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Costa IOM, Cunha MO, Bussi MT, Cassetari AJ, Zancanella E, Bagarollo MF. Impacts of conservative treatment on the clinical manifestations of obstructive sleep apnea-systematic review and meta-analysis. Sleep Breath 2024; 28:1563-1574. [PMID: 38642201 DOI: 10.1007/s11325-024-03034-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2023] [Revised: 03/08/2024] [Accepted: 04/08/2024] [Indexed: 04/22/2024]
Abstract
INTRODUCTION Obstructive sleep apnea (OSA) is a chronic disease with a high populational prevalence that is characterized as airway closure during sleep. Treatment is multidisciplinary and varies according to each case. Continuous positive airway pressure (CPAP), oral appliances, and surgery are the primary therapeutic options. Non-invasive conservative treatments such as sleep hygiene, positional therapy, physical exercises, and weight loss aim to reduce the worsening of the disease while being complementary to the invasive primary treatment. OBJECTIVE To analyze the impact of non-invasive conservative therapies on the clinical manifestations of OSA syndrome (OSA), compared with other interventions. METHOD This was a systematic review with meta-analysis. The searches were performed without filters for the time period, type of publication, or language. Randomized clinical trials on subjects over 18 years of age diagnosed with untreated OSA were included. Responses to non-invasive conservative treatment were compared with responses to the primary intervention. Primary outcomes were assessed using the Epworth Sleepiness Scale and/or Functional Outcomes of Sleep Questionnaire (FOSQ). RESULTS A total of eight studies were included in the review. The heterogeneity of the effect was estimated at 89.77%. Six studies compared conservative treatment with CPAP, one with oral appliances, and one with oropharyngeal exercises. Using the Epworth Sleepiness Scale measurements, the standardized difference in the estimated means, based on the random-effects model, was 0.457 (95% CI (1.082 to 0.169)) and the mean result did not differ significantly from zero (z = 1.43; p = 0.153). The conservative therapies assessed in this study improved the subjective quality of sleep, although the post-treatment ESE scores did not show significant results. The reduction in AHI and better outcomes in the evaluated domains, as well as in cognition and mood, were superior in the groups that received CPAP and IOD. CONCLUSION The most commonly used treatments of choice for OSA are invasive, including the use of CPAP, oral appliances, and surgeries, being the most utilized options. This study demonstrated that non-invasive conservative treatments, such as sleep hygiene, yield results as effective as invasive treatments. Further studies are needed to confirm this result and to predict whether invasive treatment can be used as the primary treatment or only as a supplement.
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Affiliation(s)
- I O M Costa
- Department of Otorhinolaryngology, University of Campinas, Campinas, Brazil.
- Department of Human Development and Rehabilitation, University of Campinas, Campinas, Brazil.
| | - M O Cunha
- Department of Otorhinolaryngology, University of Campinas, Campinas, Brazil
| | - M T Bussi
- Department of Otorhinolaryngology, University of Campinas, Campinas, Brazil
| | - A J Cassetari
- Department of Otorhinolaryngology, University of Campinas, Campinas, Brazil
| | - E Zancanella
- Department of Otorhinolaryngology, University of Campinas, Campinas, Brazil
| | - M F Bagarollo
- Department of Human Development and Rehabilitation, University of Campinas, Campinas, Brazil
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Sterling KL, Alpert N, Cistulli PA, Pepin JL, More S, Cole KV, Malhotra A. Healthcare resource utilisation and costs in patients with treated obstructive sleep apnea. J Sleep Res 2024; 33:e14099. [PMID: 37964440 PMCID: PMC11090990 DOI: 10.1111/jsr.14099] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2023] [Revised: 10/19/2023] [Accepted: 10/23/2023] [Indexed: 11/16/2023]
Abstract
Obstructive sleep apnea (OSA) is a highly prevalent yet underdiagnosed disease that creates a large economic burden on the United States healthcare system. In this retrospective study, we tested the hypothesis that adherence to positive airway pressure (PAP) therapy, the 'gold standard' treatment for OSA, is associated with reduced healthcare resource utilisation and costs. We linked de-identified payer-sourced medical claims and objective PAP usage data for patients newly diagnosed with OSA. Inverse probability of treatment weighting was used to create balanced groups of patients who were either adherent, intermediately adherent, or non-adherent to PAP therapy. From a sample of 179,542 patients (average age 52.5 years, 61% male), 37% were adherent, 40% intermediate, and 23% non-adherent. During the first year, PAP adherence was significantly associated with fewer emergency room visits (mean [SD] adherent: 0.39 [1.20] versus intermediate: 0.47 [1.30], p < 0.001; versus non-adherent: 0.54 [1.44], p < 0.001), all-cause hospitalisations (mean [SD] adherent: 0.09 [0.43] versus intermediate: 0.12 [0.51], p < 0.001; versus non-adherent: 0.13 [0.55], p < 0.001), and lower total costs (mean [SD] adherent $5874 [8045] versus intermediate $6523 [9759], p < 0.001; versus non-adherent $6355 [10,517], p < 0.001). Results were similar in the second year of PAP use. These results provide additional evidence from a large, diverse sample to support the diagnosis and treatment of OSA and encourage long-term adherence to PAP therapy.
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Affiliation(s)
| | | | - Peter A Cistulli
- Charles Perkins Centre, Faculty of Medicine and Health, University of Sydney, Sydney, Australia
| | - Jean Louis Pepin
- Institute National de la Sante et de la Recherche Medicale (INSERM) U 1300, HP2 Laboratory (Hypoxia: Pathophysiology), Grenoble Alpes University, Grenoble, France
| | - Suyog More
- ResMed Science Center, Halifax, NS Canada
| | | | - Atul Malhotra
- University of California San Diego, La Jolla, CA USA
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Zhang Y, Kim M, Prerau M, Mobley D, Rueschman M, Sparks K, Tully M, Purcell S, Redline S. The National Sleep Research Resource: making data findable, accessible, interoperable, reusable and promoting sleep science. Sleep 2024; 47:zsae088. [PMID: 38688470 PMCID: PMC11236948 DOI: 10.1093/sleep/zsae088] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2024] [Revised: 03/15/2024] [Indexed: 05/02/2024] Open
Abstract
This paper presents a comprehensive overview of the National Sleep Research Resource (NSRR), a National Heart Lung and Blood Institute-supported repository developed to share data from clinical studies focused on the evaluation of sleep disorders. The NSRR addresses challenges presented by the heterogeneity of sleep-related data, leveraging innovative strategies to optimize the quality and accessibility of available datasets. It provides authorized users with secure centralized access to a large quantity of sleep-related data including polysomnography, actigraphy, demographics, patient-reported outcomes, and other data. In developing the NSRR, we have implemented data processing protocols that ensure de-identification and compliance with FAIR (Findable, Accessible, Interoperable, Reusable) principles. Heterogeneity stemming from intrinsic variation in the collection, annotation, definition, and interpretation of data has proven to be one of the primary obstacles to efficient sharing of datasets. Approaches employed by the NSRR to address this heterogeneity include (1) development of standardized sleep terminologies utilizing a compositional coding scheme, (2) specification of comprehensive metadata, (3) harmonization of commonly used variables, and (3) computational tools developed to standardize signal processing. We have also leveraged external resources to engineer a domain-specific approach to data harmonization. We describe the scope of data within the NSRR, its role in promoting sleep and circadian research through data sharing, and harmonization of large datasets and analytical tools. Finally, we identify opportunities for approaches for the field of sleep medicine to further support data standardization and sharing.
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Affiliation(s)
- Ying Zhang
- Division of Sleep Medicine and Circadian Disorders, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA, USA
| | - Matthew Kim
- Division of Endocrinology, Diabetes and Hypertension, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA, USA
| | - Michael Prerau
- Division of Sleep Medicine and Circadian Disorders, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA, USA
| | - Daniel Mobley
- Division of Sleep Medicine and Circadian Disorders, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA, USA
| | - Michael Rueschman
- Division of Sleep Medicine and Circadian Disorders, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA, USA
| | - Kathryn Sparks
- Division of Sleep Medicine and Circadian Disorders, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA, USA
| | - Meg Tully
- Division of Sleep Medicine and Circadian Disorders, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA, USA
| | - Shaun Purcell
- Department of Psychiatry, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Susan Redline
- Division of Sleep Medicine and Circadian Disorders, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA, USA
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de Lima EA, Castro SS, Viana-Júnior AB, Sobreira-Neto MA, Leite CF. Could an increased risk of obstructive sleep apnoea be one of the determinants associated with disability in individuals with cardiovascular and cerebrovascular diseases? Sleep Breath 2024; 28:1187-1195. [PMID: 38252255 DOI: 10.1007/s11325-024-02989-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2023] [Revised: 11/21/2023] [Accepted: 01/03/2024] [Indexed: 01/23/2024]
Abstract
PURPOSE To investigate a possible association between the risk of obstructive sleep apnoea (OSA) and disability in individuals with cardiovascular or cerebrovascular diseases. METHODS Cross-sectional study was conducted with 373 individuals (313 with cardiovascular or cerebrovascular diseases and 60 healthy). Disability was assessed by the 12-item World Health Organization Disability Assessment Schedule (WHODAS), and the risk of OSA was assessed by STOP-BANG. Anxiety and depression symptoms, daytime sleepiness, and cognition were assessed by the Hospital Anxiety and Depression Scale (HADS), Epworth Sleepiness Scale (ESS), and Mini Mental State Examination (MMSE). RESULTS Greater disability was found in individuals with intermediate or high risk of OSA, considering healthy individuals (p=0.03), or individuals diagnosed with arrhythmia (p<0.01) or coronary artery disease (p=0.04). A high risk of OSA and higher WHODAS scores was significant among women as well as between OSA risk categories (p<0.01). Cognitive deficit and level of education also showed differences between OSA risk categories. Age, depression, and sleepiness were also associated with the subjects' disability (p<0.01). Gamma regression model showed higher WHODAS scores in female, in those with intermediate and high risk of OSA, and in those with depressive symptoms and cognitive deficit. Age also showed a correlation with higher WHODAS scores. The presence of all investigated cardio and cerebrovascular diseases showed an increase in the WHODAS score, implying a greater disability compared to healthy individuals. CONCLUSION Moderate and high risk of OSA is associated with disability, as well as gender, age, depressive symptoms, cognitive deficit, and cardiovascular diseases.
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Affiliation(s)
- Eriádina Alves de Lima
- Graduate Program in Cardiovascular Sciences, Federal University of Ceara, Fortaleza, Ceara, Brazil
| | - Shamyr Sulyvan Castro
- Master Program in Physiotherapy and Functioning, Federal University of Ceara, Fortaleza, Ceara, Brazil
| | - Antonio Brazil Viana-Júnior
- Clinical Research Unit of Hospital Universitário Walter Cantidio, Federal University of Ceara/EBSERH, Fortaleza, Ceara, Brazil
| | | | - Camila Ferreira Leite
- Graduate Program in Cardiovascular Sciences, Federal University of Ceara, Fortaleza, Ceara, Brazil.
- Master Program in Physiotherapy and Functioning, Federal University of Ceara, Fortaleza, Ceara, Brazil.
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Balk EM, Adam GP, Cao W, Bhuma MR, D’Ambrosio C, Trikalinos TA. Long-term effects on clinical event, mental health, and related outcomes of CPAP for obstructive sleep apnea: a systematic review. J Clin Sleep Med 2024; 20:895-909. [PMID: 38300818 PMCID: PMC11145052 DOI: 10.5664/jcsm.11030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2023] [Revised: 01/10/2024] [Accepted: 01/11/2024] [Indexed: 02/03/2024]
Abstract
STUDY OBJECTIVES We performed a systematic review of long-term health outcomes of continuous positive airway pressure (CPAP) use in adults with obstructive sleep apnea. METHODS We updated prior systematic reviews with searches in multiple databases through January 3, 2023. We included randomized controlled trials (RCTs) and adjusted nonrandomized comparative studies that reported prespecified long-term (mostly > 1 year) health outcomes. We assessed risk of bias, conducted meta-analyses, and evaluated strength of evidence. RESULTS We found 38 eligible studies (16 trials, 22 observational). All conclusions were of low strength of evidence given study and data limitations. RCTs found no evidence of effect of CPAP on mortality (summary effect size [ES] 0.89; 95% confidence interval [CI] 0.66, 1.21); inclusion of adjusted nonrandomized comparative studies yields an association with reduced risk of death (ES 0.57; 95% CI 0.44, 0.73). RCTs found no evidence of effects of CPAP for cardiovascular death (ES 0.99; 95% CI 0.64, 1.53), stroke (ES 0.99; 95% CI 0.73, 1.35), myocardial infarction (ES 1.05; 95% CI 0.78, 1.41), incident atrial fibrillation (ES 0.89; 95% CI 0.48, 1.63), or composite cardiovascular outcomes (all statistically nonsignificant). RCTs found no evidence of effects for incident diabetes (ES 1.02; 95% CI 0.69, 1.51) or accidents (all nonsignificant) and no clinically significant effects on depressive symptoms, anxiety symptoms, or cognitive function. CONCLUSIONS Whether CPAP use for obstructive sleep apnea affects long-term health outcomes remains largely unanswered. RCTs and nonrandomized comparative studies are inconsistent regarding the effect of CPAP on mortality. Current studies are underpowered, with relatively short duration follow-up and methodological limitations. CITATION Balk EM, Adam GP, Cao W, Bhuma MR, D'Ambrosio C, Trikalinos TA. Long-term effects on clinical event, mental health, and related outcomes of CPAP for obstructive sleep apnea: a systematic review. J Clin Sleep Med. 2024;20(6):895-909.
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Affiliation(s)
- Ethan M. Balk
- Center for Evidence Synthesis in Health, Brown University School of Public Health, Providence, Rhode Island
| | - Gaelen P. Adam
- Center for Evidence Synthesis in Health, Brown University School of Public Health, Providence, Rhode Island
| | - Wangnan Cao
- Center for Evidence Synthesis in Health, Brown University School of Public Health, Providence, Rhode Island
| | - Monika Reddy Bhuma
- Center for Evidence Synthesis in Health, Brown University School of Public Health, Providence, Rhode Island
| | - Carolyn D’Ambrosio
- Section of Pulmonary, Critical Care, and Sleep Medicine, Yale University School of Medicine, New Haven, Connecticut
| | - Thomas A. Trikalinos
- Center for Evidence Synthesis in Health, Brown University School of Public Health, Providence, Rhode Island
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Balk EM, Adam GP, D’Ambrosio CM. Large variability in definitions of sleep apnea indices used in clinical studies. J Clin Sleep Med 2024; 20:461-468. [PMID: 38054476 PMCID: PMC11019218 DOI: 10.5664/jcsm.10918] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2023] [Revised: 11/06/2023] [Accepted: 11/06/2023] [Indexed: 12/07/2023]
Abstract
STUDY OBJECTIVES We explored the variability of sleep apnea indices and definitions of obstructive sleep apnea in clinical studies of continuous positive airway pressure. METHODS In a systematic review of the long-term clinical effects of continuous positive airway pressure, we noted variability across studies in how sleep apnea was defined. We, thus, sought to quantify the heterogeneity. RESULTS Across 57 comparative studies of long-term clinical outcomes of continuous positive airway pressure, only 40% fully and explicitly reported their definitions of apnea and hypopnea. Most studies defined apnea as 100% airflow cessation, but a minority used 90% or even down to 75% thresholds. Almost half of the studies defined hypopnea as ≥ 50% airflow cessation, but the majority used 30% or even 25% thresholds. Similarly, about half of the studies used a 4% desaturation threshold to define oxygen desaturation and about half used a 3% threshold, with 2 studies using both thresholds for different purposes. Randomized trials were no more consistent or better-reported than observational studies. Studies that cited published criteria generally reported definitions that were different from the cited criteria. CONCLUSIONS The criteria used to define sleep apnea indices (apnea, hypopnea, and oxygen desaturation) were highly variable, even among studies stating that definitions were based on the same standard criteria. It was often difficult to discern the actual criteria used. The great variability across studies and lack of transparency about their sleep study methods hampers the interpretability and utility of the studies and calls into question whether studies are generalizable from one setting to another. CITATION Balk EM, Adam GP, D'Ambrosio CM. Large variability in definitions of sleep apnea indices used in clinical studies. J Clin Sleep Med. 2024;20(3):461-468.
