Assessment of predictive ability of Epworth scoring in screening of patients with sleep apnoea

Performance of the Alice PDx Device With the Somnolyzer Automated Scoring Algorithm for the Diagnosis of Obstructive Sleep Apnea

Objective Automated scoring of respiratory events could allow a swifter obstructive sleep apnea (OSA) identification. We assessed the accuracy of the Alice PDx device with the Somnolyzer automated scoring algorithm, compared to the manually reviewed scoring by a trained sleep technician, for the diagnosis of OSA. Methods A prospective study was conducted between March 2021 and March 2022 in Centro Hospitalar do Baixo Vouga, a level 2 hospital in Aveiro, Portugal. Patients with high pre-test probability for OSA performed a type III home sleep apnea testing with the Alice PDx device. Data were scored automatedly by the Sleepware G3 with the Somnolyzer digital system and manually by a trained sleep technician. Correlation and dependent t-tests were used. Sensitivity, specificity, positive predictive values (PPVs), negative predictive values (NPVs), and area under the receiver operating characteristic curve (AUROC) of automated scoring were calculated. Data were analyzed using the Stata Statistical Software (Release 17, StataCorp., 2023, College Station, TX: StataCorp LLC). Results In 150 participants (mean age 57.8 ± 13.9 years), the mean apnea-hypopnea index (AHI) was 21.9 ± 21.8 events/hour by manual scoring and 25.4 ± 21.6 events/hour by automated scoring. The mean difference was 3.4 ± 4.4 events/hour, and a strong, positive, linear correlation was found between the two scores (r = 0.98). At the altered AHI (AHI ≥ 5 events/hour), mild, moderate, and severe OSA, the automated scoring sensitivity/specificity values were 91.2%/100.0%, 80.0%/68.6%, 91.6%/41.9%, and 98.1%/80.9%, respectively. The PPVs/NPVs for the same categories were 100.0%/69.4%, 89.3%/51.1%, 79.7%/66.7%, and 91.8%/95.0%, respectively. Finally, the AUROC was 0.85, 0.70, 0.73, and 0.93, respectively. Conclusion The automated scoring obtained from the Alice PDx portable device, using Sleepware G3 with the Somnolyzer digital system, seems accurate enough to diagnose OSA and validate the initiation of PAP therapy in the correct clinical setting. Nevertheless, it does not replace manual reviewing by a trained sleep technician in the case of mild and moderate OSA, to obtain a correct severity classification. With this valuable time-saving tool, we expect to hasten OSA diagnosis and treatment and thus tackle the underdiagnosis problem.

Daytime Sleepiness and Quality of Life in Obstructive Sleep Apnoea Patients before and after Long-Term Mandibular Advancement Device Treatment

This study compared daytime sleepiness and quality of life in OSA patients with healthy controls and compared sleepiness and quality of life in OSA patients before and after long-term treatment with a mandibular advancement device (MAD). A total of 27 OSA patients (18 men, 9 women, mean age 52.3 years) and 32 healthy age- and sex-matched controls (20 men, 12 women, mean age 51.1 years) were included. At baseline and after MAD treatment, daytime sleepiness and quality of life were recorded by the Epworth Sleepiness Scale (ESS) and Short Form-36 questionnaires (SF-36). Daytime sleepiness occurred significantly more often in OSA patients compared to controls at baseline (p = 0.01). The quality of life domains Energy and vitality (p < 0.0001), General perception of health (p = 0.0002), Mental health (p = 0.0031), Social functioning (p = 0.0119), Role limitations due to emotional problems (p = 0.0173) and Physical functioning (p = 0.0226) were significantly poorer in OSA patients compared to controls at baseline. After long-term MAD treatment, daytime sleepiness decreased (p < 0.01) and the quality of life domain Energy and Vitality increased (p < 0.01) in OSA patients compared to baseline. The results of the present study support the relevance of MAD treatment as an effective tool for decreasing daytime sleepiness and increasing the quality of life in OSA patients—also in the long term.

Association between Patient- and Partner-Reported Sleepiness Using the Epworth Sleepiness Scale in Patients with Obstructive Sleep Apnoea

Excessive daytime sleepiness in obstructive sleep apnoea (OSA) is often measured differently by patients and their partners. This study investigated the association between patient- and partner-completed Epworth Sleepiness Scale (ESS) scores and a potential correlation with OSA severity. One hundred two participants, 51 patients and 51 partners, completed the ESS before and three months after initiating CPAP treatment. There was no significant difference when comparing patients’ and partners’ ESS scores at baseline (10.75 ± 5.29 vs. 11.47 ± 4.96, respectively) and at follow-up (6.04 ± 4.49 vs. 6.41 ± 4.60, respectively). There was a strong correlation between patients’ and partners’ ESS scores on both (baseline and follow-up) assessments (p < 0.001). There was significant improvement in patients’ and partners’ ESS scores after CPAP therapy (p < 0.001). There was no significant difference in patients’ or partners’ ESS scores between patients with mild, moderate or severe OSA. There was no significant correlation between oxygen desaturation index (ODI) and ESS score reported either by patient or by partner. In conclusion, our study revealed a strong correlation between patient- and partner-reported ESS scores. However, neither patient- nor partner-completed ESS scores were associated with OSA severity.

