Increased mortality among sleepy snorers: a prospective population based study

Sleep disorders and mortality: A prospective study in the Canadian longitudinal study on aging

BACKGROUND AND OBJECTIVES

Sleep disorders are commonly linked to various health conditions, although it remains unclear to what degree they are linked with overall mortality. We compared mortality in different self-reported sleep disorders in a large population-based prospective study.

METHODS

In this case-control study within the CLSA cohort, participants completed a questionnaire at baseline (2011-2015) measuring overall sleep satisfaction, daily sleep duration, sleep-onset and sleep-maintenance insomnia, daytime somnolence, REM sleep behavior disorder (RBD), restless leg syndrome (RLS), and obstructive sleep apnea (OSA). The vital status of participants was assessed in July 2019. Baseline sleep problems of participants who died (cases) were compared to those who survived (controls). For each case, five age/sex-matched controls were selected. Binary logistic regression was used to estimate the association between sleep symptoms and mortality, adjusting for age, sex, marital status, province, education, alcohol consumption, smoking, caffeine, and body mass index. In a complementary model, anxiety and depression were also added.

RESULTS

Among 30,097 participants at baseline, 974 deaths were reported in 2019 (60.7 % male, age = 72.3 ± 9.4 years). In the initial analysis, mortality cases reported more baseline sleep-maintenance insomnia (12.1 % vs. 8.0 %, Adjusted OR[95%CI] = 1.62[1.15,2.29]), daytime somnolence (2.4 % vs. 1.1 %, AOR = 2.70[1.34,5.44]), and higher possible RLS (16.4 % vs. 12.4 %, AOR = 1.50[1.09,2.05]). They were also more likely to screen positive for possible OSA (33.8 % vs. 24.2 %, AOR = 1.32[1.07,1.64]); however, this effect was not related to core apnea symptoms. Sleep durations exceeding 10 h/day were also associated with increased mortality (3.4 % vs. 1.9 %, AOR = 1.83[1.04,3.24]). Other sleep symptoms/disorders, such as sleep-onset insomnia (7.3 % vs. 4.3 %, AOR = 1.54 [1.00,2.37]), possible RBD (5.3 % vs. 5.1 %, AOR = 1.02[0.62,1.69]), and overall sleep dissatisfaction (26.5 % vs. 22.6 %, AOR = 1.14[0.93,1.41]) were not different among these groups. After adding anxiety and depression to the adjustment model, all differences attenuated to become statistically non-significant, except for daytime somnolence disorder. When stratified by sex, the association between sleep disorders and mortality was only observed in women, with men showing no association.

DISCUSSION

We confirm a relationship between numerous sleep disorders and mortality. This effect is most evident in women, and appears to be strongly related to co-existing anxiety and depression.

The association between sleep characteristics and the risk of all-cause mortality among individuals with cardiometabolic multimorbidity: a prospective study of UK Biobank

STUDY OBJECTIVES

To investigate the implications of both sleep factors and sleep patterns on the prognosis of cardiometabolic multimorbidity.

METHODS

From UK Biobank, individuals with cardiometabolic multimorbidity , defined as the coincidence of at least 2 cardiometabolic diseases (hypertension, diabetes mellitus, coronary heart disease, and stroke) were included in this study. Four low-risk sleep factors, including early chronotype, sleep 7-8 h/d, free of insomnia, and no frequent excessive daytime sleepiness, were used to generate a healthy sleep score ranging from 0 to 4. Participants with a score of 0-1, 2, 3-4 were clustered into groups with poor, intermediate, and healthy sleep pattern, respectively. We assessed the adjusted hazard ratios and 95% confidence intervals for all-cause mortality using the Cox proportional hazards model.

RESULTS

Among included 35,757 participants, the mean age (standard deviation)) was 61.82 (6.3) years. After full adjustment, early chronotype, sleep 7-8 h/d, no frequent excessive daytime sleepiness, and free of insomnia were independently associated with 8%, 12%, 11%, and 8% lower risk of all-cause mortality among all persons with cardiometabolic multimorbidity. We found the fully adjusted hazard ratio (95% confidence interval) for all-cause mortality was 0.90 (0.88-0.92) for a 1-point increase in the healthy sleep score. Compared with the reference group, participants with the intermediate and healthy sleep pattern had 9% and 23% lower risk of all-cause death, respectively, in the fully adjusted model.