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Affiliation(s)
- Ethan M. Balk
- Center for Evidence Synthesis in Health, Brown University School of Public Health, Providence, Rhode Island
| | - Gaelen P. Adam
- Center for Evidence Synthesis in Health, Brown University School of Public Health, Providence, Rhode Island
| | - Carolyn M. D’Ambrosio
- Section of Pulmonary, Critical Care, and Sleep Medicine, Yale University School of Medicine, New Haven, Connecticut
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Russell M, Baldwin CM, Quan SF. Exploring Sleep in Caregivers of Children with Autism Spectrum Disorder (ASD) and the Relationship to Health-Related Quality of Life (HRQoL) and Family Quality of Life (FQoL). MEDICINA (KAUNAS, LITHUANIA) 2023; 59:2132. [PMID: 38138235 PMCID: PMC10744649 DOI: 10.3390/medicina59122132] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/02/2023] [Revised: 11/21/2023] [Accepted: 12/04/2023] [Indexed: 12/24/2023]
Abstract
Background and Objectives: To investigate (1) the prevalence of sleep disorder symptoms in caregivers of children with autism spectrum disorder (ASD) and (2) the relationships between caregiver sleep problems and their health-related quality of life and family quality of life. Materials and Methods: Descriptive cross-sectional study of caregivers (N = 62) of children aged 6 to 11 years old diagnosed with ASD and receiving care at a regional autism research and resource center. Results: Participants completed the Sleep Habits Questionnaire (SHQ), the Medical Outcomes Study (MOS) SF-12, and the Beach Center Family Quality of Life Scale (FQoL). Caregivers with longer sleep duration reported better mental health and better family quality of life. Caregivers who reported insomnia symptoms, non-restorative sleep, and insufficient sleep were more likely to report poorer mental health than caregivers who did not report these sleep disorder symptoms. Caregivers with obstructive sleep apnea and restless legs syndrome experienced worse physical quality of life. Conclusions: The physical and mental health of the primary caregiver is essential to the support of the child with ASD and to the functioning of the family. The study findings point to the importance of future research and interventions to enhance sleep health in order to improve quality of life for caregivers of children with ASD.
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Affiliation(s)
- Maureen Russell
- Institute for Human Development, Northern Arizona University, Flagstaff, AZ 86011, USA;
| | - Carol M. Baldwin
- Edson College of Nursing and Health Innovation, Arizona State University, Phoenix, AZ 85287, USA;
| | - Stuart F. Quan
- Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, College of Medicine, University of Arizona, Tucson, AZ 85724, USA
- Division of Sleep and Circadian Disorders, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA 02115, USA
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Pattison E, Tolson J, Barnes M, Saunders WJ, Bartlett D, Downey LA, Jackson ML. Improved depressive symptoms, and emotional regulation and reactivity, in individuals with obstructive sleep apnea after short- and long-term CPAP therapy use. Sleep Med 2023; 111:13-20. [PMID: 37714031 DOI: 10.1016/j.sleep.2023.08.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Revised: 08/14/2023] [Accepted: 08/27/2023] [Indexed: 09/17/2023]
Abstract
Obstructive Sleep Apnoea (OSA) is associated with high rates of depression; however, if and how treatment of OSA improves depressive symptoms is unclear. To further understand this link we considered the role of emotional regulation - the ability to control and express our emotional responses - thought to be a central component of depression. This study aimed to assess changes in depressive symptoms and emotional responses in individuals with OSA after 4- and 12-months of continuous positive airway pressure (CPAP) treatment. One-hundred and twenty-one OSA participants (50 female, Mage = 51.93; mean AHI = 36.27) were recruited from a tertiary clinical sleep service prior to CPAP initiation, and randomised to either a CPAP group or a 4 month wait-list group. Participants completed the Center for Epidemiological Studies Depression Scale, the Emotional Reactivity Scale and the Difficulties in Emotion Regulation Scale at baseline, and 1-, 2-, and 4-months follow-up. The CPAP group also completed the questionnaires 12-months after CPAP initiation. CPAP use at 1 month and 12 months was 5.1h/night and 4.9h/night, respectively. Significant improvements in depressive symptoms, emotional regulation and reactivity, and subjective sleepiness were observed after 4 months in both groups, however, the within group changes were only significant for those using CPAP. After 12-months of CPAP treatment, these improvements were maintained. There was no association between CPAP treatment adherence and improvements in any outcome. CPAP treatment for 12 months may reduce symptoms of depression and improve emotional regulation in individuals with OSA.
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Affiliation(s)
- Emily Pattison
- Institute for Breathing and Sleep, Austin Health, Heidelberg, Melbourne, Australia; RMIT University, School of Health and Biomedical Science, Melbourne, Australia
| | - Julie Tolson
- Institute for Breathing and Sleep, Austin Health, Heidelberg, Melbourne, Australia
| | - Maree Barnes
- Institute for Breathing and Sleep, Austin Health, Heidelberg, Melbourne, Australia; The University of Melbourne, Melbourne, Australia
| | - William J Saunders
- Turner Institute for Brain and Mental Health, School of Psychological Sciences, Monash University, Melbourne, Australia
| | - Delwyn Bartlett
- Woolcock Institute for Medical Research, & the University of Sydney, NSW, Australia
| | - Luke A Downey
- Institute for Breathing and Sleep, Austin Health, Heidelberg, Melbourne, Australia; Centre for Human Psychopharmacology, Swinburne University, Hawthorn, Melbourne, Australia
| | - Melinda L Jackson
- Institute for Breathing and Sleep, Austin Health, Heidelberg, Melbourne, Australia; Turner Institute for Brain and Mental Health, School of Psychological Sciences, Monash University, Melbourne, Australia.
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Shen C, Ou Y, Ouyang R, Zong D. Prevalence and characteristics of pain in moderate-to-severe obstructive sleep apnea patients and effect of CPAP treatment. Sci Rep 2023; 13:15758. [PMID: 37735494 PMCID: PMC10514028 DOI: 10.1038/s41598-023-42967-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2023] [Accepted: 09/17/2023] [Indexed: 09/23/2023] Open
Abstract
Pain problems are common in patients with obstructive sleep apnea (OSA), but few studies have thoroughly evaluated pain in these patients. The objective of this study was to examine the prevalence and characteristics of pain in moderate-to-severe OSA patients and the effect of continuous positive airway pressure (CPAP) treatment. Moderate-to-severe OSA patients and healthy controls (HC) completed the Short Form McGill Pain Questionnaire (SF-MPQ) and a portion of the Brief Pain Inventory (BPI) Short Form to assess pain characteristics. The Epworth Sleepiness Scale (ESS), the Short Form-36 (SF-36), and the Hospital Anxiety and Depression Scale (HADS) were used to measure daytime sleepiness, health-related quality of life (HRQoL), and psychological status, respectively. The OSA patients with pain were divided into a CPAP-treated group and a CPAP-untreated group based on their adherence to CPAP. The subjects' pain intensity was reassessed after 3 months. The prevalence of pain was 57.5% in OSA versus 27.1% in HC (p < 0.001). Head (39.0%) accounted for the highest proportion of overall pain locations in subjects with OSA, with 28.8% of OSA patients experiencing headaches. Pain in OSA was associated with impaired HRQoL and psychological problems. Patients with very severe OSA had an increased risk for pain problems (OR: 7.000, p = 0.041). Associated factors for pain intensity in OSA included age, ESS ≥ 9.0, and lowest pulse oximetry (LSpO2) < 80.0%. Pain intensity in OSA decreased significantly after CPAP treatment (p < 0.001). Pain was prevalent among patients with moderate-to-severe OSA and was associated with depression, anxiety, and a lower HRQoL. Patients with very severe OSA had an increased risk for pain problems. The intensity of pain in OSA can be predicted by age, ESS ≥ 9.0, and LSpO2 < 80.0%, and it can be alleviated through CPAP treatment.
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Affiliation(s)
- Chong Shen
- Department of Respiratory and Critical Care Medicine, Second Xiangya Hospital, Central South University, Changsha, 410011, China
| | - Yanru Ou
- Department of Respiratory and Critical Care Medicine, Second Xiangya Hospital, Central South University, Changsha, 410011, China
| | - Ruoyun Ouyang
- Department of Respiratory and Critical Care Medicine, Second Xiangya Hospital, Central South University, Changsha, 410011, China.
| | - Dandan Zong
- Department of Respiratory and Critical Care Medicine, Second Xiangya Hospital, Central South University, Changsha, 410011, China.
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Johnson KG. Obstructive Sleep Apnea. Continuum (Minneap Minn) 2023; 29:1071-1091. [PMID: 37590823 DOI: 10.1212/con.0000000000001264] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/19/2023]
Abstract
OBJECTIVE Obstructive sleep apnea (OSA) is the most common type of sleep-disordered breathing. This article describes advances in the diagnosis, testing, treatment, and monitoring of OSA. LATEST DEVELOPMENTS Home sleep apnea testing and in-laboratory polysomnography are the most commonly used diagnostic tools in the identification and monitoring of OSA, but new methods for diagnosis and at-home monitoring of treatment response are being developed and validated. While the apnea-hypopnea index is regularly used to define OSA severity, recognition is increasing of its inability to risk-stratify patients. Other sleep study data including arousal threshold, hypoxic burden, and pulse rate variability as well as clinical characteristics can help with risk stratification. The most effective treatment is continuous positive airway pressure (CPAP), which can be limited by adherence and tolerance in some patients. Newer masks and comfort features including heated tubing and expiratory pressure relief may improve tolerance to positive airway pressure (PAP) therapy. Additional treatment options include other PAP modalities, mandibular advancement devices, tongue stimulation therapy, negative inspiratory pressure, nasal expiratory pressure valves, nasal congestion treatments, upper airway surgeries including hypoglossal nerve stimulation, and medications. ESSENTIAL POINTS OSA is a common disorder that causes sleep and daytime symptoms and increases the risk of neurologic and medical complications. Neurologists should be aware of atypical presentations and understand the diagnostic and treatment options.
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Chang JL, Goldberg AN, Alt JA, Alzoubaidi M, Ashbrook L, Auckley D, Ayappa I, Bakhtiar H, Barrera JE, Bartley BL, Billings ME, Boon MS, Bosschieter P, Braverman I, Brodie K, Cabrera-Muffly C, Caesar R, Cahali MB, Cai Y, Cao M, Capasso R, Caples SM, Chahine LM, Chang CP, Chang KW, Chaudhary N, Cheong CSJ, Chowdhuri S, Cistulli PA, Claman D, Collen J, Coughlin KC, Creamer J, Davis EM, Dupuy-McCauley KL, Durr ML, Dutt M, Ali ME, Elkassabany NM, Epstein LJ, Fiala JA, Freedman N, Gill K, Boyd Gillespie M, Golisch L, Gooneratne N, Gottlieb DJ, Green KK, Gulati A, Gurubhagavatula I, Hayward N, Hoff PT, Hoffmann OM, Holfinger SJ, Hsia J, Huntley C, Huoh KC, Huyett P, Inala S, Ishman SL, Jella TK, Jobanputra AM, Johnson AP, Junna MR, Kado JT, Kaffenberger TM, Kapur VK, Kezirian EJ, Khan M, Kirsch DB, Kominsky A, Kryger M, Krystal AD, Kushida CA, Kuzniar TJ, Lam DJ, Lettieri CJ, Lim DC, Lin HC, Liu SY, MacKay SG, Magalang UJ, Malhotra A, Mansukhani MP, Maurer JT, May AM, Mitchell RB, Mokhlesi B, Mullins AE, Nada EM, Naik S, Nokes B, Olson MD, Pack AI, Pang EB, Pang KP, Patil SP, Van de Perck E, Piccirillo JF, Pien GW, Piper AJ, Plawecki A, Quigg M, Ravesloot MJ, Redline S, Rotenberg BW, Ryden A, Sarmiento KF, Sbeih F, Schell AE, Schmickl CN, Schotland HM, Schwab RJ, Seo J, Shah N, Shelgikar AV, Shochat I, Soose RJ, Steele TO, Stephens E, Stepnowsky C, Strohl KP, Sutherland K, Suurna MV, Thaler E, Thapa S, Vanderveken OM, de Vries N, Weaver EM, Weir ID, Wolfe LF, Tucker Woodson B, Won CH, Xu J, Yalamanchi P, Yaremchuk K, Yeghiazarians Y, Yu JL, Zeidler M, Rosen IM. International Consensus Statement on Obstructive Sleep Apnea. Int Forum Allergy Rhinol 2023; 13:1061-1482. [PMID: 36068685 PMCID: PMC10359192 DOI: 10.1002/alr.23079] [Citation(s) in RCA: 62] [Impact Index Per Article: 62.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2022] [Revised: 08/12/2022] [Accepted: 08/18/2022] [Indexed: 11/08/2022]
Abstract
BACKGROUND Evaluation and interpretation of the literature on obstructive sleep apnea (OSA) allows for consolidation and determination of the key factors important for clinical management of the adult OSA patient. Toward this goal, an international collaborative of multidisciplinary experts in sleep apnea evaluation and treatment have produced the International Consensus statement on Obstructive Sleep Apnea (ICS:OSA). METHODS Using previously defined methodology, focal topics in OSA were assigned as literature review (LR), evidence-based review (EBR), or evidence-based review with recommendations (EBR-R) formats. Each topic incorporated the available and relevant evidence which was summarized and graded on study quality. Each topic and section underwent iterative review and the ICS:OSA was created and reviewed by all authors for consensus. RESULTS The ICS:OSA addresses OSA syndrome definitions, pathophysiology, epidemiology, risk factors for disease, screening methods, diagnostic testing types, multiple treatment modalities, and effects of OSA treatment on multiple OSA-associated comorbidities. Specific focus on outcomes with positive airway pressure (PAP) and surgical treatments were evaluated. CONCLUSION This review of the literature consolidates the available knowledge and identifies the limitations of the current evidence on OSA. This effort aims to create a resource for OSA evidence-based practice and identify future research needs. Knowledge gaps and research opportunities include improving the metrics of OSA disease, determining the optimal OSA screening paradigms, developing strategies for PAP adherence and longitudinal care, enhancing selection of PAP alternatives and surgery, understanding health risk outcomes, and translating evidence into individualized approaches to therapy.