A Prediction Nomogram Combining Epworth Sleepiness Scale and Other Clinical Parameters to Predict Obstructive Sleep Apnea in Patients with Hypertension

Background

Obstructive sleep apnea (OSA) is common in patients with hypertension. Nonetheless, OSA is underdiagnosed despite considerable evidence of the association between OSA and adverse health outcomes. This study developed and validated a clinical nomogram to predict OSA in patients with hypertension based on the Epworth Sleepiness Scale (ESS) score and OSA-related parameters.

Methods

A total of 347 hypertensive patients with suspected OSA were retrospectively enrolled and randomly assigned to a training set and a validation set at 70 : 30 (N = 242/N = 105) ratio. OSA was diagnosed through sleep monitoring and was defined as an apnea-hypopnea index ≥5 events/h. Using the least absolute shrinkage and selection operator regression model, we identified potential predictors of OSA and constructed a nomogram model in the training set. The predictive performance of the nomogram was assessed and validated by discrimination and calibration. The nomogram was also compared with ESS scores according to decision curve analysis (DCA), integrated discrimination index (IDI), and net reclassification index (NRI).

Results

ESS scores, body mass index, neck circumference, snoring, and observed apnea predicted OSA are considered. The nomogram showed similar discrimination between the training set (AUC: 0.799, 95% CI: 0.743–0.847) and validation set (AUC: 0.766, 95% CI: 0.673–0.843) and good calibration in the training (P=0.925 > 0.05) and validation (P=0.906 > 0.05) sets. Compared with the predictive value of the ESS, the nomogram was clinically useful and significantly improved reclassification accuracy (NRI: 0.552, 95% CI: 0.282–0.822, P < 0.001; IDI: 0.088, 95% CI: 0.045–0.133, P < 0.001) at a probability threshold of >42%.

Conclusions

We developed a novel OSA prediction nomogram based on ESS scores and OSA-related parameters. This nomogram may help improve clinical decision-making, especially in communities and primary clinics, where polysomnography is unavailable.

Prevalence and Characteristics of Erectile Dysfunction in Obstructive Sleep Apnea Patients

BACKGROUND

Obstructive sleep apnea (OSA) is a common and severe social problem. Erectile dysfunction (ED) is an important health concern. The prevalence of OSA with ED is increasing, which significantly affects the quality of life and work efficiency of patients. However, the mechanism underlying the comorbidity of these two diseases remains unclear.

OBJECTIVES

(1) Investigate the prevalence of OSA with ED; (2) analyze the correlation between OSA and ED; and (3) explore the treatment response to and possible mechanism of uvulapalatopharyngoplasty (UPPP) in patients with OSA and ED. This study aims to provide a theoretical basis for the clinical diagnosis and comprehensive treatment of OSA with ED and improve prevention and treatment strategies.

MATERIALS AND METHODS

In total, 135 subjects were enrolled in the study. Clinical data, polysomnography, the ESS score, Beck anxiety score, Beck depression score, IIEF-5 score and ASEX score were recorded before UPPP and 6 months after UPPP. Sex hormones were measured for all subjects using a Roche electrochemiluminescence analyzer.

RESULT

The prevalence of OSA with ED was 64.52%, and the prevalence of severe OSA with ED was 73.02%. The prevalence of OSA with ED increased with age, BMI and apnea-hypopnea index (AHI) value. Among polysomnography indicators, minimum oxygen saturation and average oxygen saturation may predict the occurrence of OSA with ED. Improving the patient's anxiety and depression is very important for treating OSA with ED. Sex hormone levels were not significantly correlated with the occurrence of OSA with ED.

CONCLUSION

ED is a common symptom of OSA patients. This study showed that sex hormone levels in OSA patients with ED were not significantly correlated with the condition, but further investigation of this relationship is worthwhile. It is recommended that the free and combined types of sex hormones be further distinguished during testing because the free type is the active form. UPPP surgical treatment is effective for OSA with ED, and its possible mechanism is protection of the peripheral nerves of the sex organs by improving nighttime hypoxia and arousal.

Use of the pictorial Sleepiness and Sleep Apnoea Scale in Chinese patients with suspected obstructive sleep apnoea syndrome

Background

Sleep related breathing disorders represent a significant health burden. Being able to stratify patients according to their need for differing types of investigation and predicting the likelihood of obstructive sleep apnoea syndrome (OSAS) is helpful. This study attempts to assess the value of a pictorial Sleepiness and Sleep Apnoea Scale (pSSAS) in this process.

Methods

A total of 126 sequential patients attending a sleep service with suspected OSAS completed the pSSAS, the Epworth Sleepiness Score (ESS), and the Berlin Questionnaire (BQ) prior to full polysomnography.

Results

With Apnoea-hypopnea index (AHI) >15 as the positive diagnostic criterion, the area under the receiver operating characteristic curve (AUC) of the BQ was the highest (0.683), followed by pSSAS and ESS (AUC 0.648 and 0.516, respectively). With AHI >30 as the positive diagnostic criterion, the AUC of pSSAS was the highest (0.696), followed by BQ and ESS (AUC 0.653 and 0.510, respectively). With MiniSO₂ <80% as the positive diagnostic criterion, the AUC of pSSAS was the highest (0.736), followed by BQ and ESS (AUC 0.634 and 0.516, respectively).