CONCLUSIONS

A healthy sleep pattern combining 4 low-risk sleep factors could be regarded as a healthy lifestyle for individuals with cardiometabolic multimorbidity to lower the risk of all-cause mortality.

CITATION

He L, Ma T, Cheng X, Bai Y. The association between sleep characteristics and the risk of all-cause mortality among individuals with cardiometabolic multimorbidity: a prospective study of UK Biobank. J Clin Sleep Med. 2023;19(4):651-658.

Snoring and environmental exposure: results from the Swedish GA2LEN study

OBJECTIVE

Habitual snoring is associated with fatigue, headaches and low work performance. This cross-sectional study aimed to investigate if snoring is affected by environmental factors such as home dampness and exposure to air pollution.

SETTING

General population sample from four Swedish cities.

PARTICIPANTS

25 848 participants from the Swedish part of the epidemiological Global Asthma and Allergy and European network of excellence study carried out in 2008. The participants completed a postal questionnaire on snoring and, indoor and outdoor environmental exposure as well as potential confounders including smoking, weight, height and educational level.

RESULTS

Of the participants, 4211 (16.3%) were habitual snorers. Habitual snorers reported water damage (8.3% vs 7.0% p<0.0001), floor dampness (4.6% vs 3.8% % p<0.0001) and visible mould (5.2% vs 3.8% p<0.0001) in their homes more often than non-snorers. Habitual snorers stated being annoyed by air pollution more often than non-snorers with habitual snorers reporting being irritated with the air in their residential area to a higher extent (sometimes 16.2% vs 13.9%, and daily 4.6% vs 3.1%) as well as annoyance from traffic fumes (somewhat 19% vs 18.5% and very 5% vs 3.6%) (p<0.0001). These results remained significant after adjustment for age, body mass index, smoking history and educational level.

CONCLUSION

Snoring is more prevalent in subjects reporting home dampness and air pollution. These association should be confirmed in further research using objective measurements and a longitudinal approach.

Excessive Daytime Sleepiness and Cardiovascular Mortality in US Adults: A NHANES 2005-2008 Follow-Up Study

PURPOSE

Excessive daytime sleepiness is highly prevalent and has been associated with increased risk of cardiovascular diseases, but evidence for its association with cardiovascular mortality is limited and inconsistent. We aimed to determine whether excessive daytime sleepiness is independently associated with cardiovascular mortality in general adult population.

PATIENTS AND METHODS

A prospective study of 10,330 adult participants (aged ≥20 years) from National Health and Nutrition Examination Survey (NHANES) 2005-2006 and 2007-2008 was followed up until December 31st, 2015. Excessive daytime sleepiness was defined as the self-reported feeling of being overly sleepy often or always during the day. Cox proportional hazard ratios (HRs) with 95% confidence interval (CI) were estimated to assess risk for cardiovascular mortality.

RESULTS

A total of 10,330 participants with mean age of 47.3 years (95% CI, 46.0 to 48.1) were included in this analysis. Approximately, 18.5% of US adults reported excessive daytime sleepiness. Over a mean follow-up of 8.3 years, 262 cardiovascular deaths occurred. Participants with excessive daytime sleepiness had 2.85-times greater risk (95% CI, 1.33-6.09) of cardiovascular death than those without daytime sleepiness in multivariable analysis corrected for sociodemographic factors, comorbidities and cardiovascular risk factors including depression. Further adjustment for self-reported sleep disorders and sleep duration only slightly attenuated this association (HR, 2.55; 95% CI, 1.23-5.27). No interactions between excessive daytime sleepiness and age, sex or cardiovascular disease at study entry were observed (all Ps>0.05).

CONCLUSION

Excessive daytime sleepiness is highly prevalent among US adults and is independently associated with an approximately two-and-a-half-fold increased risk of cardiovascular mortality in a large national sample. Screening for excessive daytime sleepiness may be a simple and cost-effective tool for identifying individuals at high risk of cardiovascular death.