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Affiliation(s)
- Jolie L. Chang
- University of California, San Francisco, California, USA
| | | | | | | | - Liza Ashbrook
- University of California, San Francisco, California, USA
| | | | - Indu Ayappa
- Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | | | | | | | | | - Maurits S. Boon
- Sidney Kimmel Medical Center at Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Pien Bosschieter
- Academic Centre for Dentistry Amsterdam, Amsterdam, The Netherlands
| | - Itzhak Braverman
- Hillel Yaffe Medical Center, Hadera Technion, Faculty of Medicine, Hadera, Israel
| | - Kara Brodie
- University of California, San Francisco, California, USA
| | | | - Ray Caesar
- Stone Oak Orthodontics, San Antonio, Texas, USA
| | | | - Yi Cai
- University of California, San Francisco, California, USA
| | | | | | | | | | | | | | | | | | - Susmita Chowdhuri
- Wayne State University and John D. Dingell VA Medical Center, Detroit, Michigan, USA
| | - Peter A. Cistulli
- Faculty of Medicine and Health, University of Sydney, Sydney, Australia
| | - David Claman
- University of California, San Francisco, California, USA
| | - Jacob Collen
- Uniformed Services University, Bethesda, Maryland, USA
| | | | | | - Eric M. Davis
- University of Virginia, Charlottesville, Virginia, USA
| | | | | | - Mohan Dutt
- University of Michigan, Ann Arbor, Michigan, USA
| | - Mazen El Ali
- University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | | | | | | | | | - Kirat Gill
- Stanford University, Palo Alto, California, USA
| | | | - Lea Golisch
- University Hospital Mannheim, Ruprecht-Karls-University Heidelberg, Heidelberg, Germany
| | | | | | | | - Arushi Gulati
- University of California, San Francisco, California, USA
| | | | | | - Paul T. Hoff
- University of Michigan, Ann Arbor, Michigan, USA
| | - Oliver M.G. Hoffmann
- University Hospital Mannheim, Ruprecht-Karls-University Heidelberg, Heidelberg, Germany
| | | | - Jennifer Hsia
- University of Minnesota, Minneapolis, Minnesota, USA
| | - Colin Huntley
- Sidney Kimmel Medical Center at Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | | | | | - Sanjana Inala
- Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | | | | | | | | | | | | | | | | | | | - Meena Khan
- Ohio State University, Columbus, Ohio, USA
| | | | - Alan Kominsky
- Cleveland Clinic Head and Neck Institute, Cleveland, Ohio, USA
| | - Meir Kryger
- Yale School of Medicine, New Haven, Connecticut, USA
| | | | | | | | - Derek J. Lam
- Oregon Health and Science University, Portland, Oregon, USA
| | | | | | | | | | | | | | - Atul Malhotra
- University of California, San Diego, California, USA
| | | | - Joachim T. Maurer
- University Hospital Mannheim, Ruprecht-Karls-University Heidelberg, Heidelberg, Germany
| | - Anna M. May
- Case Western Reserve University, Cleveland, Ohio, USA
| | - Ron B. Mitchell
- University of Texas, Southwestern and Children’s Medical Center Dallas, Texas, USA
| | | | | | | | | | - Brandon Nokes
- University of California, San Diego, California, USA
| | | | - Allan I. Pack
- University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | | | | | | | | | | | | | | | | | - Mark Quigg
- University of Virginia, Charlottesville, Virginia, USA
| | | | - Susan Redline
- Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | | | - Armand Ryden
- Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, California, USA
| | | | - Firas Sbeih
- Cleveland Clinic Head and Neck Institute, Cleveland, Ohio, USA
| | | | | | | | | | - Jiyeon Seo
- University of California, Los Angeles, California, USA
| | - Neomi Shah
- Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | | | | | - Ryan J. Soose
- University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | | | - Erika Stephens
- University of California, San Francisco, California, USA
| | | | | | | | | | - Erica Thaler
- University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Sritika Thapa
- Yale School of Medicine, New Haven, Connecticut, USA
| | | | - Nico de Vries
- Academic Centre for Dentistry Amsterdam, Amsterdam, The Netherlands
| | | | - Ian D. Weir
- Yale School of Medicine, New Haven, Connecticut, USA
| | | | | | | | - Josie Xu
- University of Toronto, Ontario, Canada
| | | | | | | | | | | | - Ilene M. Rosen
- University of Pennsylvania, Philadelphia, Pennsylvania, USA
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12
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Donovan LM, Hoyos CM, Kimoff RJ, Morrell MJ, Bosch NA, Chooljian DM, McEvoy RD, Sawyer AM, Wagner TH, Al-Lamee RR, Bishop D, Carno MA, Epstein M, Hanson M, Ip MSM, Létourneau M, Pamidi S, Patel SR, Pépin JL, Punjabi NM, Redline S, Thornton JD, Patil SP. Strategies to Assess the Effect of Continuous Positive Airway Pressure on Long-Term Clinically Important Outcomes among Patients with Symptomatic Obstructive Sleep Apnea: An Official American Thoracic Society Workshop Report. Ann Am Thorac Soc 2023; 20:931-943. [PMID: 37387624 DOI: 10.1513/annalsats.202303-258st] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/01/2023] Open
Abstract
Continuous positive airway pressure (CPAP) is the first-line treatment for obstructive sleep apnea (OSA). Although CPAP improves symptoms (e.g., daytime sleepiness), there is a lack of high-quality evidence that CPAP prevents many long-term outcomes, including cognitive impairment, myocardial infarction, and stroke. Observational studies suggest that patients with symptoms may be particularly likely to experience these preventive benefits with CPAP, but ethical and practical concerns limited the participation of such patients in prior long-term randomized trials. As a result, there is uncertainty about the full benefits of CPAP, and resolving this uncertainty is a key priority for the field. This workshop assembled clinicians, researchers, ethicists, and patients to identify strategies to understand the causal effects of CPAP on long-term clinically important outcomes among patients with symptomatic OSA. Quasi-experimental designs can provide valuable information and are less time and resource intensive than trials. Under specific conditions and assumptions, quasi-experimental studies may be able to provide causal estimates of CPAP's effectiveness from generalizable observational cohorts. However, randomized trials represent the most reliable approach to understanding the causal effects of CPAP among patients with symptoms. Randomized trials of CPAP can ethically include patients with symptomatic OSA, as long as there is outcome-specific equipoise, adequate informed consent, and a plan to maximize safety while minimizing harm (e.g., monitoring for pathologic sleepiness). Furthermore, multiple strategies exist to ensure the generalizability and practicality of future randomized trials of CPAP. These strategies include reducing the burden of trial procedures, improving patient-centeredness, and engaging historically excluded and underserved populations.
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13
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Ou YH, Colpani JT, Chan SP, Loke W, Cheong CS, Kong W, Chin CW, Kojodjojo P, Wong P, Cistulli P, Lee CH. Mandibular advancement device versus CPAP in lowering 24-hour blood pressure in patients with obstructive sleep apnoea and hypertension: the CRESCENT trial protocol. BMJ Open 2023; 13:e072853. [PMID: 37258080 DOI: 10.1136/bmjopen-2023-072853] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/02/2023] Open
Abstract
INTRODUCTION Although treatment of obstructive sleep apnoea (OSA) using continuous positive airway pressure (CPAP) reduces blood pressure (BP), adherence to CPAP is often suboptimal. A mandibular advancement device (MAD) is a guideline-endorsed alternative therapy for OSA. Still, there is limited evidence on the relative efficacy between MAD and CPAP on BP reduction. We evaluate whether treatment of moderate-to-severe OSA using MAD can improve BP and other health-related outcomes compared with CPAP. METHODS AND ANALYSIS This is a randomised, controlled, non-inferiority trial conducted. We will recruit 220 Asians with a history of hypertension and high cardiovascular risk for an overnight polysomnography screening. Those with moderate-to-severe OSA (apnoea-hypopnoea index ≥15 events/hour) will be randomised to treatment with either MAD or CPAP in a 1:1 ratio. Stratified by age (60 vs <60 years old), body mass index (25 vs <25 kg/m2) and apnoea-hypopnoea index (30 vs <30 events/hour), an adaptive randomisation scheme with permuted blocks constructed in real-time is implemented to restrict imbalance. The overall study duration is 12 months. The primary endpoint is the 24-hour mean arterial BP difference between baseline and 6-month follow-up. The secondary endpoints include other measures of ambulatory BP monitoring, arrhythmia based on a 4-day electrocardiographic monitoring, biomarker and proteomic analysis, cardiovascular magnetic resonance-derived myocardial fibrosis and remodelling and quality-of-life questionnaires. Recruitment began in October 2019 and ended in December 2022. Comparison between MAD and CPAP will be performed using covariance (ANCOVA) analysis of the changes in 24-hour mean arterial BP while adjusting for the baseline 24-hour mean arterial BP. We will compare the 95% CIs around the treatment difference point estimate with the prespecified non-inferiority margin (1.5 mm Hg). If the upper limit of the 95% CI is <1.5 mm Hg and crosses 0, non-inferiority of the MAD relative to CPAP will be established. ETHICS AND DISSEMINATION The Domain Specific Review Board-C, National Healthcare Group under approved the study protocol (NHG DSRB Ref: 2019/00359, approved on 28 August 2019). Study findings will be disseminated to various local, national, and international audiences through abstract presentations and publication in peer-reviewed journals. TRIAL REGISTRATION NUMBER NCT04119999.
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Affiliation(s)
- Yi-Hui Ou
- Department of Medicine, National University of Singapore, Singapore
| | - Juliana Tereza Colpani
- Department of Endodontics, Operative Dentistry and Prosthodontics, National University of Singapore, Singapore
| | - Siew-Pang Chan
- Department of Medicine, National University of Singapore, Singapore
- National University Heart Centre, Singapore
| | - Weiqiang Loke
- Department of Endodontics, Operative Dentistry and Prosthodontics, National University of Singapore, Singapore
| | - Crystal S Cheong
- Department of Otolaryngology-Head and Neck Surgery, National University Hospital, Singapore
| | | | - Calvin W Chin
- Department of Cardiology, National Heart Centre Singapore, Singapore
| | | | - Philip Wong
- Department of Medicine, Raffles Hospital, Singapore
| | - Peter Cistulli
- Charles Perkins Centre, The University of Sydney, Sydney, New South Wales, Australia
| | - Chi-Hang Lee
- Department of Medicine, National University of Singapore, Singapore
- National University Heart Centre, Singapore
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14
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Huang L, Li H, Shu Y, Li K, Xie W, Zeng Y, Long T, Zeng L, Liu X, Peng D. Changes in Functional Connectivity of Hippocampal Subregions in Patients with Obstructive Sleep Apnea after Six Months of Continuous Positive Airway Pressure Treatment. Brain Sci 2023; 13:brainsci13050838. [PMID: 37239310 DOI: 10.3390/brainsci13050838] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2023] [Revised: 05/12/2023] [Accepted: 05/17/2023] [Indexed: 05/28/2023] Open
Abstract
Previous studies have shown that the structural and functional impairments of hippocampal subregions in patients with obstructive sleep apnea (OSA) are related to cognitive impairment. Continuous positive airway pressure (CPAP) treatment can improve the clinical symptoms of OSA. Therefore, this study aimed to investigate functional connectivity (FC) changes in hippocampal subregions of patients with OSA after six months of CPAP treatment (post-CPAP) and its relationship with neurocognitive function. We collected and analyzed baseline (pre-CPAP) and post-CPAP data from 20 patients with OSA, including sleep monitoring, clinical evaluation, and resting-state functional magnetic resonance imaging. The results showed that compared with pre-CPAP OSA patients, the FC between the right anterior hippocampal gyrus and multiple brain regions, and between the left anterior hippocampal gyrus and posterior central gyrus were reduced in post-CPAP OSA patients. By contrast, the FC between the left middle hippocampus and the left precentral gyrus was increased. The changes in FC in these brain regions were closely related to cognitive dysfunction. Therefore, our findings suggest that CPAP treatment can effectively change the FC patterns of hippocampal subregions in patients with OSA, facilitating a better understanding of the neural mechanisms of cognitive function improvement, and emphasizing the importance of early diagnosis and timely treatment of OSA.
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Affiliation(s)
- Ling Huang
- Medical Imaging Center, The First Affiliated Hospital of Nanchang University, Nanchang 330000, China
| | - Haijun Li
- Medical Imaging Center, The First Affiliated Hospital of Nanchang University, Nanchang 330000, China
- PET Center, The First Affiliated Hospital of Nanchang University, Nanchang 330000, China
| | - Yongqiang Shu
- Medical Imaging Center, The First Affiliated Hospital of Nanchang University, Nanchang 330000, China
| | - Kunyao Li
- Medical Imaging Center, The First Affiliated Hospital of Nanchang University, Nanchang 330000, China
| | - Wei Xie
- Medical Imaging Center, The First Affiliated Hospital of Nanchang University, Nanchang 330000, China
| | - Yaping Zeng
- Medical Imaging Center, The First Affiliated Hospital of Nanchang University, Nanchang 330000, China
| | - Ting Long
- Medical Imaging Center, The First Affiliated Hospital of Nanchang University, Nanchang 330000, China
| | - Li Zeng
- Medical Imaging Center, The First Affiliated Hospital of Nanchang University, Nanchang 330000, China
| | - Xiang Liu
- Medical Imaging Center, The First Affiliated Hospital of Nanchang University, Nanchang 330000, China
| | - Dechang Peng
- Medical Imaging Center, The First Affiliated Hospital of Nanchang University, Nanchang 330000, China
- PET Center, The First Affiliated Hospital of Nanchang University, Nanchang 330000, China
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15
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Syndrome d’apnées du sommeil 1999–2022 : des essais randomisés aux études de cohorte. BULLETIN DE L'ACADÉMIE NATIONALE DE MÉDECINE 2023. [DOI: 10.1016/j.banm.2022.10.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/03/2023]
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16
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Placebo response in objective and subjective measures of hypersomnia in randomized clinical trials on obstructive sleep apnea. A systematic review and meta-analysis. Sleep Med Rev 2023; 67:101720. [PMID: 36495752 DOI: 10.1016/j.smrv.2022.101720] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2022] [Revised: 11/14/2022] [Accepted: 11/14/2022] [Indexed: 11/23/2022]
Abstract
Sleepiness is one of the outcomes most used in randomized clinical trials (RCT) on the effect of treatments for obstructive sleep apnea (OSA). Furthermore, it is known that there is a placebo effect, especially in subjective measures. Therefore, given that sleepiness is a subjective measure, the objective of this systematic review with meta-analysis and three-level meta-regression was to assess the response to different placebos (pills and sham-CPAP) used in RCTs in OSA, both on subjective (Epworth Sleepiness Scale [ESS]) and objective (Multiple Sleep Latency Test [MSLT], Maintenance Wake Test [MWT], the Osler test and the Psychomotor Vigilance Task [PVT]). We observed a statistically significant placebo effect in both subjective and objective measures of hypersomnia, and in both sham-CPAP and pills. This placebo effect was greater, even clinically significant, in subjective measures (ESS: -2.84 points) and in those RCTs that used pills as a placebo. In the meta-regression, only a higher baseline value of the ESS and Osler test was related to the placebo effect.
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17
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Feltner C, Wallace IF, Aymes S, Cook Middleton J, Hicks KL, Schwimmer M, Baker C, Balio CP, Moore D, Voisin CE, Jonas DE. Screening for Obstructive Sleep Apnea in Adults: Updated Evidence Report and Systematic Review for the US Preventive Services Task Force. JAMA 2022; 328:1951-1971. [PMID: 36378203 DOI: 10.1001/jama.2022.18357] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
IMPORTANCE Obstructive sleep apnea (OSA) is associated with adverse health outcomes. OBJECTIVE To review the evidence on screening for OSA in asymptomatic adults or those with unrecognized OSA symptoms to inform the US Preventive Services Task Force. DATA SOURCES PubMed/MEDLINE, Cochrane Library, Embase, and trial registries through August 23, 2021; surveillance through September 23, 2022. STUDY SELECTION English-language studies of screening test accuracy, randomized clinical trials (RCTs) of screening or treatment of OSA reporting health outcomes or harms, and systematic reviews of treatment reporting changes in blood pressure and apnea-hypopnea index (AHI) scores. DATA EXTRACTION AND SYNTHESIS Dual review of abstracts, full-text articles, and study quality. Meta-analysis of intervention trials. MAIN OUTCOMES AND MEASURES Test accuracy, excessive daytime sleepiness, sleep-related and general health-related quality of life (QOL), and harms. RESULTS Eighty-six studies were included (N = 11 051). No study directly compared screening with no screening. Screening accuracy of the Multivariable Apnea Prediction score followed by unattended home sleep testing for detecting severe OSA syndrome (AHI ≥30 and Epworth Sleepiness Scale [ESS] score >10) measured as the area under the curve in 2 studies (n = 702) was 0.80 (95% CI, 0.78 to 0.82) and 0.83 (95% CI, 0.77 to 0.90). Five studies assessing the accuracy of other screening tools were heterogeneous and results were inconsistent. Compared with inactive control, positive airway pressure was associated with a significant improvement in ESS score from baseline (pooled mean difference, -2.33 [95% CI, -2.75 to -1.90]; 47 trials; n = 7024), sleep-related QOL (standardized mean difference, 0.30 [95% CI, 0.19 to 0.42]; 17 trials; n = 3083), and general health-related QOL measured by the 36-Item Short Form Health Survey (SF-36) mental health component summary score change (pooled mean difference, 2.20 [95% CI, 0.95 to 3.44]; 15 trials; n = 2345) and SF-36 physical health component summary score change (pooled mean difference, 1.53 [95% CI, 0.29 to 2.77]; 13 trials; n = 2031). Use of mandibular advancement devices was also associated with a significantly larger ESS score change compared with controls (pooled mean difference, -1.67 [95% CI, 2.09 to -1.25]; 10 trials; n = 1540). Reporting of other health outcomes was sparse; no included trial found significant benefit associated with treatment on mortality, cardiovascular events, or motor vehicle crashes. In 3 systematic reviews, positive airway pressure was significantly associated with reduced blood pressure; however, the difference was relatively small (2-3 mm Hg). CONCLUSIONS AND RELEVANCE The accuracy and clinical utility of OSA screening tools that could be used in primary care settings were uncertain. Positive airway pressure and mandibular advancement devices reduced ESS score. Trials of positive airway pressure found modest improvement in sleep-related and general health-related QOL but have not established whether treatment reduces mortality or improves most other health outcomes.