Conclusions

This study shows that the pSSAS which was first tested in a European population performs equally well amongst a Chinese population. The pSSAS performed in a similar fashion to the BQ in predicting those likely to have OSAS and was superior at predicting those who have severe OSAS. Because it is a pictorial questionnaire, it has advantages for those who may have reduced health literacy, a problem which is under-recognized in most healthcare systems.

Sleepiness Behind the Wheel and the Implementation of European Driving Regulations

Sleep disturbance and sleepiness are established risk factors for driving accidents and obstructive sleep apnea (OSA) is the most prevalent medical disorder associated with excessive daytime sleepiness. Because effective treatment of OSA reduces accident risk, several jurisdictions have implemented regulations concerning the ability of patients with OSA to drive, unless effectively treated. This review provides a practical guide for clinicians who may be requested to certify a patient with OSA as fit to drive regarding the scope of the problem, the role of questionnaires and driving simulators to evaluate sleepiness, and the benefit of treatment on accident risk.

Two effective clinical prediction models to screen for obstructive sleep apnoea based on body mass index and other parameters

BACKGROUND AND OBJECTIVE

The diagnosis of obstructive sleep apnea (OSA) relies on polysomnography which is time-consuming and expensive. We therefore aimed to develop two simple, non-invasive models to screen adults for OSA.

METHODS

The effectiveness of using body mass index (BMI) and a new visual prediction model to screen for OSA was evaluated using a development set (1769 participants) and confirmed using an independent validation set (642 participants).

RESULTS

Based on the development set, the best BMI cut-off value for diagnosing OSA was 26.45 kg/m², with an area under the curve (AUC) of 0.7213 (95% confidence interval (CI), 0.6861-0.7566), a sensitivity of 57% and a specificity of 78%. Through forward conditional logistic regression analysis using a stepwise selection model developed from observed data, seven clinical variables were evaluated as independent predictors of OSA: age, BMI, sex, Epworth Sleepiness Scale score, witnessed apnoeas, dry mouth and arrhythmias. With this new model, the AUC was 0.7991 (95% CI, 0.7668-0.8314) for diagnosing OSA (sensitivity, 75%; specificity, 71%). The results were confirmed using the validation set. A nomogram for predicting OSA was generated based on this new model using statistical software.

CONCLUSIONS

BMI can be used as an indicator to screen for OSA in the community. We created an internally validated, highly distinguishable, visual and parsimonious prediction model comprising BMI and other parameters that can be used to identify patients with OSA among outpatients. Use of this prediction model may help to improve clinical decision-making.

Change in Quality of Life of OSAHS Patients with Minimally Invasive Surgery or CPAP Therapy: A 2-year Retrospective, Single-center Parallel-group Study

BACKGROUND

By including untreated obstructive sleep apnea-hypopnea syndrome (OSAHS) patients as the control group, this study explores the influence of minimally invasive surgical treatment and continuous positive airway pressure (CPAP) therapy on OSAHS patients, with the subjective and objective performance. The study also discusses their relationship, determines the effect factor, and provides a simple and practical method for evaluation of clinical efficacy.

METHODS

A total of 90 OSAHS patients, who were diagnosed in the Sleep Disorders Diagnosis and Treatment Center of Sichuan Province from May 2014 to May 2016, were selected for the present study. These patients were divided into three groups: surgery group, CPAP group, and untreated group. These patients were followed up at six months, one year, and two years, respectively. The physiological indicators, clinical symptoms, degree of daytime sleepiness and quality of life were compared among these three groups. The daytime sleepiness and the quality of life before and after minimally invasive surgery and CPAP treatment were evaluated, and the subjective and objective efficacy of surgery and CPAP treatment was explored.

RESULTS

Among these 90 patients, 11 (12.2%) patients had hypertension, while two (2.2%) patients had diabetes. The average AHI score was 50.53±23.39 per hour, and the mean minimum oxygen saturation and mean oxygen saturation was 71.25±14.16% and 90.13±5.90%, respectively. There were statistically significant differences in mouth breathing, morning sore throat and daytime sleepiness in the group having received surgery at 0.5 year and one year. In the CPAP group, there were statistically significant differences in mouth breathing, morning sore throat and daytime sleepiness at 0.5 year, one year and two years. Moreover, there were statistically significant differences in memory loss at one year and two years, and there were statistically significant differences in frequent nocturia at one year. The ESS value in the surgery group decreased at 0.5 year and one year, but increased at two years. The situation was the same in terms of the total points and in each dimension of the SF-36 paramter. The delta values of ESS among the three groups had statistical significance at 0.5 year, one year and two years, in which the CPAP group experienced the most changes, followed by the surgery group and the group received health education.

CONCLUSION

For minimally invasive surgery, CPAP therapy and health education can improve daytime sleepiness and quality of life. CPAP therapy was found to be the most effective, followed by minimally invasive surgery and provision of health education. However, the treatment of OSAHS should be comprehensive.

