructive Sleep Apnea Syndrome

Introduction: The treatment of choice for obstructive sleep apnea syndrome (OSAS) is continuous positive airway pressure (CPAP). However, CPAP is usually poorly tolerated and mandibular advancement devices (MADs) are an alternative innovative therapeutic approach. Uncertainty still remains as to the most suitable candidates for MAD. Herein, it is hypothesized that the presence of low arousal threshold (low ArTH) could be predictive of MAD treatment failure. Methods: A total of 32 consecutive patients, with OSAS of any severity, who preferred an alternate therapy to CPAP, were treated with a tailored MAD aimed at obtaining 50% of their maximal mandibular advancement. Treatment response after 6 months of therapy was defined as AHI < 5 events per hour or a reduction of AHI ≥ 50% from baseline. Low ArTH was predicted based on the following polysomnography features, as previously shown by Edwards et al.: an AHI of 82.5% and a hypopnea fraction of total respiratory events of >58.3%. Results: There were 25 (78.1%) responders (p-value < 0.01) at 6 months. Thirteen patients (40.6%) in the non-severe group reached AHI lower than 5 events per hour. MAD treatment significantly reduced the median AHI in all patients from a median value of 22.5 to 6.5 (74.7% of reduction, p-value < 0.001). The mandibular advancement device reduced AHI, whatever the disease severity. A significant higher reduction of Delta AHI, after 6 months of treatment, was found for patients without low ArTH. Conclusions: Low ArTH at baseline was associated with a poorer response to MAD treatment and a lower AHI reduction at 6 months. A non-invasive assessment of Low ArTH can be performed through the Edwards’ score, which could help to identify an endotype with a lower predicted response to oral appliances in a clinical setting.

CPAP for secondary cardiovascular prevention in obstructive sleep apnoea patients: not only one moon, but many stars

While continuous positive airway pressure (CPAP) therapy has a strong evidence base for the treatment of obstructive sleep apnoea (OSA), its impact on cardiovascular comorbidity remains unclear. This journal club reviews three recent randomised controlled trials aimed to evaluate the impact of CPAP therapy in secondary prevention of cerebrovascular and coronary heart disease (SAVE trial), comorbid coronary heart disease (RICCADSA trial) and in patients admitted with acute coronary syndrome (ISAACC trial). All three trials included patients with moderate-to-severe OSA and excluded patients with severe daytime sleepiness. When CPAP was compared with usual care, they all reported no difference in a similar primary composite end-point including death from cardiovascular disease, cardiac events, and strokes. These trials faced the same methodological challenges, including a low primary end-point incidence, the exclusion of sleepy patients, and a low CPAP adherence. Therefore, caution must be taken when broadening their results to the wider OSA population. Although randomised controlled trials provide a high level of evidence, they may not be sufficient to capture the diversity of OSA. Large-scale, real-world data may be able to provide a more rounded and generalisable picture of the effects of routine clinical use of CPAP on cardiovascular morbimortality.

Effect of Sleep Surgery on Inflammatory Cytokines in Adult Obstructive Sleep Apnea: A Systematic Review and Meta-Analysis

OBJECTIVE

To evaluate whether sleep surgery is associated with inflammatory cytokine changes. This study hypothesizes cytokines may change after surgery in adult obstructive sleep apnea (OSA).

STUDY DESIGN

Systematic review and meta-analysis.

METHODS

The study protocol was registered on PROSPERO (CRD42020154425). Two authors independently searched PubMed, Embase, and Cochrane review databases from their inception to June 2021. The keywords used were sleep apnea, inflammatory markers, cytokines, and surgery. The effects of sleep surgery on the apnea-hypopnea index (AHI) and inflammatory cytokines were evaluated using a random-effects model. Both mean difference (MD) and standardized mean difference (SMD) of the changes in cytokines were calculated.

RESULTS

Nine studies with 235 adults were included (mean age: 43 years; 82% were men). After sleep surgery, AHI significantly reduced by -11.3 events/h (95% confidence interval [CI], -15.8 to -6.9). In total, 8 and 6 studies were pooled for examining tumor necrosis factor-alpha (TNF-α) and interleukin-6 (IL-6) levels, respectively. Sleep surgery significantly reduced TNF-α levels, with an MD of -2.8 pg/ml (95% CI, -5.1 to -0.6) and an SMD of -0.56 (95% CI, -0.85 to -0.27). Furthermore, sleep surgery reduced IL-6 levels, with an MD of -0.6 pg/ml (95% CI, -1.0 to -0.2) and an SMD of -0.66 (95% CI, -0.89 to -0.43). No covariates were identified to be correlated with cytokine changes in subgroup and meta-regression analyses. Funnel plots showed possible publication bias in current data.