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Affiliation(s)
- Cynthia Feltner
- RTI International-University of North Carolina at Chapel Hill Evidence-based Practice Center
- Department of Medicine, University of North Carolina at Chapel Hill
- Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill
| | - Ina F Wallace
- RTI International-University of North Carolina at Chapel Hill Evidence-based Practice Center
- RTI International, Research Triangle Park, North Carolina
| | - Shannon Aymes
- Department of Medicine, University of North Carolina at Chapel Hill
| | - Jennifer Cook Middleton
- RTI International-University of North Carolina at Chapel Hill Evidence-based Practice Center
- Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill
| | - Kelli L Hicks
- Department of Otolaryngology-Head and Neck Surgery, University of North Carolina at Chapel Hill
| | - Manny Schwimmer
- RTI International-University of North Carolina at Chapel Hill Evidence-based Practice Center
- Department of Internal Medicine, The Ohio State University, Columbus
| | - Claire Baker
- RTI International-University of North Carolina at Chapel Hill Evidence-based Practice Center
- Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill
| | - Casey P Balio
- Center for Rural Health Research, Department of Health Services Management and Policy, College of Public Health, East Tennessee State University, Johnson City
| | - Daniel Moore
- Department of Medicine, University of North Carolina at Chapel Hill
| | - Christiane E Voisin
- RTI International-University of North Carolina at Chapel Hill Evidence-based Practice Center
- Department of Internal Medicine, The Ohio State University, Columbus
| | - Daniel E Jonas
- RTI International-University of North Carolina at Chapel Hill Evidence-based Practice Center
- Department of Internal Medicine, The Ohio State University, Columbus
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18
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Tighe CA, Buysse DJ, Weiner DK, Beehler GP, Forman DE. Prevalence, Impact, and Trajectories of Sleep Disturbance in Cardiac Rehabilitation: A NARRATIVE REVIEW AND SUGGESTIONS FOR EVALUATION AND TREATMENT. J Cardiopulm Rehabil Prev 2022; 42:316-323. [PMID: 35522949 PMCID: PMC9437109 DOI: 10.1097/hcr.0000000000000694] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVE The aim of this review was to summarize literature examining the prevalence, impact, and trajectories of sleep disturbance in cardiac rehabilitation (CR) patients and discuss how CR programs may incorporate targeted evaluation and interventions to promote sleep health. REVIEW METHODS A narrative review of literature allowed for an examination of the prevalence of sleep disturbance in CR patients, the effects of sleep disturbance on CR outcomes, and trajectories of sleep disturbance in CR. SUMMARY Sleep disturbance is prevalent in CR patient populations and is related to clinical and functional outcomes. Sleep may be an important biobehavioral process to target in CR to improve important patient outcomes and achieve secondary prevention goals.
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Affiliation(s)
- Caitlan A. Tighe
- VISN 4 Mental Illness Research, Education and Clinical Center, VA Pittsburgh Healthcare System
| | - Daniel J. Buysse
- Department of Psychiatry, University of Pittsburgh School of Medicine
| | - Debra K. Weiner
- Department of Psychiatry, University of Pittsburgh School of Medicine
- Geriatric Research Education and Clinical Center, VA Pittsburgh Healthcare System
- Department of Medicine, University of Pittsburgh School of Medicine
- Department of Anesthesiology, University of Pittsburgh School of Medicine
- Clinical and Translational Science Institute, University of Pittsburgh School of Medicine
| | - Gregory P. Beehler
- VA Center for Integrated Healthcare
- Community Health and Health Behavior, School of Public Health and Health Professions, University of Buffalo
| | - Daniel E. Forman
- Geriatric Research Education and Clinical Center, VA Pittsburgh Healthcare System
- Department of Medicine, University of Pittsburgh School of Medicine
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19
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Li Z, Cai S, Wang J, Chen R. Predictors of the Efficacy for Daytime Sleepiness in Patients With Obstructive Sleep Apnea With Continual Positive Airway Pressure Therapy: A Meta-Analysis of Randomized Controlled Trials. Front Neurol 2022; 13:911996. [PMID: 35832171 PMCID: PMC9271709 DOI: 10.3389/fneur.2022.911996] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Accepted: 05/24/2022] [Indexed: 11/23/2022] Open
Abstract
Objective The main aim of this meta-analysis was to evaluate the predictors of the efficacy of continuous positive airway pressure (CPAP) in ameliorating excessive daytime sleepiness (EDS) in patients with obstructive sleep apnea (OSA). Methods Randomized controlled trials (RCTs) published between January 1994 and October 2021 were searched in the PubMed, EMBASE, and Cochrane Library databases. The weighted mean differences (WMDs) for the Epworth Sleepiness Scale (ESS) scores, the Multiple Sleep Latency Test (MSLT), and the Maintenance of Wakefulness Test (MWT) were pooled in STATA. Results A total of 41 RCTs involving 7,332 patients were included. CPAP therapy was found to be significantly associated with changes in ESS (WMD = −2.14, P < 0.001), MSLT (WMD = 1.23, P < 0.001), and MWT (WMD = 1.6, P < 0.001). Meta-regression analysis and subgroup analysis indicated that in mild OSA, the efficacy of CPAP therapy for subjective EDS was limited to patients <50 years of age, with a baseline body mass index (BMI) of ≥30 kg/m2, baseline ESS score of ≥11, therapy adherence for ≥3 h/night, and treatment duration of ≥2 months. In moderate OSA, significant differences were observed in the changes in ESS among groups stratified by baseline ESS score (P = 0.005), adherence (P < 0.001), treatment duration (P = 0.009), and trial design type (P = 0.001). In severe OSA, this difference was observed among groups stratified by baseline BMI (P = 0.028), baseline ESS score (P = 0.001), and adherence (P = 0.047). Patients with moderate-severe OSA but not mild OSA showed significant improvements in MSLT. Patients with the age <50 years or BMI ≥33 kg/m2 had a more significant increase in MWT. Conclusion Continuous positive airway pressure therapy improved subjective and objective sleepiness in patients with OSA. Age, baseline BMI, baseline ESS score, adherence, and duration of treatment may predict the effects of CPAP on EDS in patients with OSA. Notably, the baseline ESS scores and adherence were stable predictors regardless of OSA severity.
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Affiliation(s)
- Zhiqiang Li
- Department of Respiratory and Critical Care Medicine, Sleep Center, The Second Affiliated Hospital of Soochow University, Soochow University, Suzhou, China
| | - Sijie Cai
- Department of Respiratory and Critical Care Medicine, Sleep Center, The Second Affiliated Hospital of Soochow University, Soochow University, Suzhou, China
- Department of Pulmonary and Critical Care Medicine Affiliated Kunshan Hospital of Jiangsu University, Suzhou, China
| | - Jing Wang
- Department of Respiratory and Critical Care Medicine, Sleep Center, The Second Affiliated Hospital of Soochow University, Soochow University, Suzhou, China
| | - Rui Chen
- Department of Respiratory and Critical Care Medicine, Sleep Center, The Second Affiliated Hospital of Soochow University, Soochow University, Suzhou, China
- *Correspondence: Rui Chen
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20
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Association of sleep apnea with outcomes in peripheral artery disease: Insights from the PORTRAIT study. PLoS One 2021; 16:e0256933. [PMID: 34506511 PMCID: PMC8432750 DOI: 10.1371/journal.pone.0256933] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2021] [Accepted: 08/18/2021] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Sleep apnea is a predictor of adverse cardiovascular outcome in many cardiovascular diseases but whether it is associated with worse health status outcomes or mortality in peripheral artery disease (PAD) is unknown. METHODS PORTRAIT is an international (US, Netherlands, Australia) prospective PAD registry that consecutively enrolled patients who presented with new-onset or recent exacerbations of PAD symptoms to any of 16 vascular specialty clinics. Health status was assessed upon presentation and at 12 months with the disease-specific Peripheral Artery Questionnaire (PAQ). Higher PAQ scores indicate better health status. A sequentially-adjusted hierarchical linear regression model examined the association between sleep apnea and 1-year PAQ symptoms, quality of life, and summary scores. Five-year survival curves by comorbid sleep apnea status for US patients were compared using the log-rank test. RESULTS The mean age of the 1204 PORTRAIT participants was 67.6 ± 9.4 years with 37.5% women and 8.3% (n = 100) having sleep apnea. Patients with sleep apnea were more likely to be from the US, more sedentary, and to have diabetes, obesity, coronary disease, more depressive symptoms and a history of prior peripheral interventions. Paradoxically, they also had higher ankle-brachial indices, but lower PAQ Summary scores at presentation and 12 months (41.2 ± 22.0 vs. 49. 9± 21.6 and 58.6 ± 27.9 vs. 71.3 ± 24.9, respectively, p = <0.05). The association between sleep apnea and 1-year health status persisted after multivariable adjustment, but there were no differences in all-cause mortality over 5 years (28.0% vs. 23.4%, p = 0.76). CONCLUSION In patients presenting with PAD, comorbid sleep apnea is independently associated with worse health status over time. Future studies should test whether better treatment of sleep apnea can improve the health status of patients with PAD. CLINICAL TRIAL REGISTRATION NCT01419080.
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21
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CPAP Treatment Improves Pure Tone Audiometry Threshold in Sensorineural Hearing Loss Patients with Sleep-Disordered Breathing. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph18136768. [PMID: 34202447 PMCID: PMC8297118 DOI: 10.3390/ijerph18136768] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/02/2021] [Revised: 06/08/2021] [Accepted: 06/21/2021] [Indexed: 11/17/2022]
Abstract
This article investigates the effects of continuous positive airway pressure (CPAP) on hearing impairment in sensorineural hearing loss (SNHL) patients with sleep-disordered breathing (SDB). This retrospective and observational study took place from September 2016 to February 2021, accumulating 77 subjects with SNHL and SDB (60.7 ± 11.1 years). Of which, 28 received CPAP treatment (63.0 ± 8.5 years). In our methodology, hearing thresholds at low, medium, high, and average frequencies are assessed by pure-tone audiometry at baseline (BL), three (3 m), six (6 m), and 12 (12 m) months. Our results show that the BL of at least three frequencies in all subjects is positively associated with old age, males, smoking, alcohol, coronary artery disease, hypertension, and apnea-hypopnea index [AHI] (all p < 0.05). Moreover, low, medium, and average frequencies are negatively correlated at CPAP-6 m (-5.60 ± 2.33, -5.82 ± 2.56, and -5.10 ± 2.26 dB; all p < 0.05) and CPAP-12 m (-7.97 ± 2.74, -8.15 ± 2.35, and -6.67 ± 2.37 dB; all p < 0.01) against corresponding measures of CPAP-BL. High, medium, and average frequencies positively correlated with age (p < 0.001 for high and average frequencies and <0.01 for medium frequencies). We conclude that in SNHL patients with SDB, hearing thresholds at low and medium frequencies improves under CPAP use after six months, which persists at least to the end of one year.
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22
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Wanberg L, Rottapel RE, Reid ML, Bertisch SM, Bron M, Kapur VK, Bujanover S, Harrington Z, Bakker JP, Javaheri S, Hanson M, Figetakis K, Page K, Hanes S, Villa KF, Redline S. Prevalence of sleepiness and associations with quality of life in patients with sleep apnea in an online cohort. J Clin Sleep Med 2021; 17:2363-2372. [PMID: 34170220 DOI: 10.5664/jcsm.9436] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
STUDY OBJECTIVES Excessive daytime sleepiness (EDS) is a treatment target for many patients with obstructive sleep apnea (OSA). We aimed to understand the prevalence, risk factors and quality of life associated with EDS in a non-clinical, "real world" sample of patients with OSA. METHODS Cross-sectional survey of patients with OSA participating in an online peer support community, assessing demographics, comorbidities, treatment, and quality of life. Differences in those with and without EDS (Epworth Sleepiness Scale [ESS] > and ≤ 10) were assessed. RESULTS The sample (n=422) was 54.2% male, 65.9% were ≥ 55 years, and 43.3% reported sleeping ≤ 6 hours/night. EDS was identified among 31.0% of respondents and 51.7% reported sleepiness as a precipitating factor for seeking initial OSA treatment. EDS was more prevalent in individuals reporting asthma, insomnia symptoms, positive airway pressures (PAP) use less than 6 hours/night on ≥ 5 nights/week, or sleep duration < 6 hours/night. After adjusting for demographics and comorbidities, patients with EDS reported poorer mental and physical health and well-being, lower disease-specific functional status, more activity and work impairment, and more driving impairment (p values < 0.05). In the sub-sample (n=265) with high PAP adherence, 26.0% reported EDS, and similar associations between EDS and outcomes were observed. CONCLUSIONS These "real-world" data suggest that patients seeking online OSA support experience a high prevalence of EDS, which was associated with poorer quality of life and worse functional status. Associations persisted among respondents with high self-reported PAP-adherence, potentially driving these individuals to seek online support for sleepiness-related symptoms.
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Affiliation(s)
- Lindsay Wanberg
- Division of Sleep and Circadian Disorders, Brigham and Women's Hospital
| | | | - Michelle L Reid
- Division of Sleep and Circadian Disorders, Brigham and Women's Hospital
| | - Suzanne M Bertisch
- Division of Sleep and Circadian Disorders, Brigham and Women's Hospital.,Harvard Medical School, Boston, Massachusetts
| | | | - Vishesh K Kapur
- Department of Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, University of Washington, Seattle, WA
| | | | | | - Jessie P Bakker
- Division of Sleep and Circadian Disorders, Brigham and Women's Hospital.,Harvard Medical School, Boston, Massachusetts
| | - Sogol Javaheri
- Division of Sleep and Circadian Disorders, Brigham and Women's Hospital.,Harvard Medical School, Boston, Massachusetts
| | - Mark Hanson
- Sleep Apnea Patient-Centered Outcomes Network, Boston, MA
| | | | - Kathy Page
- Sleep Apnea Patient-Centered Outcomes Network, Boston, MA
| | - Sherry Hanes
- Sleep Apnea Patient-Centered Outcomes Network, Boston, MA
| | | | - Susan Redline
- Division of Sleep and Circadian Disorders, Brigham and Women's Hospital.,Harvard Medical School, Boston, Massachusetts
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23
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Sex differences within symptom subtypes of mild obstructive sleep apnea. Sleep Med 2021; 84:253-258. [PMID: 34182353 DOI: 10.1016/j.sleep.2021.06.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2021] [Revised: 05/14/2021] [Accepted: 06/02/2021] [Indexed: 11/22/2022]
Abstract
OBJECTIVES Prior studies have identified symptom subtypes of moderate to severe (AHI >15) obstructive sleep apnea (OSA). They have not yet been consistently examined in those with mild OSA (AHI 5-15 events/hour). This is important as women are more likely than men to present with mild OSA and may present with different OSA symptoms. The objectives of this study were to determine 1) symptom subtypes in mild OSA and 2) if there are sex differences in the distribution of subtypes. METHODS The sample included men (n = 921) and women (n = 797) with mild OSA, aged 39-90 years, evaluated with a single night of in-home polysomnography as part of the Sleep Heart Health Study. Latent class analysis determined symptom subtypes. Testing for sex differences relative to OSA severity and symptom subtype used chi-squared test for independence. Bonferroni corrected z-tests compared column proportions. RESULTS Symptom subtypes of mild OSA were not significantly different than those identified in prior studies of moderate-severe OSA (p > 0.05): minimally symptomatic (36.4%), disturbed sleep (11.6%), moderately sleepy (37%), and excessively sleepy (15%), p > 0.05. Sex differences within the symptom subtypes were significant [χ2(df = 3) = 30.04, p < 0.001, Cramer's V = 0.132]. Relative to men, women were more likely to be in the disturbed sleep subtype (p < 0.05), and the excessively sleepy subtype (p < 0.05) while less likely to be in the moderately sleep (<0.05) subtype. Women and men were equally represented in the minimal symptoms subtype (p > 0.05). CONCLUSIONS Results suggest symptom reporting among individuals with mild OSA differs as a function of sex. These data have important clinical implications for screening men and women for OSA.