European Respiratory Society statement on sleep apnoea, sleepiness and driving risk

Obstructive sleep apnoea (OSA) is highly prevalent and is a recognised risk factor for motor vehicle accidents (MVA). Effective treatment with continuous positive airway pressure has been associated with a normalisation of this increased accident risk. Thus, many jurisdictions have introduced regulations restricting the ability of OSA patients from driving until effectively treated. However, uncertainty prevails regarding the relative importance of OSA severity determined by the apnoea–hypopnoea frequency per hour and the degree of sleepiness in determining accident risk. Furthermore, the identification of subjects at risk of OSA and/or accident risk remains elusive. The introduction of official European regulations regarding fitness to drive prompted the European Respiratory Society to establish a task force to address the topic of sleep apnoea, sleepiness and driving with a view to providing an overview to clinicians involved in treating patients with the disorder. The present report evaluates the epidemiology of MVA in patients with OSA; the mechanisms involved in this association; the role of screening questionnaires, driving simulators and other techniques to evaluate sleepiness and/or impaired vigilance; the impact of treatment on MVA risk in affected drivers; and highlights the evidence gaps regarding the identification of OSA patients at risk of MVA.

The Epworth Sleepiness Scale in Service Members with Sleep Disorders

INTRODUCTION

Excessive daytime sleepiness affects an estimated 20% of the general population. While the prevalence of sleepiness in the military is largely unknown, it is well established that short sleep duration is endemic. The reasons for this include: the demanding nature of their duties, shift work and 24-hour duty periods, deployments and exigencies of military service as well as sleep disorders. The Epworth Sleepiness Scale (ESS) is the most widely used sleep questionnaire and provides a self-assessment of daytime sleepiness. To date the clinical utility of this questionnaire in differentiating sleep disorders in military patients with sleep disorders has never been evaluated.

MATERIALS AND METHODS

The primary aim of this manuscript was to assess if Epworth Sleepiness Scale (ESS) scores differed between military personnel with insomnia, obstructive sleep apnea (OSA), comorbid insomnia/obstructive sleep apnea (COMISA), and a group with neither insomnia nor obstructive sleep apnea (NISA). This study assessed the clinical utility of the ESS in differentiating sleep disorders amongst a sample (N = 488) of U.S. military personnel with insomnia (n = 92), OSA (n = 142), COMISA (n = 221), and a NISA group (n = 33) which served as the control population.

RESULTS

In the present sample, 68.4% of service members reported excessive daytime sleepiness (EDS) with an ESS > 10. ESS scores differed between military personnel with COMISA (13.5 ± 4.83) and those with OSA only (11.5 ± 4.08; p < 0.001) and the NISA group (9.46 ± 4.84; p < 0.001). Also, ESS scores differed between patients with insomnia only (13.0 ± 4.84) and the NISA group (p < 0.01).

CONCLUSIONS

Overall, the ESS had poor ability to differentiate sleep disorders. In military personnel, the ESS appears elevated in the most common sleep disorders, likely due to their insufficient sleep, and does not help to differentiate OSA from insomnia. Further studies are required to validate this questionnaire and determine an appropriate threshold value for abnormal sleepiness in the military population.

Strategies in the clinical diagnosis and surgical treatment of OSAHS with multilevel obstruction

OBJECTIVE

To examine the safety and effectiveness of individualized treatment strategies that include three principles (security, top-down and priority) for patients with obstructive sleep apnoea hypopnea syndrome (OSAHS) and multilevel obstruction who decline therapy with continuous positive airway pressure (CPAP).

METHODS

Patients with OSAHS and upper airway obstruction who were diagnosed with multilevel obstruction were included in this retrospective study. Patients were evaluated for the degree of obstruction in each level. Three principles were followed in planning the appropriate intervention level and measures to reduce perioperative risks. Polysomnography indices and Epworth sleepiness scores were used to evaluate the efficacy of surgery and improvement in patients' sleepiness at ≥3 months post-surgery.

RESULTS

Among 51 patients with OSAHS and multilevel obstruction, three were treated with CPAP, 41 were treated with nasopharyngeal surgery, and seven were treated with oropharyngeal surgery. No severe complications were reported. Following surgery, apnoea hypopnea index and Epworth sleepiness scores were significantly reduced, and the lowest oxygen saturation level was significantly increased.

CONCLUSION

The three-principle strategy was safe and effective in planning surgical treatments for patients with OSAHS and multilevel obstruction.

The role of home sleep testing for evaluation of patients with excessive daytime sleepiness: focus on obstructive sleep apnea and narcolepsy

Excessive daytime sleepiness (EDS) is a common complaint in the general population, which may be associated with a wide range of sleep disorders and other medical conditions. Narcolepsy is a sleep disorder characterized primarily by EDS, which involves a substantial burden of illness but is often overlooked or misdiagnosed. In addition to identifying low cerebrospinal fluid (CSF) hypocretin (orexin) levels, evaluation for narcolepsy requires in-laboratory polysomnography (PSG). Polysomnography is the gold standard for diagnosis of obstructive sleep apnea (OSA) as well as other sleep disorders. However, the use of home sleep apnea testing (HSAT) to screen for OSA in adults with EDS has increased greatly based on its lower cost, lower technical complexity, and greater convenience, versus PSG. The most commonly used, types 3 and 4, portable monitors for HSAT lack capability for electroencephalogram recording, which is necessary for the diagnosis of narcolepsy and other sleep disorders and is provided by PSG. These limitations, combined with the increased use of HSAT for evaluation of EDS, may further exacerbate the under-recognition of narcolepsy and other hypersomnias, either as primary or comorbid disorders with OSA. Adherence to expert consensus guidelines for use of HSAT is essential. Differential clinical characteristics of patients with narcolepsy and OSA may help guide correct diagnosis. Continued EDS in patients diagnosed and treated for OSA may indicate comorbid narcolepsy or another sleep disorder. Although HSAT may diagnose OSA in appropriately selected patients, it cannot rule out or diagnose narcolepsy. Therefore, at present, PSG and MSLT remain the cornerstone for narcolepsy diagnosis.