CONCLUSIONS

In adults, OSA treatment with sleep surgery improves inflammatory cytokines. Laryngoscope, 2022.

Sleep and Stroke: Opening Our Eyes to Current Knowledge of a Key Relationship

PURPOSE OF REVIEW

To elucidate the interconnection between sleep and stroke.

RECENT FINDINGS

Growing data support a bidirectional relationship between stroke and sleep. In particular, there is strong evidence that sleep-disordered breathing plays a pivotal role as risk factor and concur to worsening functional outcome. Conversely, for others sleep disorders (e.g., insomnia, restless legs syndrome, periodic limb movements of sleep, REM sleep behavior disorder), the evidence is weak. Moreover, sleep disturbances are highly prevalent also in chronic stroke and concur to worsening quality of life of patients. Promising novel technologies will probably allow, in a near future, to guarantee a screening of commonest sleep disturbances in a larger proportion of patients with stroke. Sleep assessment and management should enter in the routinary evaluation of stroke patients, of both acute and chronic phase. Future research should focus on the efficacy of specific sleep intervention as a therapeutic option for stroke patients.

European Respiratory Society guideline on non-CPAP therapies for obstructive sleep apnoea

Treatment of obstructive sleep apnoea (OSA) in adults is evolving, as new therapies have been explored and introduced in clinical practice, while other approaches have been refined or reconsidered. In this European Respiratory Society (ERS) guideline on non-continuous positive airway pressure (CPAP) therapies for OSA, we present recommendations determined by a systematic review of the literature. It is an update of the 2011 ERS statement on non-CPAP therapies, advanced into a clinical guideline. A multidisciplinary group of experts, including pulmonary, surgical, dentistry and ear–nose–throat specialists, methodologists and patient representatives considered the most relevant clinical questions (for both clinicians and patients) relating to the management of OSA. Eight key clinical questions were generated and a systematic review was conducted to identify published randomised clinical trials that answered these questions. We used the GRADE (Grading of Recommendations Assessment, Development and Evaluation) approach to assess the quality of the evidence and the strength of recommendations. The resulting guideline addresses gastric bypass surgery, custom-made dual-block mandibular advancement devices, hypoglossal nerve stimulation, myofunctional therapy, maxillo-mandibular osteotomy, carbonic anhydrase inhibitors and positional therapy. These recommendations can be used to benchmark quality of care for people with OSA across Europe and to improve outcomes.

OSA-patients who refuse/don't adhere to CPAP can profit from established/emerging treatment options. High scientific evidence is lacking. Patients’ values/preference may weigh heavy in the decision for non-CPAP options, while health inequity is a concern.https://bit.ly/3o0tJeP

Sleep apnoea and ischaemic stroke: current knowledge and future directions

Sleep apnoea, one of the most common chronic diseases, is a risk factor for ischaemic stroke, stroke recurrence, and poor functional recovery after stroke. More than half of stroke survivors present with sleep apnoea during the acute phase after stroke, with obstructive sleep apnoea being the most common subtype. Following a stroke, sleep apnoea frequency and severity might decrease over time, but moderate to severe sleep apnoea is nevertheless present in up to a third of patients in the chronic phase after an ischaemic stroke. Over the past few decades evidence suggests that treatment for sleep apnoea is feasible during the acute phase of stroke and might favourably affect recovery and long-term outcomes. Nevertheless, sleep apnoea still remains underdiagnosed and untreated in many cases, due to challenges in the detection and prediction of post-stroke sleep apnoea, uncertainty as to the optimal timing for its diagnosis, and a scarcity of clear treatment guidelines (ie, uncertainty on when to treat and the optimal treatment strategy). Moreover, the pathophysiology of sleep apnoea associated with stroke, the proportion of stroke survivors with obstructive and central sleep apnoea, and the temporal evolution of sleep apnoea subtypes following stroke remain to be clarified. To address these shortcomings, the management of sleep apnoea associated with stroke should be integrated into a multidisciplinary diagnostic, treatment, and follow-up strategy.