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24
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Chou MSH, Ting NCH, El-Turk N, Harrington Z, Dobler CC. Treatment burden experienced by patients with obstructive sleep apnoea using continuous positive airway pressure therapy. PLoS One 2021; 16:e0252915. [PMID: 34097721 PMCID: PMC8183990 DOI: 10.1371/journal.pone.0252915] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2020] [Accepted: 05/25/2021] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Little is known about the treatment burden experienced by patients with obstructive sleep apnoea (OSA) who use continuous positive airway pressure (CPAP) therapy. PARTICIPANTS 18 patients (33.3% males, mean age 59.7±11.8 years) with OSA who use CPAP therapy were interviewed. METHODS Patients treated with CPAP for OSA at a tertiary hospital outpatient clinic in Sydney, Australia, were invited to participate in an interview in person or via phone. Semi-structured interviews were used to explore the treatment burden associated with using CPAP. The interviews were recorded, transcribed, and analysed using NVivo 12 qualitative analysis software. RESULTS Four categories of OSA-specific treatment burden were identified: healthcare tasks, consequences of healthcare tasks, exacerbating and alleviating factors of treatment burden. Participants reported a significant burden associated with using CPAP, independently of how frequently they used their device. Common sources of their treatment burden included attending healthcare appointments, the financial cost of treatment, lifestyle changes, treatment-related side effects and general discomfort. CONCLUSIONS This study demonstrated that there is a significant treatment burden associated with the use of CPAP, and that treatment non-adherence is not the only consequence of treatment burden. Other consequences include relationship burden, stigma and financial burden. It is important for physicians to identify other negative impacts of treatment burden in order to optimise the patient experience.
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Affiliation(s)
- Michael S. H. Chou
- Department of Respiratory and Sleep Medicine, Liverpool Hospital, Sydney, NSW, Australia
- South Western Sydney Clinical School, University of New South Wales (UNSW), Sydney, NSW, Australia
| | - Natasha C. H. Ting
- Department of Respiratory and Sleep Medicine, Liverpool Hospital, Sydney, NSW, Australia
- South Western Sydney Clinical School, University of New South Wales (UNSW), Sydney, NSW, Australia
| | - Nicole El-Turk
- Department of Respiratory and Sleep Medicine, Liverpool Hospital, Sydney, NSW, Australia
- South Western Sydney Clinical School, University of New South Wales (UNSW), Sydney, NSW, Australia
| | - Zinta Harrington
- Department of Respiratory and Sleep Medicine, Liverpool Hospital, Sydney, NSW, Australia
- South Western Sydney Clinical School, University of New South Wales (UNSW), Sydney, NSW, Australia
| | - Claudia C. Dobler
- Department of Respiratory and Sleep Medicine, Liverpool Hospital, Sydney, NSW, Australia
- South Western Sydney Clinical School, University of New South Wales (UNSW), Sydney, NSW, Australia
- Institute for Evidence-Based Healthcare, Bond University and Gold Coast University Hospital, Gold Coast, QLD, Australia
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25
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Rimke AN, Ahmed SB, Turin TC, Pendharkar SR, Raneri JK, Lynch EJ, Hanly PJ. Recruitment of patients with chronic kidney disease and obstructive sleep apnoea for a clinical trial. J Sleep Res 2021; 30:e13384. [PMID: 33973687 DOI: 10.1111/jsr.13384] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2020] [Revised: 02/05/2021] [Accepted: 04/19/2021] [Indexed: 11/27/2022]
Abstract
Obstructive sleep apnoea is common in chronic kidney disease (CKD) and may accelerate the decline in kidney function. Recruitment for a randomised controlled trial to address whether treatment of sleep apnoea with continuous positive airway pressure (CPAP) slows the progression of kidney failure may be challenging because sleep apnoea is often asymptomatic in this patient population. The present report outlines recruitment challenges and how to address them. Adult patients with CKD were recruited for a 12-month randomised, controlled, non-blinded, parallel clinical trial to evaluate the impact of CPAP therapy on kidney function. Patients completed a home sleep apnoea test and those that met pre-specified sleep apnoea and nocturnal hypoxaemia severity criteria were randomised to receive CPAP or no therapy. Although 1,665 patients were eligible to participate in the study over 3 years, only 57 (3.4%) were ultimately randomised. The sequential reasons (and number of patients) for recruitment failure were: no show at clinic appointment (137), insufficient recruiters to approach every eligible patient (461), on therapy for sleep apnoea (122), unable to provide informed consent (67), refused consent (645), home sleep apnoea test not completed (47) or inclusion criteria not met (116), and declined pre-randomisation education session (12). Many challenges limit effective recruitment, which may be addressed by hiring additional recruiters and increasing the awareness of sleep apnoea among patients with CKD. These findings can be used to improve recruitment strategies and the design of future studies.
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Affiliation(s)
- Alex N Rimke
- Sleep Centre, Foothills Medical Centre, University of Calgary, Calgary, AB, Canada.,Libin Cardiovascular Institute of Alberta, Calgary, AB, Canada
| | - Sofia B Ahmed
- Libin Cardiovascular Institute of Alberta, Calgary, AB, Canada.,Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada.,Alberta Kidney Disease Network, Calgary, AB, Canada
| | - Tanvir C Turin
- Department of Family Medicine, University of Calgary, Calgary, AB, Canada
| | - Sachin R Pendharkar
- Sleep Centre, Foothills Medical Centre, University of Calgary, Calgary, AB, Canada.,Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada.,Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Jill K Raneri
- Sleep Centre, Foothills Medical Centre, University of Calgary, Calgary, AB, Canada
| | - Emma J Lynch
- Sleep Centre, Foothills Medical Centre, University of Calgary, Calgary, AB, Canada
| | - Patrick J Hanly
- Sleep Centre, Foothills Medical Centre, University of Calgary, Calgary, AB, Canada.,Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada.,Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada.,Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada
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26
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Rocha AL, Wagner LE, Paiva DN. Effects of the mandibular advancement device on daytime sleepiness, quality of life and polysomnographic profile of public transport drivers with obstructive sleep apnea syndrome. Sleep Sci 2021; 14:136-141. [PMID: 34381577 PMCID: PMC8340896 DOI: 10.5935/1984-0063.20200058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2020] [Accepted: 09/08/2020] [Indexed: 11/20/2022] Open
Abstract
OBJECTIVE To evaluate the effects of the mandibular advancement device (MAD) on daytime sleepiness, quality of life (QoL) and polysomnographic profile of intercity transport drivers with obstructive sleep apnea syndrome (OSAS). MATERIAL AND METHODS A quasi-experimental study evaluating intercity transport drivers from March to September 2019. The apnea-hypopnea index (AHI) was evaluated by type III polysomnography, which defined the severity of the disease. OSAS: mild (5 to 15), moderate (15 to 29), or severe (= 30). Sleepiness was assessed using the Epworth sleepiness scale, consisting of 8 questions about the likelihood of drowsiness in daily situations. QoL was assessed using the SF-36 questionnaire, which provides the score in eight domains: functional capacity, physical aspects, pain, general health status, vitality, social aspects, emotional aspects, and mental health. Drivers with OSAS underwent intervention with application of personalized MAD for 8 to 12 weeks. RESULTS The total sample (n=23) (44.77±11.56 years) had a body mass index (BMI) of 30.64±4.66kg/m2, and an OSAS prevalence of 65.2% of drivers (n=15). There were losses of 4 drivers so that the final sample of drivers with OSAS for the intervention with the MAD was 11 individuals, with an average age of 45.54±9.41 years and BMI of 32.21±3.17kg/m². There was a decrease in AHI (28.51±15.66ev/h 012.11±6.70ev/h, p=0.002) and pain (60 (50-60)040 (40-50), p=0.015) after the intervention. CONCLUSION There was a reduction in AHI in intercity transport drivers after implementing the MAD procedure.
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Affiliation(s)
- Antonio Luiz Rocha
- Universidade de Santa Cruz do Sul (UNISC) - Programa de
Pós-Graduação Mestrado e Doutorado em Promoção da
Saúde (PPGPS). Santa Cruz do Sul, Rio Grande do Sul - Brazil
| | - Litiele Evelin Wagner
- Universidade de Santa Cruz do Sul (UNISC) - Programa de
Residência Multiprofissional em Saúde do Hospital Santa Cruz (HSC).
Santa Cruz do Sul, Rio Grande do Sul - Brazil
| | - Dulciane Nunes Paiva
- Universidade de Santa Cruz do Sul (UNISC) - Departamento de
Ciências da Saúde e Programa de Pós-Graduação
Mestrado e Doutorado em Promoção da Saúde (PPGPS). Santa Cruz
do Sul - RS - Rio Grande do Sul - Brazil
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27
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Zeng S, Li F, Wang R, Li F. Propensity score weighting for covariate adjustment in randomized clinical trials. Stat Med 2021; 40:842-858. [PMID: 33174296 DOI: 10.1002/sim.8805] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2020] [Revised: 08/11/2020] [Accepted: 10/23/2020] [Indexed: 01/15/2023]
Abstract
Chance imbalance in baseline characteristics is common in randomized clinical trials. Regression adjustment such as the analysis of covariance (ANCOVA) is often used to account for imbalance and increase precision of the treatment effect estimate. An objective alternative is through inverse probability weighting (IPW) of the propensity scores. Although IPW and ANCOVA are asymptotically equivalent, the former may demonstrate inferior performance in finite samples. In this article, we point out that IPW is a special case of the general class of balancing weights, and advocate to use overlap weighting (OW) for covariate adjustment. The OW method has a unique advantage of completely removing chance imbalance when the propensity score is estimated by logistic regression. We show that the OW estimator attains the same semiparametric variance lower bound as the most efficient ANCOVA estimator and the IPW estimator for a continuous outcome, and derive closed-form variance estimators for OW when estimating additive and ratio estimands. Through extensive simulations, we demonstrate OW consistently outperforms IPW in finite samples and improves the efficiency over ANCOVA and augmented IPW when the degree of treatment effect heterogeneity is moderate or when the outcome model is incorrectly specified. We apply the proposed OW estimator to the Best Apnea Interventions for Research (BestAIR) randomized trial to evaluate the effect of continuous positive airway pressure on patient health outcomes. All the discussed propensity score weighting methods are implemented in the R package PSweight.
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Affiliation(s)
- Shuxi Zeng
- Department of Statistical Science, Duke University, Durham, North Carolina, USA
| | - Fan Li
- Department of Biostatistics, Yale School of Public Health, New Haven, Connecticut, USA
- Center for Methods in Implementation and Prevention Science, Yale School of Public Health, New Haven, Connecticut, USA
| | - Rui Wang
- Department of Population Medicine, Harvard Pilgrim Health Care Institute and Harvard Medical School, Boston, Massachusetts, USA
- Department of Biostatistics, Harvard T. H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Fan Li
- Department of Statistical Science, Duke University, Durham, North Carolina, USA
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The long-term impact of expansion sphincter pharyngoplasty treatment on blood pressure control and health-related quality of life in patients with obstructive sleep apnea and hypertension. Sleep Breath 2021; 25:2155-2162. [PMID: 33580840 DOI: 10.1007/s11325-021-02314-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2020] [Revised: 01/23/2021] [Accepted: 02/03/2021] [Indexed: 10/22/2022]
Abstract
PURPOSE To assess how expansion sphincter pharyngoplasty (ESP) impacts blood pressure (BP) and health-related quality of life (HRQOL) in hypertensive patients with obstructive sleep apnea (OSA). METHODS Patients were separated into two groups based upon whether or not they adhered to antihypertensive drug regimens. Patients underwent 24-h ambulatory BP monitoring before and at 6 months post-ESP, while clinical BP measurements and HRQOL questionnaires (SF-36) were conducted over the course of 24 months post-surgery. RESULTS We enrolled 62 patients, with 25 and 37 in the medicated and non-medicated groups, respectively. Mean 24-h BP differed significantly, with systolic and diastolic BP (SBP and DBP) decreases of 5.3 mmHg and 2.5 mmHg, respectively (P <0.01). Mean 24-h SBP and DBP decreases in the medicated group were 10.2 mmHg and 4.6 mmHg, respectively (P < 0.001), with significant decreases during the daytime of 8.6 mmHg, 3.0 mmHg, and nighttime of 12.3 mmHg, 7.7 mmHg (P <0.001). In the non-medicated treatment group, 24-h SBP and DBP decreases were 1.9 mmHg and 1.1 mmHg (P < 0.005) with significant decreases in mean nighttime BP values of 3.2 mmHg and 1.9 mmHg (P < 0.001). While pre- and postoperative SF-36 results differed significantly, no differences were observed between the two groups. CONCLUSION ESP decreases BP and improves HRQOL in OSA patients with hypertension, particularly in combination with antihypertensive drugs.
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de Barros Phys JL, Rodrigues WC, Marão AC, de Oliveira Antunes LC, Trindade SHK, Weber SAT. Impact of CPAP treatment for a short period in moderate-to-severe OSAS patients: a randomized double-blind clinical trial. Braz J Otorhinolaryngol 2021; 88:917-924. [PMID: 33563569 DOI: 10.1016/j.bjorl.2020.12.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2020] [Revised: 10/06/2020] [Accepted: 12/15/2020] [Indexed: 11/02/2022] Open
Abstract
INTRODUCTION Obesity is the most frequent reversible aggravating factor of obstructive sleep apnea syndrome, OSAS, with physical activity very important for its control. Continuous positive air pressure during sleep is the "gold standard" treatment for OSAS. OBJECTIVE we aimed to investigate if the use of CPAP for a short period (7 days), would improve sleep quality, daytime sleepiness, and the disposition for physical activity. METHODS Eighty OSAS patients were randomly assigned as follows: group I - CPAP with a steady pressure of 4 cm H2O; group II - ideal therapeutic pressure. After filling out the questionnaires related to the studied variables (International physical activity questionnaire long-form, Epworth sleepiness scale, Pittsburgh sleep quality index), patients underwent a baseline pulmonary function test and CPAP titration. After CPAP therapy for 4≥ hours a night for 7 consecutive days, patients returned and filled out new (International physical activity questionnaire long-form, Epworth sleepiness scale, Pittsburgh sleep quality index) forms. New spirometry was carried out. RESULTS 39 patients completed the study. The mean age was 52 ± 11 years old and 28 patients (71.79%) were obese. Both groups were similar for all variables studied at baseline. After CPAP use, patients of group II presented more significant improvements (p < 0.05) for sleep quality and diurnal sleepiness. Time spent with physical activities did not change. Spirometric data were at normal range at baseline. Solely the variable FEF 25%-75% was significantly enhanced (p < 0.05) in group II. CONCLUSION CPAP therapy for 1 week, with ideal pressure, improves daytime sleepiness and sleep quality, enhances pulmonary function, but does not change the mean time spent with physical activities.
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Affiliation(s)
| | - Willian Caetano Rodrigues
- Universidade Estadual Paulista (UNESP), Faculdade de Medicina, Departamento de Oftalmologia, Otorrinolaringologia e Cirurgia de Cabeça e Pescoço, Botucatu, SP, Brazil.
| | - Antônio Carlos Marão
- Universidade Estadual Paulista (UNESP), Faculdade de Medicina, Botucatu, SP, Brazil
| | | | | | - Silke Anna Theresa Weber
- Universidade Estadual Paulista (UNESP), Faculdade de Medicina, Departamento de Oftalmologia, Otorrinolaringologia e Cirurgia de Cabeça e Pescoço, Divisão de Otorrinolaringologia, Botucatu, SP, Brazil
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Song Y, Sun F, Redline S, Wang R. Random-effects meta-analysis of combined outcomes based on reconstructions of individual patient data. Res Synth Methods 2020; 11:594-616. [PMID: 32270909 PMCID: PMC7680580 DOI: 10.1002/jrsm.1406] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2019] [Revised: 01/19/2020] [Accepted: 03/13/2020] [Indexed: 12/15/2022]
Abstract
Meta-analyses of clinical trials typically focus on one outcome at a time. However, treatment decision-making depends on an overall assessment of outcomes balancing benefit in various domains and potential risks. This calls for meta-analysis methods for combined outcomes that encompass information from different domains. When individual patient data (IPD) are available from all studies, combined outcomes can be calculated for each individual and standard meta-analysis methods would apply. However, IPD are usually difficult to obtain. We propose a method to estimate the overall treatment effect for combined outcomes based on first reconstructing pseudo IPD from available summary statistics and then pooling estimates from multiple reconstructed datasets. We focus on combined outcomes constructed from two continuous original outcomes. The reconstruction step requires the specification of the joint distribution of these two original outcomes, including the correlation which is often unknown. For outcomes that are combined in a linear fashion, misspecifications of this correlation affect efficiency, but not consistency, of the resulting treatment effect estimator. For other combined outcomes, an accurate estimate of the correlation is necessary to ensure the consistency of treatment effect estimates. To this end, we propose several ways to estimate this correlation under different data availability scenarios. We evaluate the performance of the proposed methods through simulation studies and apply these to two examples: (a) a meta-analysis of dipeptidyl peptidase-4 inhibitors vs control on treating type 2 diabetes; and (b) a meta-analysis of positive airway pressure therapy vs control on lowering blood pressure among patients with obstructive sleep apnea.