Obstructive sleep apnea: focus on myofunctional therapy

PURPOSE

Orofacial myofunctional therapy (OMT) is a modality of treatment for children and adults with obstructive sleep apnea (OSA) to promote changes in the musculature of the upper airways. This review summarizes and discusses the effects of OMT on OSA, the therapeutic programs employed, and their possible mechanisms of action.

METHODS

We conducted an online literature search using the databases MEDLINE/PubMed, EMBASE, and Web of Science. Search terms were "obstructive sleep apnea" in combination with "myofunctional therapy" OR "oropharyngeal exercises" OR "speech therapy". We considered original articles in English and Portuguese containing a diagnosis of OSA based on polysomnography (PSG). The primary outcomes of interest for this review were objective measurement derived from PSG and subjective sleep symptoms. The secondary outcome was the evaluation of orofacial myofunctional status.

RESULTS

Eleven studies were included in this review. The studies reviewed reveal that several benefits of OMT were demonstrated in adults, which include significant decrease of apnea-hypopnea index (AHI), reduced arousal index, improvement in subjective symptoms of daytime sleepiness, sleep quality, and life quality. In children with residual apnea, OMT promoted a decrease of AHI, increase in oxygen saturation, and improvement of orofacial myofunctional status. Few of the studies reviewed reported the effects of OMT on the musculature.

CONCLUSION

The present review showed that OMT is effective for the treatment of adults in reducing the severity of OSA and snoring, and improving the quality of life. OMT is also successful for the treatment of children with residual apnea. In addition, OMT favors the adherence to continuous positive airway pressure. However, randomized and high-quality studies are still rare, and the effects of treatment should also be analyzed on a long-term basis, including measures showing if changes occurred in the musculature.

Clinical Reproducibility of the Epworth Sleepiness Scale for Patients With Suspected Sleep Apnea

STUDY OBJECTIVES

To determine the reproducibility of the Epworth Sleepiness Scale (ESS) score in a clinical population referred for diagnostic testing with suspected obstructive sleep apnea.

METHODS

A retrospective audit of patients referred for a diagnostic sleep study with suspected sleep apnea was undertaken. Data collection was two 3-month time periods from January to March in 2012 and 2014. To evaluate reproducibility, the ESS score at primary care referral was compared to the ESS score at first specialist assessment/sleep assessment. The proportion of scores changing by more than 2, 3, 5, or 7 points was determined. Data were analyzed using Bland-Altman plots and paired t tests.

RESULTS

A total of 154 patients (68% male) with a mean ± standard deviation age of 51 ± 13 years, body mass index 36 ± 10 kg/m², and apnea-hypopnea index 43 ± 40 events/h were included. The average ESS score change was -0.2 with a standard deviation of 3.9 reflecting a wide scatter. A difference between the sequential ESS scores of 5 or more was seen in 21% of subjects.

CONCLUSIONS

In a clinical obstructive sleep apnea referral population, the ESS score was variable when administered sequentially. Given this variability the ESS should not be used as the sole tool to prioritize patients for obstructive sleep apnea assessment.

COMMENTARY

A commentary on this article appears in this issue on page 711.

Observational pilot study of reported symptoms of obstructive sleep apnoea in children with epilepsy

AIM

To estimate symptoms of obstructive sleep apnoea (OSA) and excessive daytime sleepiness (EDS) in children with epilepsy (CWE) compared with those in a typically developing comparison group. CWE are known to have poor sleep, with increased rates of OSA suggested.

METHOD

The Sleep-Related Breathing Disorder scale of the Pediatric Sleep Questionnaire (PSQ-SRBD) was used to estimate OSA symptoms, with scores ≤0.33 known to be highly sensitive and specific for OSA. The Epworth Sleepiness Scale (ESS) was used to assess EDS, with scores of 10 or above considered abnormal.

RESULTS

Thirty-three CWE (21 males, 12 females) were studied (median age [interquartile range {IQR}] 9y [5-12]), along with 42 comparison children (20 males, 22 females; median age [IQR] 6y [4-8.5]). Fifty-five per cent of CWE scored 0.33 or higher on the PSQ-SRBD compared with 7% in the comparison group (p<0.001), and 30% of CWE had an abnormal ESS compared with 5% controls (p=0.003). Within the CWE cohort, PSQ-SRDB and ESS appeared higher in those taking antiepileptic drugs (AEDs); although PSQ-SRBD score for CWE not on AEDs was higher than in the comparison group.

INTERPRETATION

This study suggests higher rates of symptoms of OSA and EDS in CWE compared with typically developing children. AEDs may be a confounding factor, but do not alone account for the associations seen. Further studies including polysomnography to verify the presence (rather than suggestion by questionnaire) of OSA are warranted.