Obstructive sleep apnea and stroke: The mechanisms, the randomized trials, and the road ahead

When considered separately from cardiovascular disease, stroke is the third leading cause of death in the U.S. and is the leading cause of long-term disability in adults. New approaches that can be offered to the majority of ischemic stroke patients, can be continued throughout post-stroke care, can limit stroke severity, and can complement or even enhance rehabilitation, would transform ischemic stroke recovery. The treatment of obstructive sleep apnea (OSA) in patients with acute ischemic stroke may represent one such approach. This manuscript reviews the epidemiologic studies of the bidirectional association between OSA and stroke, and the mechanisms and molecular signatures of OSA leading to transient ischemic attack and stroke as well as the randomized controlled trials and observational cohort studies examining continuous positive airway treatment efficacy on the impact of stroke outcomes. Finally, the insights these studies provide on future research are also discussed.

Post-operative Complication Rate Comparison Between Airway Surgery and Upper Airway Stimulation Using NSQIP and ADHERE

Objective

Postoperative complication rates were compared between obstructive sleep apnea surgery (OSAS) and hypoglossal nerve upper airway stimulation (UAS).

Study Design

Cohort.

Setting

Multi-institutional international databases.

Methods

OSAS data were collected from the NSQIP database (2014; American College of Surgeons National Surgery Quality Improvement Program). UAS data were obtained from the ADHERE registry (Adherence and Outcome of Upper Airway Stimulation for OSA International Registry; 2016-December 2019). ADHERE comorbidities and complications were categorized to match NSQIP definitions. A chi-square test was used for proportion P values.

Results

There were 1623 UAS procedures in ADHERE and 310 in NSQIP. The UAS group was older than the OSAS group (mean ± SD, 60 ± 11 vs 42 ± 13 years) but similarly male (75% vs 77%) and overweight (body mass index, 29 ± 4 vs 29 ± 3 kg/m²). There was a higher proportion of hypertension, diabetes, and heart disease in the UAS cohort. Palatopharyngoplasty was the most common surgical procedure (71%), followed by tonsillectomy (25%). UAS operative time was longer (132 ± 47 vs 54 ± 33 minutes). Postoperative length of stay was not normally distributed, as 71% of UAS stays were <1 day as opposed to 40% of OSA stays (P < .0001). Thirty-day return to the operating room related to the procedure was 0.1% for UAS and 4.8% for OSAS (P < .0001). Surgical site infections were 0.13% for UAS and 0.9% for OSAS (P = .046).

Conclusion

The UAS cohort was older and more likely to have comorbid hypertension, diabetes, and heart disease. Despite baseline differences, the postoperative complication rate was lower with UAS than with OSAS.

Prevalence and Determinants of Sleep Apnea in Patients with Stroke: A Meta-Analysis

OBJECTIVES

Recent meta-analyses have noted that ∼70% of transient ischemic attack (TIA)/stroke patients have sleep apnea. However, the heterogeneity between studies was high and did not appear to be accounted by the phase of stroke. We conducted an updated meta-analysis and aimed to determine whether the prevalence of sleep apnea amongst stroke patients differs by the subtype, etiology, severity and location of stroke and hence could account for some of the unexplained heterogeneity observed in previous studies.

MATERIALS AND METHODS

We searched Medline, Embase, CINAHL and Cochrane Library (from their commencements to July 2020) for studies which reported the prevalence of sleep apnea by using polysomnography in TIA/stroke patients. We used random-effects model to calculate the pooled prevalence of sleep apnea and explored whether the prevalence differed by stroke characteristics.

RESULTS

Seventy-five studies describing 8670 stroke patients were included in this meta-analysis. The overall prevalence of sleep apnea was numerically higher in patients with hemorrhagic vs. ischemic stroke [82.7% (64.4-92.7%) vs. 67.5% (63.2-71.5%), p=0.098], supratentorial vs. infratentorial stroke [64.4% (56.7-71.4%) vs. 56.5% (42.2-60.0%), p=0.171], and cardioembolic [74.3% (59.6-85.0%)] vs. other ischemic stroke subtypes [large artery atherosclerosis: 68.3% (52.5-80.7%), small vessel occlusion: 56.1% (38.2-72.6%), others/undetermined: 47.9% (31.6-64.6%), p=0.089]. The heterogeneity in sleep apnea prevalence was partially accounted by the subtype (1.9%), phase (5.0%) and location of stroke (14.0%) among reported studies.

CONCLUSIONS

The prevalence of sleep apnea in the stroke population appears to differ by the subtype, location, etiology and phase of stroke.