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Affiliation(s)
- Yue Song
- Department of Biostatistics, Harvard T.H. Chan School of Public Health
| | - Feng Sun
- Department of Epidemiology and Biostatistics, Peking University Health Science Center
| | - Susan Redline
- Division of Sleep Medicine and Circadian Disorders, Department of Medicine, Brigham and Women’s Hospital
| | - Rui Wang
- Department of Biostatistics, Harvard T.H. Chan School of Public Health
- Department of Population Medicine, Harvard Pilgrim Health Care Institute and Harvard Medical School
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Orr JE, Wallace MS, Malhotra A. Might chronic opioid use impact sleep-disordered breathing and vice versa? J Clin Sleep Med 2020; 16:843-845. [PMID: 32317097 PMCID: PMC7849661 DOI: 10.5664/jcsm.8500] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Revised: 04/15/2020] [Accepted: 04/15/2020] [Indexed: 11/13/2022]
Abstract
Orr JE, Wallace MS, Malhotra A. Might chronic opioid use impact sleep-disordered breathing and vice versa? J Clin Sleep Med . 2020;16(6):843–845.
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Affiliation(s)
- Jeremy E. Orr
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of California, San Diego, La Jolla, California
| | - Mark S. Wallace
- Division of Pain Medicine, University of California, San Diego, La Jolla, California
| | - Atul Malhotra
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of California, San Diego, La Jolla, California
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Yang Y, Ning Y, Wen W, Jia Y, Chen X, Huang M, Sara JD, Qin Y, Fang F, Zhang H, Du Y, Li L, Jiao X, Yang Y, Han X, Zhang M, Wei Y. CPAP is associated with decreased risk of AF recurrence in patients with OSA, especially those younger and slimmer: a meta-analysis. J Interv Card Electrophysiol 2020; 58:369-379. [DOI: 10.1007/s10840-020-00738-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2019] [Accepted: 03/25/2020] [Indexed: 01/02/2023]
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Reid ML, Gleason KJ, Bakker JP, Wang R, Mittleman MA, Redline S. The role of sham continuous positive airway pressure as a placebo in controlled trials: Best Apnea Interventions for Research Trial. Sleep 2020; 42:5497419. [PMID: 31116848 DOI: 10.1093/sleep/zsz099] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2018] [Revised: 03/19/2019] [Indexed: 11/13/2022] Open
Abstract
STUDY OBJECTIVES The main objective of this study was to evaluate the role of sham continuous positive airway pressure (CPAP) compared to conservative medical therapy (CMT) as a control arm in the Best Apnea Interventions for Research (BestAIR) study by assessing differences in subjectively and objectively measured outcomes, adverse events, adherence, and retention rates. METHODS BestAIR is a clinical trial aimed to identify important design features for future randomized controlled trials of CPAP. Participants with obstructive sleep apnea were randomized to one of four groups; two control arms (CMT, sham-CPAP) and two active CPAP arms (with and without behavioral interventions). Blood pressure and health-related quality of life outcomes were assessed at baseline, 6 and 12 months. Study outcomes, retention, and adverse event rates were compared between the two control arms. Sham-CPAP adherence and self-efficacy were also compared to active-CPAP adherence (without behavioral intervention). RESULTS Our sample included 86 individuals in the control arms and 42 participants in the active-CPAP arm. There were no differences in longitudinal profiles in blood pressure, health-related quality of life outcomes, dropout rates, or adverse events in sham-CPAP group compared to CMT-only group (all ps > 0.05); standardized differences were generally small and with inconsistent directionality across measurements. When compared to active-CPAP, sham-CPAP was associated with 93 fewer minutes/night of usage over 12 months (p = 0.007) and lower outcome expectations (p < 0.05). CONCLUSION We observed no evidence of differences in objectively or subjectively measured outcomes with the use of sham-CPAP compared to CMT group. The lower adherence on sham-CPAP and poorer self-efficacy compared to active-CPAP may suggest differences in perceived benefit. REGISTRATION NCT01261390 Best Apnea Interventions for Research (BestAIR) www.clinicaltrials.gov.
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Affiliation(s)
- Michelle L Reid
- Division of Sleep and Circadian Disorders, Department of Medicine, Brigham and Women's Hospital, Boston MA
| | - Kevin J Gleason
- Division of Sleep and Circadian Disorders, Department of Medicine, Brigham and Women's Hospital, Boston MA.,Department of Public Health Sciences, University of Chicago, Chicago, IL
| | - Jessie P Bakker
- Division of Sleep and Circadian Disorders, Department of Medicine, Brigham and Women's Hospital, Boston MA.,Division of Sleep Medicine, Harvard Medical School, Boston, MA
| | - Rui Wang
- Division of Sleep and Circadian Disorders, Department of Medicine, Brigham and Women's Hospital, Boston MA.,Division of Sleep Medicine, Harvard Medical School, Boston, MA.,Department of Biostatistics, Harvard University T.H. Chan School of Public Health, Boston, MA.,Department of Population Medicine, Harvard Pilgrim Health Care Institute, Boston, MA
| | - Murray A Mittleman
- Department of Epidemiology, Harvard University T.H. Chan School of Public Health, Boston, MA.,Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA
| | - Susan Redline
- Division of Sleep and Circadian Disorders, Department of Medicine, Brigham and Women's Hospital, Boston MA.,Division of Sleep Medicine, Harvard Medical School, Boston, MA.,Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA
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Mysliwiec V, Martin JL, Ulmer CS, Chowdhuri S, Brock MS, Spevak C, Sall J. The Management of Chronic Insomnia Disorder and Obstructive Sleep Apnea: Synopsis of the 2019 U.S. Department of Veterans Affairs and U.S. Department of Defense Clinical Practice Guidelines. Ann Intern Med 2020; 172:325-336. [PMID: 32066145 DOI: 10.7326/m19-3575] [Citation(s) in RCA: 57] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
DESCRIPTION In September 2019, the U.S. Department of Veterans Affairs (VA) and the U.S. Department of Defense (DoD) approved a new joint clinical practice guideline for assessing and managing patients with chronic insomnia disorder and obstructive sleep apnea (OSA). This guideline is intended to give health care teams a framework by which to screen, evaluate, treat, and manage the individual needs and preferences of VA and DoD patients with either of these conditions. METHODS In October 2017, the VA/DoD Evidence-Based Practice Work Group initiated a joint VA/DoD guideline development effort that included clinical stakeholders and conformed to the Institute of Medicine's tenets for trustworthy clinical practice guidelines. The guideline panel developed key questions, systematically searched and evaluated the literature, created three 1-page algorithms, and advanced 41 recommendations using the GRADE (Grading of Recommendations Assessment, Development and Evaluation) system. RECOMMENDATIONS This synopsis summarizes the key recommendations of the guideline in 3 areas: diagnosis and assessment of OSA and chronic insomnia disorder, treatment and management of OSA, and treatment and management of chronic insomnia disorder. Three clinical practice algorithms are also included.
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Affiliation(s)
- Vincent Mysliwiec
- University of Texas Health Science Center at San Antonio, San Antonio, Texas (V.M.)
| | - Jennifer L Martin
- David Geffen School of Medicine at UCLA and VA Greater Los Angeles Healthcare System, Los Angeles, California (J.L.M.)
| | - Christi S Ulmer
- Durham VA Healthcare System and Duke University School of Medicine, Durham, North Carolina (C.S.U.)
| | - Susmita Chowdhuri
- John D. Dingell VA Sleep Wake Disorders Center and Wayne State University, Detroit, Michigan (S.C.)
| | - Matthew S Brock
- U.S. Army SAMHS Sleep Medicine Service, San Antonio, Texas, and Wilford Hall Ambulatory Surgical Center, Lackland Air Force Base, Texas (M.S.B.)
| | - Christopher Spevak
- Walter Reed National Military Medical Center/Defense Health Agency, Bethesda, Maryland (C.S.)
| | - James Sall
- Department of Veterans Affairs, Washington, DC (J.S.)
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Carneiro-Barrera A, Amaro-Gahete FJ, Sáez-Roca G, Martín-Carrasco C, R. Ruiz J, Buela-Casal G. Anxiety and Depression in Patients with Obstructive Sleep Apnoea before and after Continuous Positive Airway Pressure: The ADIPOSA Study. J Clin Med 2019; 8:jcm8122099. [PMID: 31805748 PMCID: PMC6947599 DOI: 10.3390/jcm8122099] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2019] [Revised: 11/19/2019] [Accepted: 11/27/2019] [Indexed: 12/11/2022] Open
Abstract
The prevalence and treatment response of depression and anxiety symptoms in obstructive sleep apnoea (OSA), although widely addressed in research and clinical settings, still remain unclear due to overlapping symptoms. The ADIPOSA study sought to elucidate the presence of non-overlapping symptoms of depression and anxiety in patients with moderate to severe OSA before and after continuous positive airway pressure (CPAP) treatment. Forty-eight adults aged 18-80 (68.75% men) with moderate to severe OSA were enrolled in this twelve-week longitudinal single-arm trial and completed a full-night ambulatory sleep diagnostic test and an assessment of cognitive-affective depression and anxiety symptoms using the Beck-Depression Inventory-Fast Screen (BDI-FS), the State-Trait Depression Inventory (IDER) and the State-Trait Anxiety Inventory (STAI). We found no cognitive-affective depression or anxiety symptoms of clinical relevance at baseline. The amelioration of depression and anxiety symptoms after CPAP use was only statistically significant when considering anxiety-trait (p < 0.01; d = 0.296) and euthymia (p < 0.05; d = 0.402), the distinctive component of depression. Although dysthymia or high negative affect remained unchanged, CPAP may be effective at reducing the lack of positive affect, a well-established health-protective factor. However, not until depression and anxiety disorders related to OSA are accurately measured in clinical and research settings will it be possible to obtain robust conclusions on the occurrence and amelioration of these symptoms after treatment.
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Affiliation(s)
- Almudena Carneiro-Barrera
- Sleep and Health Promotion Laboratory, Mind, Brain and Behaviour Research Centre (CIMCYC), University of Granada, 18011 Granada, Spain;
- Correspondence:
| | - Francisco J. Amaro-Gahete
- EFFECTS-262 Research group, Department of Medical Physiology, School of Medicine, University of Granada, 18071 Granada, Spain;
- PROmoting FITness and Health through physical activity research group (PROFITH), Sport and Health University Research Institute (iMUDS), Department of Physical Education and Sports, Faculty of Sport Sciences, University of Granada, 18071 Granada, Spain;
| | - Germán Sáez-Roca
- Unidad de Trastornos Respiratorios del Sueño, Servicio de Neumología, “Virgen de las Nieves” University Hospital, 18014 Granada, Spain; (G.S.-R.); (C.M.-C.)
| | - Carlos Martín-Carrasco
- Unidad de Trastornos Respiratorios del Sueño, Servicio de Neumología, “Virgen de las Nieves” University Hospital, 18014 Granada, Spain; (G.S.-R.); (C.M.-C.)
| | - Jonatan R. Ruiz
- PROmoting FITness and Health through physical activity research group (PROFITH), Sport and Health University Research Institute (iMUDS), Department of Physical Education and Sports, Faculty of Sport Sciences, University of Granada, 18071 Granada, Spain;
| | - Gualberto Buela-Casal
- Sleep and Health Promotion Laboratory, Mind, Brain and Behaviour Research Centre (CIMCYC), University of Granada, 18011 Granada, Spain;
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Abstract
Drowsy driving is common and causes 21% of fatal crashes. Individuals at risk include young men, shift workers, older adults, and people with chronic short sleep duration, untreated obstructive sleep apnea (OSA), and narcolepsy. Untreated OSA is a particular concern in commercial drivers, who are at higher risk for the disorder. Treatment for sleep problems such as sleep extension for chronic short sleep, positive airway pressure (PAP) for OSA, pharmacologic treatments, and drowsy driving countermeasures may reduce the risk of crashes. Implementing screening measures to identify common sleep problems contributing to drowsy driving continues to be of high importance.
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Affiliation(s)
- Catherine A McCall
- Department of Pulmonary, Critical Care, and Sleep Medicine, VA Puget Sound Health Care System, 1660 South Columbian Way, Seattle, WA 98108, USA; Department of Psychiatry, University of Washington Sleep Medicine Center, Seattle, WA, USA.
| | - Nathaniel F Watson
- Department of Neurology, University of Washington Sleep Medicine Center, 908 Jefferson Street, Seattle, WA 98104, USA
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Interdisciplinary Weight Loss and Lifestyle Intervention for Obstructive Sleep Apnoea in Adults: Rationale, Design and Methodology of the INTERAPNEA Study. Nutrients 2019; 11:nu11092227. [PMID: 31540168 PMCID: PMC6770131 DOI: 10.3390/nu11092227] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2019] [Revised: 09/09/2019] [Accepted: 09/11/2019] [Indexed: 12/12/2022] Open
Abstract
Obesity is a major risk factor for obstructive sleep apnoea (OSA), the most common sleep-disordered breathing related to neurocognitive and metabolic syndromes, type II diabetes, and cardiovascular diseases. Although strongly recommended for this condition, there are no studies on the effectiveness of an interdisciplinary weight loss and lifestyle intervention including nutrition, exercise, sleep hygiene, and smoking and alcohol cessation. INTERAPNEA is a randomised controlled trial with a two-arm parallel design aimed at determining the effects of an interdisciplinary tailored weight loss and lifestyle intervention on OSA outcomes. The study will include 84 males aged 18–65 with a body mass index of ≥25 kg/m2 and severe to moderate OSA randomly assigned to usual care (i.e., continuous positive airway pressure), or interdisciplinary weight loss and lifestyle intervention combined with usual care. Outcomes will be measured at baseline, intervention end-point, and six-month post-intervention, including apnoea-hypopnoea index (primary outcome), other neurophysical and cardiorespiratory polysomnographic outcomes, sleep quality, daily functioning and mood, body weight and composition, physical fitness, blood biomarkers, health-related quality of life, and cost-effectiveness. INTERAPNEA may serve to establish a cost-effective treatment not only for the improvement of OSA and its vast and severe comorbidities, but also for a potential remission of this condition.
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van Wyk M, McCreesh-Toselli S, Williams S, O Ebrahim I. The distinct roles of OSA and depression severity in day- and night-time symptomatology in OSA patients: a pilot study. Sleep Breath 2019; 24:931-939. [DOI: 10.1007/s11325-019-01924-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2019] [Revised: 08/05/2019] [Accepted: 08/10/2019] [Indexed: 01/10/2023]
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Lo Bue A, Salvaggio A, Iacono Isidoro S, Romano S, Insalaco G. OSA and CPAP therapy: effect of gender, somnolence, and treatment adherence on health-related quality of life. Sleep Breath 2019; 24:533-540. [PMID: 31309464 DOI: 10.1007/s11325-019-01895-3] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2019] [Revised: 07/03/2019] [Accepted: 07/04/2019] [Indexed: 12/22/2022]
Abstract
BACKGROUND Obstructive sleep apnea (OSA) often has a significant impact on health-related quality of life (HRQoL) with social and psychological implications. For most OSA patients, a reduction in their HRQoL is due to symptoms such as poor sleep quality, excessive daytime somnolence, and fatigue with differences between gender. PURPOSE This study explores the CPAP treatment effect on self-perceived HRQoL related to gender, somnolence, and CPAP adherence. METHODS Out of 1082 consecutive Italian outpatients, 125 (82 M) (60.3 ± 9.6 years) completed the prospective observational study and were evaluated at the first visit (T0), and the follow-up visit (T1). Two self-reported HRQoL questionnaires were administered: six subscales Psychological General Well-Being Index (PGWBI) and 12-Item Short-Form Health Survey (SF-12). RESULTS Scores of PGWBI and SF-12 MCS improved from T0 to T1. Patients with CPAP use ≥ 4 h/night showed a significant improvement in all dimensions evaluated, except for SF-12 PCS. At T1, participants with ESS > 10 improved in all scores, except SF-12 PCS. Gender comparison shows better-perceived HRQoL in males at first visit and CPAP follow-up visit. Variation of PGWBI was significantly correlated with CPAP use, ESS at T0 and T1 (p < 0.0001; r2 = 0.26). CONCLUSIONS This study provides evidence on the effectiveness of CPAP treatment on perceived HRQoL. Participants with greater adherence to therapy, greater sleepiness, and greater improvement of daytime sleepiness with CPAP therapy, reported a higher quality of life improvement. Gender comparison shows better-perceived HRQoL in males at first visit and CPAP follow-up, despite a more considerable improvement in females.