Effectiveness of Oral Appliances in Obstructive Sleep Apnea with Respiratory Arousals

STUDY OBJECTIVES

To compare adherence and treatment effects with an oral appliance (OA) in patients with different types of obstructive sleep apnea (OSA): those with mainly respiratory arousals ("arousers"), and those with oxygen desaturations ("desaturaters") at polysomnography (PSG).

METHODS

A prospective intervention study on 72 "tired snorers" with "normal" home sleep study (HSS), but later diagnosed as OSA with PSG, who accepted OA treatment. They were offered evaluation with a follow-up PSG and questionnaires, including the Epworth Sleepiness Scale (ESS), general health (GH), satisfaction, and side effects.

RESULTS

Sixty-six patients, 33 arousers and 33 desaturaters, were adapted to OA. The 1-year adherence rate was significantly higher among arousers (85%) than desaturaters (55%) (p = 0.034). Thirty-six of 66 patients underwent follow-up PSG; the apnea-hypopnea index was significantly reduced in 22 arousers from a median of 14 to 3 (p < 0.001), and in 14 desaturaters from 18 to 7 (p = 0.002; no significant group difference). ESS and GH showed no significant improvements in either group, although sleepy "arousers" (ESS ≥ 10) significantly improved their ESS. In total, 77% reported side effects, while 63% were still satisfied with the OA treatment. Gender analysis showed a significant dominance of females classified as "arousers" (p = 0.025).

CONCLUSIONS

OSA patients with mainly arousals at PSG showed higher adherence to OA treatment, compared to patients with desaturations. Both groups responded similarly to treatment: improved nocturnal respiration, but only a small reduction of symptoms. We suggest that "tired snorers" with "normal HSS" should be offered PSG, and if OSA, also OA treatment.

Altered functioning of the HPA axis in depressed postpartum women

BACKGROUND

The present study aimed to evaluate the relationship between the functioning of the hypothalamic-pituitary-adrenal (HPA) axis and major depressive episodes in the remote postpartum period.

METHODS

The sample (mean age, 28.0±5.3 years) consisted of 37 depressed postpartum women (DPP), 42 euthymic postpartum women (EPP) and 25 non-postpartum healthy women (HC). Salivary cortisol samples were collected immediately after awakening and 30min, 3 and 12h later, at approximately the sixth month postpartum (mean, 169.6±60.3 days).

RESULTS

Differences in cortisol levels were observed at awakening (DPP<EPP=HC), at 30min (DPP<EPP<HC), at 3h (DPP=EPP<HC) and at 12h (DPP>EPP=HC). The relative increment in the cortisol awakening response (CARi%) was significantly higher in HC (113.5±94.3) than in EPP (63.1±69.8) and DPP (32.2±49.6). The relative reduction in diurnal variation (DVr%) was lower in DPP (56.5±41.8) than in EPP (75.6±22.4) and HC (75.1±13.0).

LIMITATIONS

The main limitation was cortisol collection on a single day and without measurement at midnight.

CONCLUSIONS

Our findings suggest that the remote postpartum period involves attenuation of HPA axis reactivity; this dysregulation is more pronounced in the presence of DPP, which is associated with a reduction in cortisol diurnal variation. Abnormalities in the neuroendocrine system related to stress processing, present even several months after delivery, can represent vulnerability to mental disorders. Thus, improvements in the mental health care of postpartum women are needed.

A new approach for the assessment of sleepiness and predictivity of obstructive sleep apnea in drivers: A pilot study

BACKGROUND

Falling asleep behind the wheel is one of the most relevant consequences of obstructive sleep apnea (OSA). We created a new screening questionnaire, named the Driver Sleepiness Score (DSS), aiming to assess sleepiness in drivers with suspected OSA. The primary aim of our study was to evaluate sleepiness in drivers with a suspicion of OSA by the DSS in order to assess its correlation with the apnea-hypopnea index (AHI), oxygen desaturation index (ODI), and total sleep time with oxyhemoglobin saturation below 90% (TST90). We also aimed to assess the diagnostic accuracy of DSS for three different cutoffs of AHI (AHI = 5, AHI = 15, AHI = 30), which allow stratification of the severity of OSA.

MATERIALS AND METHODS

Seventy-three driving patients at risk for OSA participated in the study. DSS and the Epworth Sleepiness Scale (ESS) were both administered in operator-dependent modality and in randomized sequence.

RESULTS

The DSS showed higher accuracy in screening patients with mild OSA [area under curve (AUC): 0.88 vs 0.74] and moderate OSA (AUC: 0.88 vs 0.79), whereas ESS showed higher accuracy in screening patients with severe OSA (AUC: 0.91 vs 0.78). A DSS score ≥ 7 is the optimal cutoff for distinguishing true positives from false positives for the presence of OSA and for its different severity levels. The administration of both questionnaires increases the accuracy for the detection of all OSA severity levels.

CONCLUSIONS

If validated, DSS may qualify as a new screening tool specifically for drivers with the suspicion of having OSA, in combination with the ESS.

Italian recommendations on dental support in the treatment of adult obstructive sleep apnea syndrome (OSAS)

BACKGROUND

The aim of the present article is to present a set of proposed clinical recommendations aimed at Italian dentists involved in the management of patients with obstructive sleep apnea syndrome or snoring.

METHODS

With the purpose of creating a study group, some of the most important Italian scientific societies operating in fields relevant to the issue of sleep medicine in dentistry were asked to appoint a representative. Each member of the study group was required to answer questions regarding the clinical management of OSAS and snoring.

RESULTS

Oral appliances can be used to treat: - simple snoring, in patients who do not respond to, or do not appear to be suitable candidates for behavioral measures such as weight loss or positional therapy; - mild or moderate OSAS, in patients who prefer OAs to continuous positive airway pressure (CPAP) or who are not suitable candidates for CPAP, because of its failure or failure of behavioral approaches like weight loss or positional therapy; - severe OSAS, in patients who do not respond to or do not tolerate CPAP and in whom no indication for either maxillofacial or ENT surgery appears applicable.

CONCLUSIONS

The application of oral appliances is highly desirable in cases of simple snoring or mild to moderate OSAS, whereas considerable caution is warranted when treating severe OSAS. It is fundamental to ensure that the patient understands his problem and, at the same time, to present all the various treatment options.

Sex differences in sleep apnea predictors and outcomes from home sleep apnea testing

STUDY OBJECTIVES

To evaluate sex differences in predictors of obstructive sleep apnea (OSA) as per outcomes from home sleep apnea testing.

DESIGN

This was a retrospective analysis of a large repository of anonymous test results and pretest risk factors for OSA.

SETTING AND PATIENTS

A total of 272,705 patients were referred for home sleep apnea testing from a variety of clinical practices for suspected sleep disordered breathing across North America from 2009 to 2013.

INTERVENTIONS

Not applicable.

MEASUREMENTS AND RESULTS

Predictors of OSA (apnea hypopnea index4%≥5) were evaluated by multiple logistic regression; sex differences were evaluated by interaction effects. Middle age was the single most robust predictor of OSA for both sexes and was particularly foretelling for females (P<0.001) even after controlling for measures of adiposity and medical conditions. Females over the age of 45 years were much more likely to have OSA compared to their younger counterparts (78.7% vs 42.5%, respectively; odds ratio: 5.0) versus males (88.1% vs 68.8%, respectively; odds ratio: 3.4). Snoring, although more frequently reported by males, was similarly predictive of OSA for both sexes. Witnessed apneas and measures of adiposity were better predictors of OSA for males than females. Insomnia, depression, and use of sleep medication, although more commonly reported in females, did not predict OSA. Hypertension, although equally reported by both sexes, performed better as a predictor in females (P<0.001), even after controlling for age, measures of adiposity, and other medical conditions. Diabetes, heart disease, stroke, and sleepiness did not contribute unique variance in OSA in adjusted models.

CONCLUSION

This study found that males and females report different symptoms upon clinical evaluation for suspected sleep apnea, with some of the "classic" OSA features to be more common in and robustly predictive for males. The finding that advancing age uniquely and robustly predicted OSA in females reinforces our understanding that age-related changes in sex hormones play a role in the development and/or manifestation of sleep disordered breathing. Need exists for sex-specific prediction models and quantification of menopausal status in OSA screening tools.

Measurement properties of patient-reported outcome measures (PROMs) in adults with obstructive sleep apnea (OSA): A systematic review

This systematic review summarizes the evidence regarding the quality of patient-reported outcome measures (PROMs) validated in patients with obstructive sleep apnea (OSA). We performed a systematic literature search of all PROMs validated in patients with OSA, and found 22 measures meeting our inclusion criteria. The quality of the studies was assessed using the consensus-based standards for the selection of health status measurement instruments (COSMIN) checklist. The results showed that most of the measurement properties of the PROMs were not, or not adequately, assessed. For many identified PROMs there was no involvement of patients with OSA during their development or before the PROM was tested in patients with OSA. Positive exceptions and the best current candidates for assessing health status in patients with OSA are the sleep apnea quality of life index (SAQLI), Maugeri obstructive sleep apnea syndrome (MOSAS) questionnaire, Quebec sleep questionnaire (QSQ) and the obstructive sleep apnea patient-oriented severity index (OSAPOSI). Even though there is not enough evidence to fully judge the quality of these PROMs as outcome measure, when interpreted with caution, they have the potential to add value to clinical research and clinical practice in evaluating aspects of health status that are important to patients.

[Diagnostic accuracy of Epworth sleepiness scale in the acute phase of myocardial infarction]

BACKGROUND

Obstructive sleep apnea syndrome (OSAS) is underdiagnosed in cardiologist daily practice, especially in patients with acute coronary syndrome. Its diagnosis is based on a polysomnography study. The Epworth Sleepiness Scale (ESS) stands as a simple and rapid means to select patients for the sleep investigation.

AIM

The aim of this study was to determine the diagnostic accuracy of the ESS for screening OSAS in patients with ST elevation myocardial infarction.

METHODS

We conducted a prospective study of 120 consecutive patients admitted for acute myocardial infarction, from April 2011 to March 2012. Daytime sleepiness was evaluated using the ESS, when patients were in the intensive care unit. All patients have undergone an overnight sleep study using a portable diagnostic device, in the 15 days following the acute coronary syndrome. The diagnostic of OSA was considered as apnea-hypopnea index (AHI) of ≥5 events/hour, severe OSA was defined as AHI of ≥30.