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Affiliation(s)
- Anna Lo Bue
- National Research Council of Italy, Institute for Biomedical Research and Innovation, Via Ugo La Malfa, 153, 90146, Palermo, Italy
| | - Adriana Salvaggio
- National Research Council of Italy, Institute for Biomedical Research and Innovation, Via Ugo La Malfa, 153, 90146, Palermo, Italy.
| | - Serena Iacono Isidoro
- National Research Council of Italy, Institute for Biomedical Research and Innovation, Via Ugo La Malfa, 153, 90146, Palermo, Italy
| | - Salvatore Romano
- National Research Council of Italy, Institute for Biomedical Research and Innovation, Via Ugo La Malfa, 153, 90146, Palermo, Italy
| | - Giuseppe Insalaco
- National Research Council of Italy, Institute for Biomedical Research and Innovation, Via Ugo La Malfa, 153, 90146, Palermo, Italy
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Burgess HJ, Burns JW, Buvanendran A, Gupta R, Chont M, Kennedy M, Bruehl S. Associations Between Sleep Disturbance and Chronic Pain Intensity and Function: A Test of Direct and Indirect Pathways. Clin J Pain 2019; 35:569-576. [PMID: 30913041 PMCID: PMC6551250 DOI: 10.1097/ajp.0000000000000711] [Citation(s) in RCA: 45] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVES Sleep disturbance and chronic pain are related. The present study evaluated both direct and indirect (mediated) pathways through which sleep disturbance might be related to chronic pain intensity and function. METHODS In total, 87 individuals (64% female) with chronic low back pain but not using opioids daily completed questionnaires assessing their sleep disturbance, chronic pain intensity, function, depression, anxiety, positive affect, and catastrophizing. RESULTS Greater sleep disturbance was associated with greater pain intensity, worse function, greater emotional distress, lower positive affect, and higher levels of catastrophizing. Cross-sectional mediation analyses revealed that the positive associations between sleep disturbance and chronic pain intensity were conveyed statistically not only by significant indirect effects of elevated emotional distress, lower positive affect, and greater catastrophizing associated with sleep disturbance, but also by significant direct effects of sleep disturbance on chronic pain intensity. Similarly, we found that the associations between sleep disturbance and impaired function were conveyed statistically not only by significant indirect effects of elevated chronic pain intensity associated with sleep disturbance, but also by significant direct effects of sleep disturbance on function. DISCUSSION Sleep disturbance was related significantly with chronic pain intensity and function by both direct and indirect pathways. These results are consistent with an emerging literature highlighting the potential significance of sleep disturbance in chronic pain patients, and provide further support for addressing sleep disturbance in the assessment and management of chronic pain.
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Affiliation(s)
- Helen J. Burgess
- Department of Psychiatry, University of Michigan, Ann Arbor, MI, USA
| | - John W. Burns
- Department of Behavioral Sciences, Rush University Medical Center, Chicago, IL, USA
| | | | - Rajnish Gupta
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Melissa Chont
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Mary Kennedy
- Department of Behavioral Sciences, Rush University Medical Center, Chicago, IL, USA
| | - Stephen Bruehl
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN, USA
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Zheng D, Xu Y, You S, Hackett ML, Woodman RJ, Li Q, Woodward M, Loffler KA, Rodgers A, Drager LF, Lorenzi-Filho G, Wang X, Quan WW, Tripathi M, Mediano O, Ou Q, Chen R, Liu Z, Zhang X, Luo Y, McArdle N, Mukherjee S, McEvoy RD, Anderson CS. Effects of continuous positive airway pressure on depression and anxiety symptoms in patients with obstructive sleep apnoea: results from the sleep apnoea cardiovascular Endpoint randomised trial and meta-analysis. EClinicalMedicine 2019; 11:89-96. [PMID: 31312807 PMCID: PMC6610775 DOI: 10.1016/j.eclinm.2019.05.012] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2019] [Revised: 05/23/2019] [Accepted: 05/28/2019] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Whether continuous positive airway pressure (CPAP) treatment can improve depression or anxiety symptoms in obstructive sleep apnoea (OSA) patients remains uncertain. METHODS Secondary analysis of the Sleep Apnea Cardiovascular Endpoints (SAVE) trial, combined with a systematic review of randomised evidence. The SAVE secondary analyses involved 2410 patients with co-existing moderate-severe OSA and established cardiovascular disease randomly allocated to CPAP treatment plus usual care or usual care alone and followed up for 3·7 (SD 1·6) years. We evaluated the effect of CPAP treatment on depression and anxiety caseness (scores ≥ 8 on the Hospital Anxiety and Depression Scale depression and anxiety subscales [HADS-D and HADS-A]) for OSA patients. FINDINGS CPAP treatment was associated with reduced odds of depression caseness (adjusted odds ratio [OR] 0·80, 95% confidence interval [CI] 0·65-0·98, P = 0·031) compared to usual care in the SAVE trial and the treatment effect was greater in those with pre-existing depression symptoms. A systematic review of 20 randomised trials including 4255 participants confirmed a benefit of CPAP in reducing depression symptoms in OSA patients: the overall effect (standardised mean difference) was - 0·18 (95% CI - 0·24 to - 0·12). No effect of CPAP treatment on anxiety caseness was found both in patients of the SAVE study (adjusted OR 0·98, 95% CI 0·78-1·24, P = 0·89) and the systematic review. INTERPRETATION CPAP reduces depression symptoms in patients with co-existing OSA and CVD independently of improvements in sleepiness.
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Affiliation(s)
- Danni Zheng
- Centre for Big Data Research in Health, University of New South Wales, Sydney, NSW, Australia
- The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, NSW, Australia
| | - Ying Xu
- The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, NSW, Australia
- Sydney Medical School, University of Sydney, Sydney, NSW, Australia
| | - Shoujiang You
- Department of Neurology, The Second Affiliated Hospital of Soochow University, Suzhou, Jiangsu, PR China
| | - Maree L. Hackett
- The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, NSW, Australia
- Faculty of Health and Wellbeing, The University of Central Lancashire, Preston, Lancashire, UK
| | - Richard J. Woodman
- Flinders Centre for Epidemiology and Biostatistics, College of Medicine and Public Health, Flinders University, Adelaide, SA, Australia
| | - Qiang Li
- The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, NSW, Australia
| | - Mark Woodward
- The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, NSW, Australia
- The George Institute for Global Health, University of Oxford, Oxford, Oxfordshire, UK
- Department of Epidemiology, Johns Hopkins University, Baltimore, MD, USA
| | - Kelly A. Loffler
- Adelaide Institute for Sleep Health, Flinders University, Adelaide, SA, Australia
| | - Anthony Rodgers
- The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, NSW, Australia
| | - Luciano F. Drager
- Hypertension Unit, Heart Institute (InCor), University of Sao Paulo Medical School, Sao Paulo, Brazil
- Hypertension Unit, Renal Division, University of Sao Paulo Medical School, Sao Paulo, Brazil
| | - Geraldo Lorenzi-Filho
- Sleep Laboratory, Pulmonary Division, University of Sao Paulo Medical School, Sao Paulo, Brazil
| | - Xia Wang
- The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, NSW, Australia
| | - Wei Wei Quan
- Department of Cardiology, Rui Jin Hospital and Institute of Cardiovascular Diseases, Shanghai Jiao Tong University School of Medicine, Shanghai, PR China
| | - Manjari Tripathi
- Department of Neurology, All India Institute of Medical Sciences, Delhi, India
| | - Olga Mediano
- Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Madrid, Spain
- Respiratory Department, Hospital Universitario de Guadalajara, Universidad de Alcalá, Madrid, Spain
| | - Qiong Ou
- Sleep Center, Respiratory and Critical Medical Department, Guangdong Institute of Geriatrics, Guangdong Academy of Medical Sciences, Guangdong Provincial People's Hospital, Guangzhou 510000, Guangdong PR, PR China
| | - Rui Chen
- The Second Affiliated Hospital of Soochow University, Suzhou, Jiangsu, PR China
| | - Zhihong Liu
- Department of Cardiology, Fuwai Hospital, Beijing, PR China
| | - Xilong Zhang
- The First Affiliated Hospital of Nanjing Medical University, Nanjing, PR China
| | - Yuanming Luo
- The First Affiliated Hospital of Guangzhou Medical University, State Key Laboratory of Respiratory Disease, Guangzhou, PR China
| | - Nigel McArdle
- West Australian Sleep Disorders Research Institute, Department of Pulmonary Physiology and Sleep Medicine, Sir Charles Gairdner Hospital, Nedlands, WA, Australia
| | - Sutapa Mukherjee
- Adelaide Institute for Sleep Health, Flinders University, Adelaide, SA, Australia
- West Australian Sleep Disorders Research Institute, Department of Pulmonary Physiology and Sleep Medicine, Sir Charles Gairdner Hospital, Nedlands, WA, Australia
- Sleep Health Service, Respiratory and Sleep Services, Southern Adelaide Local Health Network, Flinders Medical Centre, Adelaide, SA, Australia
| | - R. Douglas McEvoy
- Adelaide Institute for Sleep Health, Flinders University, Adelaide, SA, Australia
- Sleep Health Service, Respiratory and Sleep Services, Southern Adelaide Local Health Network, Flinders Medical Centre, Adelaide, SA, Australia
| | - Craig S. Anderson
- The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, NSW, Australia
- Neurology Department, Royal Prince Alfred Hospital, Sydney Health Partners, Sydney, NSW, Australia
- The George Institute for Global Health China at Peking University Health Science Center, Beijing, PR China
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Carneiro-Barrera A, Díaz-Román A, Guillén-Riquelme A, Buela-Casal G. Weight loss and lifestyle interventions for obstructive sleep apnoea in adults: Systematic review and meta-analysis. Obes Rev 2019; 20:750-762. [PMID: 30609450 DOI: 10.1111/obr.12824] [Citation(s) in RCA: 68] [Impact Index Per Article: 13.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2018] [Revised: 11/27/2018] [Accepted: 11/28/2018] [Indexed: 12/17/2022]
Abstract
Lifestyle interventions addressing diet, exercise-training, sleep hygiene, and/or tobacco/alcohol cessation are recommended in the management of obstructive sleep apnoea (OSA). Yet their effectiveness on this condition still requires further research. This systematic review and meta-analysis was aimed at establishing (a) the effectiveness of lifestyle interventions on apnoea-hypopnoea index (AHI), oxygen desaturation index (ODI), excessive daytime sleepiness (EDS), and secondary OSA measures among adults, and (b) which intervention characteristics may drive the greatest improvements. A systematic search of studies was conducted using CINAHL, ProQuest, Psicodoc, Scopus, and Web of Science, from inception to April 2018. Standardized mean differences were calculated using the inverse variance method and random-effects models. The meta-analyses of 13 randomized controlled trials and 22 uncontrolled before-and-after studies (1420 participants) revealed significant reductions on AHI (d = -0.61 and -0.46, respectively), ODI (d = -0.61 and -0.46) and EDS (d = -0.41 and -0.49). Secondary OSA outcomes were also improved after interventions. However, effectiveness of interventions differed depending on their components, OSA severity, and gender. Thus, until future research further supports the differential effectiveness among lifestyle interventions on OSA, those addressing weight loss through diet and exercise-training may be the most effective treatments for male patients with moderate-severe OSA.
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Affiliation(s)
| | - Amparo Díaz-Román
- Mind, Brain, and Behaviour Research Centre, CIMCYC, University of Granada, Granada, Spain
| | | | - Gualberto Buela-Casal
- Mind, Brain, and Behaviour Research Centre, CIMCYC, University of Granada, Granada, Spain
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Quan SF, Lockyer BJ, Batool-Anwar S, Aeschbach D. Out of Center Sleep Testing in Ostensibly Healthy Middle Aged to Older Adults. SOUTHWEST JOURNAL OF PULMONARY AND CRITICAL CARE 2019; 18:87-93. [PMID: 31123637 DOI: 10.13175/swjpcc016-19] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Background Out of Center Sleep Testing (OCST) is used increasingly to diagnose obstructive sleep apnea (OSA). However, there are few data using OCST that quantify the amount of intrinsic apneic and hypopneic events among asymptomatic healthy persons, especially those who are elderly. This analysis reports the results of OCST in a small group of ostensibly healthy asymptomatic individuals. Methods The study population was comprised of ostensibly healthy middle-aged to elderly volunteers for studies of circadian physiology. Before undergoing an OCST, they were found to be free of any chronic medical or psychiatry condition by history, physical and psychologic examination and by a variety of questionnaires and laboratory tests. Results There were 24 subjects ranging in age from 55-70 years who had an OCST performed. Repeat studies were required in only 3 subjects. Over half the study population was over the age of 60 years (54.2% vs 45.8%); the majority were men (70.8%). The mean apnea hypopnea index (AHI) was 9.2 /hour with no difference between younger and older subjects. However, 11 had an AHI ≥ 5 /hour. Five had an AHI ≥15 /hour and 2 had an AHI ≥40 /hour. Those with an AHI <15 /hour had a mean AHI of 4.4 /hour (95% CI:2.8-6.0 /hour). Conclusions Although OCST has a low failure rate, there is a high prevalence of intrinsic obstructive apnea and hypopnea in ostensibly healthy asymptomatic persons.
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Affiliation(s)
- Stuart F Quan
- Department of Neurology; Division of Sleep and Circadian Disorders, Department of Medicine and Brigham and Women's Hospital and Division of Sleep Medicine, Harvard Medical School, Boston, MA.,Asthma and Airways Research Center, University of Arizona College of Medicine, Tucson, AZ
| | - Brandon J Lockyer
- Department of Neurology; Division of Sleep and Circadian Disorders, Department of Medicine and Brigham and Women's Hospital and Division of Sleep Medicine, Harvard Medical School, Boston, MA
| | - Salma Batool-Anwar
- Department of Neurology; Division of Sleep and Circadian Disorders, Department of Medicine and Brigham and Women's Hospital and Division of Sleep Medicine, Harvard Medical School, Boston, MA
| | - Daniel Aeschbach
- Department of Neurology; Division of Sleep and Circadian Disorders, Department of Medicine and Brigham and Women's Hospital and Division of Sleep Medicine, Harvard Medical School, Boston, MA.,Department of Sleep and Human Factors Research; Institute of Aerospace Medicine; German Aerospace Center; Cologne, 51147; Germany
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Patil SP, Ayappa IA, Caples SM, Kimoff RJ, Patel SR, Harrod CG. Treatment of Adult Obstructive Sleep Apnea With Positive Airway Pressure: An American Academy of Sleep Medicine Systematic Review, Meta-Analysis, and GRADE Assessment. J Clin Sleep Med 2019; 15:301-334. [PMID: 30736888 DOI: 10.5664/jcsm.7638] [Citation(s) in RCA: 348] [Impact Index Per Article: 69.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2018] [Accepted: 01/14/2019] [Indexed: 02/07/2023]
Abstract
INTRODUCTION The purpose of this systematic review is to provide supporting evidence for the clinical practice guideline for the treatment of obstructive sleep apnea (OSA) in adults using positive airway pressure (PAP). METHODS The American Academy of Sleep Medicine commissioned a task force of experts in sleep medicine. A systematic review was conducted to identify studies that compared the use of PAP with no treatment as well as studies that compared different PAP modalities. Meta-analyses were performed to determine the clinical significance of using PAP in several modalities (ie, continuous PAP, auto-adjusting PAP, and bilevel PAP), to treat OSA in adults. In addition, meta-analyses were performed to determine the clinical significance of using an in-laboratory versus ambulatory strategy for the initiation of PAP, educational and behavioral interventions, telemonitoring, humidification, different mask interfaces, and flexible or modified pressure profile PAP in conjunction with PAP to treat OSA in adults. Finally, the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) process was used to assess the evidence for making recommendations. RESULTS The literature search resulted in 336 studies that met inclusion criteria; 184 studies provided data suitable for meta-analyses. The data demonstrated that PAP compared to no treatment results in a clinically significant reduction in disease severity, sleepiness, blood pressure, and motor vehicle accidents, and improvement in sleep-related quality of life in adults with OSA. In addition, the initiation of PAP in the home demonstrated equivalent effects on patient outcomes when compared to an in-laboratory titration approach. The data also demonstrated that the use of auto-adjusting or bilevel PAP did not result in clinically significant differences in patient outcomes compared with standard continuous PAP. Furthermore, data demonstrated a clinically significant improvement in PAP adherence with the use of educational, behavioral, troubleshooting, and telemonitoring interventions. Systematic reviews for specific PAP delivery method were also performed and suggested that nasal interfaces compared to oronasal interfaces have improved adherence and slightly greater reductions in OSA severity, heated humidification compared to no humidification reduces some continuous PAP-related side effects, and pressure profile PAP did not result in clinically significant differences in patient outcomes compared with standard continuous PAP.
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Affiliation(s)
| | - Indu A Ayappa
- Icahn School of Medicine at Mount Sinai, New York, New York
| | | | - R Joh Kimoff
- McGill University Health Centre, Montreal, Quebec, Canada
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Garbarino S, Scoditti E, Lanteri P, Conte L, Magnavita N, Toraldo DM. Obstructive Sleep Apnea With or Without Excessive Daytime Sleepiness: Clinical and Experimental Data-Driven Phenotyping. Front Neurol 2018; 9:505. [PMID: 29997573 PMCID: PMC6030350 DOI: 10.3389/fneur.2018.00505] [Citation(s) in RCA: 62] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2018] [Accepted: 06/08/2018] [Indexed: 12/15/2022] Open
Abstract
Introduction: Obstructive sleep apnea (OSA) is a serious and prevalent medical condition with major consequences for health and safety. Excessive daytime sleepiness (EDS) is a common-but not universal-accompanying symptom. The purpose of this literature analysis is to understand whether the presence/absence of EDS is associated with different physiopathologic, prognostic, and therapeutic outcomes in OSA patients. Methods: Articles in English published in PubMed, Medline, and EMBASE between January 2000 and June 2017, focusing on no-EDS OSA patients, were critically reviewed. Results: A relevant percentage of OSA patients do not complain of EDS. EDS is a significant and independent predictor of incident cardiovascular disease (CVD) and is associated with all-cause mortality and an increased risk of metabolic syndrome and diabetes. Male gender, younger age, high body mass index, are predictors of EDS. The positive effects of nasal continuous positive airway pressure (CPAP) therapy on blood pressure, insulin resistance, fatal and non-fatal CVD, and endothelial dysfunction risk factors have been demonstrated in EDS-OSA patients, but results are inconsistent in no-EDS patients. The most sustainable cause of EDS is nocturnal hypoxemia and alterations of sleep architecture, including sleep fragmentation. These changes are less evident in no-EDS patients that seem less susceptible to the cortical effects of apneas. Conclusions: There is no consensus if we should consider OSA as a single disease with different phenotypes with or without EDS, or if there are different diseases with different genetic/epigenetic determinants, pathogenic mechanisms, prognosis, and treatment.The small number of studies focused on this issue indicates the need for further research in this area. Clinicians must carefully assess the presence or absence of EDS and decide accordingly the treatment. This approach could improve combination therapy targeted to a patient's specific pathology to enhance both efficacy and long-term adherence to OSA treatment and significantly reduce the social, economic, and health negative impact of OSA.
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Affiliation(s)
- Sergio Garbarino
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics and Maternal/Child Sciences, University of Genoa, Genoa, Italy.,Department of Health Sciences, University of Genoa, Genoa, Italy
| | - Egeria Scoditti
- Institute of Clinical Physiology, National Research Council (CNR), Lecce, Italy
| | - Paola Lanteri
- Department of Neurological Science, G. Gaslini Institute, Genoa, Italy
| | - Luana Conte
- Interdisciplinary Laboratory of Applied Research in Medicine (DReAM), "V Fazzi" University Hospital, ASL Lecce, Lecce, Italy.,Department of Biological and Environmental Sciences and Technologies, University of Salento, Lecce, Italy
| | - Nicola Magnavita
- Institute of Public Health, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Domenico M Toraldo
- Rehabilitation Department, Cardio-Respiratory Care Unit, "V Fazzi" Hospital, ASL Lecce, Lecce, Italy
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Voulgaris A, Archontogeorgis K, Nena E, Tsigalou C, Xanthoudaki M, Kouratzi M, Tripsianis G, Froudarakis M, Steiropoulos P. Serum levels of NGAL and cystatin C as markers of early kidney dysfunction in patients with obstructive sleep apnea syndrome. Sleep Breath 2018; 23:161-169. [PMID: 29946947 DOI: 10.1007/s11325-018-1677-8] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2018] [Revised: 05/20/2018] [Accepted: 05/30/2018] [Indexed: 12/26/2022]
Abstract
PURPOSE Obstructive sleep apnea syndrome (OSAS) has been recently proposed as an independent risk factor for chronic kidney disease. Cystatin C (Cyst C) and neutrophil gelatinase-associated lipocalin (NGAL) are novel biomarkers for the earlier detection of latent kidney disease. The aim of the study was to assess serum Cyst C and NGAL levels in otherwise healthy OSAS patients and to explore possible associations with sleep parameters. METHODS Consecutive subjects (n = 96, 79.2% males), without known comorbidities, with symptoms suggestive of OSAS were included. All of them underwent polysomnography (PSG) and blood examination for the measurement of serum Cyst C and NGAL levels. RESULTS Based on apnea-hypopnea index (AHI), subjects were classified into two groups: 32 controls and 64 OSAS patients, with no significant differences in terms of age (50.1 ± 11.7 vs 51 ± 12.2 years, p = 0.747) and BMI (33.9 ± 8.8 vs 35.9 ± 13.1 kg/m2, p = 0.449). Serum Cyst C and NGAL mean levels were higher in OSAS patients compared to those in controls (1155.2 ± 319.3 vs 966.8 ± 173 ng/ml, p = 0.001, and 43.7 ± 23.2 vs 35.6 ± 13.8 ng/ml, p = 0.035, respectively). After adjustment for age and BMI in OSAS patients, serum NGAL levels were associated with AHI (β = 0.341, p = 0.015) and minimum oxyhemoglobin saturation during sleep (β = - 0.275, p = 0.032), while serum Cyst C levels were associated with percentage of time with oxyhemoglobin saturation < 90% (β = 0.270, p = 0.043), average (β = - 0.308, p = 0.018), and minimum (β = - 0.410, p = 0.001) oxyhemoglobin saturation during sleep. CONCLUSIONS Higher risk for latent kidney disease in otherwise healthy OSAS patients is indicated. Sleep hypoxia seems to be a significant contributor in the pathogenetic process of renal dysfunction in OSAS.
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Affiliation(s)
- Athanasios Voulgaris
- MSc Programme in Sleep Medicine, Medical School, Democritus University of Thrace, Alexandroupolis, Greece.,Department of Pneumonology, Medical School, Democritus University of Thrace and University General Hospital, Alexandroupolis, Greece
| | - Kostas Archontogeorgis
- MSc Programme in Sleep Medicine, Medical School, Democritus University of Thrace, Alexandroupolis, Greece
| | - Evangelia Nena
- MSc Programme in Sleep Medicine, Medical School, Democritus University of Thrace, Alexandroupolis, Greece.,Laboratory of Hygiene and Environmental Protection, Medical School, Democritus University of Thrace, Alexandroupolis, Greece
| | - Christina Tsigalou
- Laboratory of Microbiology, Medical School, Democritus University of Thrace, Alexandroupolis, Greece
| | - Maria Xanthoudaki
- Department of Pneumonology, Medical School, Democritus University of Thrace and University General Hospital, Alexandroupolis, Greece
| | - Maria Kouratzi
- Department of Pneumonology, Medical School, Democritus University of Thrace and University General Hospital, Alexandroupolis, Greece
| | - Grigorios Tripsianis
- Laboratory of Medical Statistics, Medical School, Democritus University of Thrace, Alexandroupolis, Greece
| | - Marios Froudarakis
- Department of Pneumonology, Medical School, Democritus University of Thrace and University General Hospital, Alexandroupolis, Greece
| | - Paschalis Steiropoulos
- MSc Programme in Sleep Medicine, Medical School, Democritus University of Thrace, Alexandroupolis, Greece. .,Department of Pneumonology, Medical School, Democritus University of Thrace and University General Hospital, Alexandroupolis, Greece.
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Marrone O, Cibella F, Pépin JL, Grote L, Verbraecken J, Saaresranta T, Kvamme JA, Basoglu OK, Lombardi C, McNicholas WT, Hedner J, Bonsignore MR. Fixed But Not Autoadjusting Positive Airway Pressure Attenuates the Time-dependent Decline in Glomerular Filtration Rate in Patients With OSA. Chest 2018; 154:326-334. [PMID: 29698721 DOI: 10.1016/j.chest.2018.04.020] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2018] [Revised: 02/17/2018] [Accepted: 04/02/2018] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND The impact of treating OSA on renal function decline is controversial. Previous studies usually included small samples and did not consider specific effects of different CPAP modalities. The aim of this study was to evaluate the respective influence of fixed and autoadjusting CPAP modes on estimated glomerular filtration rate (eGFR) in a large sample of patients derived from the prospective European Sleep Apnea Database cohort. METHODS In patients of the European Sleep Apnea Database, eGFR prior to and after follow-up was calculated by using the Chronic Kidney Disease-Epidemiology Collaboration equation. Three study groups were investigated: untreated patients (n = 144), patients receiving fixed CPAP (fCPAP) (n = 1,178), and patients on autoadjusting CPAP (APAP) (n = 485). RESULTS In the whole sample, eGFR decreased over time. The rate of eGFR decline was significantly higher in the subgroup with eGFR above median (91.42 mL/min/1.73 m2) at baseline (P < .0001 for effect of baseline eGFR). This decline was attenuated or absent (P < .0001 for effect of treatment) in the subgroup of patients with OSA treated by using fCPAP. A follow-up duration exceeding the median (541 days) was associated with eGFR decline in the untreated and APAP groups but not in the fCPAP group (P < .0001 by two-way ANOVA for interaction between treatment and follow-up length). In multiple regression analysis, eGFR decline was accentuated by advanced age, female sex, cardiac failure, higher baseline eGFR, and longer follow-up duration, whereas there was a protective effect of fCPAP. CONCLUSIONS fCPAP but not APAP may prevent eGFR decline in OSA.
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Affiliation(s)
- Oreste Marrone
- CNR, Institute of Biomedicine and Molecular Immunology, Palermo, Italy.
| | - Fabio Cibella
- CNR, Institute of Biomedicine and Molecular Immunology, Palermo, Italy
| | - Jean-Louis Pépin
- INSERM Unit 1042, Université Grenoble Alpes, and CHU de Grenoble, Laboratoire EFCR, Pôle Thorax et Vaisseaux, Grenoble, France
| | - Ludger Grote
- Sleep Medicine, Sahlgrenska University Hospital and Sahlgrenska Academy, Gothenburg, Sweden
| | - Johan Verbraecken
- Multidisciplinary Sleep Disorders Centre, Antwerp University Hospital and University of Antwerp, Edegem-Antwerp, Belgium
| | - Tarja Saaresranta
- Division of Medicine, Department of Pulmonary Diseases, Turku University Hospital, and Sleep Research Center, Department of Pulmonary Diseases and Clinical Allergology, University of Turku, Turku, Finland
| | - John A Kvamme
- ENT Department, Førde Central Hospital, Førde, Norway
| | - Ozen K Basoglu
- Department of Chest Diseases, Ege University School of Medicine, Izmir, Turkey
| | - Carolina Lombardi
- Sleep Disorders Center, Department of Cardiovascular Neural and Metabolic Sciences, IRCCS Istituto Auxologico Italiano, Milano-Bicocca University, Milan, Italy
| | - Walter T McNicholas
- School of Medicine and Medical Science, University College Dublin, and Department of Respiratory and Sleep Medicine, St. Vincent's Hospital Group, Dublin, Ireland
| | - Jan Hedner
- Sleep Medicine, Sahlgrenska University Hospital and Sahlgrenska Academy, Gothenburg, Sweden
| | - Maria R Bonsignore
- CNR, Institute of Biomedicine and Molecular Immunology, Palermo, Italy; DiBiMIS, University of Palermo, Palermo, Italy
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Jin S, Jiang S, Hu A. Association between obstructive sleep apnea and non-alcoholic fatty liver disease: a systematic review and meta-analysis. Sleep Breath 2018; 22:841-851. [PMID: 29335916 DOI: 10.1007/s11325-018-1625-7] [Citation(s) in RCA: 46] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2017] [Revised: 01/03/2018] [Accepted: 01/05/2018] [Indexed: 12/23/2022]
Abstract
The relationship between obstructive sleep apnea (OSA) and non-alcoholic fatty liver disease (NAFLD) has been an issue of great concern. The primary purpose of this study was to determine the influence of OSA on the levels of liver enzymes including alanine transaminase (ALT) and aspartate transaminase (AST). The secondary purpose was to estimate the effect of OSA on the histological lesions of NAFLD, such as steatosis, lobular inflammation, ballooning degeneration, fibrosis, as well as NAFLD activity score (NAS). A systematic literature review using PubMed, Cochrane Library, Embase, and Ovid technologies from January 2007 to April 2017 was performed, and 9 studies (2272 participants) that met the selection criteria were evaluated. The present study demonstrated that OSA was related to ALT levels, but no significant correlation was found with AST levels. The subgroup analysis showed that the severity of OSA was associated with ALT levels, not with AST levels. The meta-regression analysis showed that age, sex, homeostasis model assessment, diabetes mellitus, body mass index, and waist circumference did not have a significant effect on the levels of ALT and AST. OSA was also found to be significantly correlated with steatosis, lobular inflammation, ballooning degeneration, and fibrosis, but was not correlated with NAS. OSA was independently related to the development and progression of NAFLD in terms of liver enzyme level and histological alterations. Future studies should investigate the possible relevant mechanisms, thereby guiding the exploration of potential therapeutic implications to prevent the progression of disease.
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Affiliation(s)
- Shanshan Jin
- Ningbo University School of Medicine, Ningbo City, Zhejiang Province, China
| | - Suwen Jiang
- Institute of Liver Diseases, Ningbo No. 2 Hospital, 41 Xibei Street, Haishu District, Ningbo City, Zhejiang Province, 315010, China
| | - Airong Hu
- Ningbo University School of Medicine, Ningbo City, Zhejiang Province, China. .,Institute of Liver Diseases, Ningbo No. 2 Hospital, 41 Xibei Street, Haishu District, Ningbo City, Zhejiang Province, 315010, China.
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Gouveia CJ, Zaghi S, Awad M, Camacho M, Liu SYC, Capasso R, Kern RC. Publication trends and levels of evidence in obstructive sleep apnea literature. Laryngoscope 2018; 128:2193-2199. [DOI: 10.1002/lary.27075] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2017] [Revised: 11/14/2017] [Accepted: 12/04/2017] [Indexed: 11/10/2022]
Affiliation(s)
- Christopher J. Gouveia
- Department of Otolaryngology-Head and Neck Surgery; Stanford University; Stanford California U.S.A
- Department of Otolaryngology-Head and Neck Surgery; Northwestern University Feinberg School of Medicine; Chicago Illinois U.S.A
| | - Soroush Zaghi
- Department of Otolaryngology-Head and Neck Surgery; University of California, Los Angeles Medical Center; Santa Monica California U.S.A
| | - Michael Awad
- Department of Otolaryngology-Head and Neck Surgery; University of Toronto; Toronto Ontario Canada
| | - Macario Camacho
- Department of Otolaryngology-Head and Neck Surgery; Tripler Army Medical Center; Honolulu Hawaii U.S.A
| | - Stanley Y. C. Liu
- Department of Otolaryngology-Head and Neck Surgery; Stanford University; Stanford California U.S.A
| | - Robson Capasso
- Department of Otolaryngology-Head and Neck Surgery; Stanford University; Stanford California U.S.A
| | - Robert C. Kern
- Department of Otolaryngology-Head and Neck Surgery; Stanford University; Stanford California U.S.A
- Department of Otolaryngology-Head and Neck Surgery; Northwestern University Feinberg School of Medicine; Chicago Illinois U.S.A
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