RESULTS

The study included 120 patients comprising 102 men and 18 women. The mean age was 58 ± 12 years. Smoking was the major cardiovascular risk factor with 72% of all patients; prevalence of diabetes was 40% and hypertension was found in 44% of the population. The prevalence of OSA was 79%. Severe OSA was diagnosed in 16% of all patients and mean AHI was 15.76 ± 14.93. Mean ESS was 2.2 ± 1.84 in the global population while it was 5.2 ± 1.2 in patients with severe OSAS. Multivariate analysis showed that ESS score ≥ 4 was an independent predictive factor for severe OSA (OR=28; 95% IC: 8-101; P<0.001).

CONCLUSION

The prevalence of OSA in patients with acute myocardial infarction was very high. ESS score ≥ 4 was an independent predictive factor for severe OSA. Despite its subjective feature, the ESS seems to be an interesting score for screening patients to undergo polysomnography.

Relative atrial natriuretic peptide deficiency and inadequate renin and angiotensin II suppression in obese hypertensive men

Obesity is a strong risk factor for hypertension, but the mechanisms by which obesity leads to hypertension are incompletely understood. On this background, we assessed dietary sodium intake, serum levels of natriuretic peptides (NPs), and the activity of the renin-angiotensin system in 63 obese hypertensive men (obeseHT: body mass index, ≥30.0 kg/m(2); 24-hour ambulatory blood pressure, ≥130/80 mm Hg), in 40 obese normotensive men (obeseNT: body mass index, ≥30.0 kg/m(2); 24-hour ambulatory blood pressure, <130/80 mm Hg), and in 27 lean normotensive men (leanNT: body mass index, 20.0-24.9 kg/m(2); 24-hour ambulatory blood pressure, <130/80 mm Hg). All study subjects were medication free. As a surrogate estimate for dietary sodium intake, we measured sodium excretion in a 24-hour urine collection and we measured serum levels of midregional proatrial NP and plasma levels of renin and angiotensin II. The obese men had higher mean (±SD) urinary sodium excretion (obeseHT, 213.6±85.2 mmol; obeseNT, 233.0±70.0 mmol) than the lean normotensive men (leanNT, 155.5±51.7 mmol; P=0.003). ObeseHT had lower (median [interquartile range]) serum midregional proatrial NP levels (49.2 [37.3-64.7] pmol/L) than leanNT (69.3 [54.3-82.9] pmol/L; P=0.003), whereas obeseNT had midregional proatrial NP levels in between (54.1 [43.2-64.7] pmol/L); obeseNT had lower (median [interquartile range]) plasma levels of renin (5.0 [3.0-8.0] mIU/L versus 9.0 [4.0-18.0]) and angiotensin II (2.4 [1.5-3.5] pmol/L versus 4.2 [2.2-7.9]) than obeseHT (P≤0.049), whereas obeseHT had similar plasma levels of renin and angiotensin II as leanNT (P≥0.19). Thus, despite a high sodium intake and a high blood pressure, obese hypertensive men have a relative NP deficiency and an inadequate renin-angiotensin system suppression.

Relationship between the Pittsburgh Sleep Quality Index and the Epworth Sleepiness Scale in a sleep laboratory referral population

BACKGROUND

Sleep health questionnaires are often employed as a first assessment step for sleep pathology. The Epworth Sleepiness Scale (ESS) and the Pittsburgh Sleep Quality Index (PSQI) are two commonly employed questionnaire instruments. Aspects of sleep health may be measured differently depending on choice of instrument.

OBJECTIVES

In a patient population at high risk for sleep disorders, referred for polysomnography (PSG), we evaluated the level of association between results from these two instruments. Questionnaire results were also compared with measured PSG parameters.

METHODS

Records of patients undergoing overnight PSG in the sleep laboratory between February-June 2011 were retrospectively reviewed for eligibility. Inclusion criteria were met by 236 patients. PSQI and ESS scores, demographic information, and PSG data were extracted from each record for analysis. Four subgroups based on normal/abnormal values for ESS and PSQI were evaluated for between-group differences.

RESULTS

Of 236 adult participants, 72.5% were male, the mean age was 52.9 years (13.9), mean body mass index (BMI) 34.4 kg/m(2) (8.3), mean ESS 9.0 (4.8; range: 0-22), PSQI mean 8.6 (4.2; range: 2-19). The Pearson correlation coefficient was r = 0.13 (P = 0.05) for association between ESS and PSQI. Participants with an abnormal ESS were more likely to have an abnormal PSQI score (odds ratio 1.9 [1.1-3.6]; P = 0.03). Those with an abnormal ESS had higher BMI (P = 0.008) and higher apnea-hypopnea indexes (AHI) (P = 0.05). Differences between the four subgroups were observed for BMI and sex proportions, but not for AHI.

CONCLUSIONS

We observed limited association between these two commonly used questionnaire instruments, the ESS and the PSQI. These two questionnaires appear to evaluate different aspects of sleep. In terms of clinical application, for global assessment of patients with sleep problems, care should be taken to include instruments measuring different facets of sleep health.