Use of mandibular advancement devices for the treatment of primary snoring with or without obstructive sleep apnea (OSA): A systematic review

The aim of this review was to systematically evaluate the available scientific evidence on the benefit of mandibular advancement devices (MADs) in the treatment of primary snoring (PS). From 905 initially identified articles, 18 were selected. Papers that provided indirect information regarding obstructive sleep apnea syndrome (OSAS) and/or sleep breathing disorders (SBD) were included. Information was obtained on monoblock and duoblock appliances from the selected studies. The devices were most commonly able to achieve 50%-70% of the maximum mandibular protrusion. The frequently used outcome measurements were the apnea-hypopnea index, Epworth sleepiness scale, and oxygen desaturation index, which all yielded positive post-treatment results. The most common side effects were temporomandibular joint pain and excessive salivation, which improved with time. Our findings indicated that the use of MADs, even with varying designs, improved outcomes in all the reported patient populations (PS, OSAS, and SBD). Despite the lack of studies on PS, the available evidence supports the use of MADs for treatment of PS. Snoring should be treated from a preventive and psychosocial perspective to avoid progression to more severe diseases that could have a significant medical and economic impact.

Eight-Year Follow-up of Modified Uvulopalatopharyngoplasty in Patients With Obstructive Sleep Apnea

OBJECTIVE

To investigate whether modified uvulopalatopharyngoplasty (UPPP) for treatment of obstructive sleep apnea (OSA) remained effective after 8 years.

METHODS

Prospective intervention study. Sixty-five patients with OSA were offered re-evaluation with polysomnography and the Epworth Sleepiness Scale (ESS) 8 years after UPPP. Results were compared with baseline and with a previous 2-year follow-up. Baseline predictors were analyzed with regression analyses.

RESULTS

The dropout rate at the 8-year follow-up was 28%. The mean decrease in apnea-hypopnea index (AHI) between baseline and the 8-year follow-up was significant, 14.0 events/hour (from 52.9 to 38.9), 27% (P < .001). The mean increase in AHI between the 2-year and the 8-year follow-up was significant, 14.7 events/hour (from 24.2 to 38.9), 61% (P < .0001). Overweight at baseline predicted an AHI at the 8-year follow-up that was 22.9 events higher compared to patients with normal weight (P = .015). An increase in body mass index (BMI) of 1 kg/m² between baseline and the 8-year follow-up predicted a mean AHI increase of 3.8 events/hour (P = .015). The median decrease in ESS between baseline and the 8-year follow-up was significant, 7 (from 13.0 to 6.0), 54% (P < .0001). The median increase in ESS between the 2-year and the 8-year follow-up was not significant, 1.0 (from 5.0 to 6.0), 20%.

CONCLUSION

Modified UPPP was effective as a long-term treatment for OSA in selected patients, although the effect on AHI decreased over time. Daytime sleepiness remained improved even in the long term. High BMI at baseline and an increase in BMI predicted a reduced long-term respiratory outcome.

LEVEL OF EVIDENCE

3 Laryngoscope, 131:E307-E313, 2021.

Sleep disordered breathing in pregnancy: A review of the pathophysiology of adverse pregnancy outcomes

Sleep disordered breathing (SDB) is a common obesity-related co-morbidity with strong associations to cardiometabolic disease. The risk of SDB is increased during pregnancy, particularly among obese pregnant women. Accumulating evidence suggests that an association exists between maternal SDB and the development of adverse pregnancy outcomes, particularly gestational diabetes and hypertensive disorders of pregnancy. Intermittent hypoxia, a central characteristic of SDB, has been shown in animal and clinical studies to dysregulate several biological pathways. This includes the promotion of oxidative stress, increased inflammation, activation of the hypothalamic-pituitary-adrenal axis, increased sympathetic activity and impaired glucose and insulin metabolism. This review considers how, during pregnancy, these pathophysiological processes are plausible mechanisms through which SDB may contribute to an increased risk of adverse outcomes, for the mother and perhaps also the offspring. However, a lack of robust evidence specific to the pregnant population, including limited evaluation of the placental function in affected pregnancies, limits our ability to draw definite conclusions on mechanisms contributing to adverse pregnancy outcomes and, indeed, the strength of association between SDB and certain pregnancy complications.

Factors Influencing Adherence to Auto-CPAP: An Observational Monocentric Study Comparing Patients With and Without Cardiovascular Diseases

Introduction: Obstructive sleep apnea/hypopnea (OSAH) affects more than 15% of the general population and increases the occurrence of cardiovascular (CV) and metabolic events. Continuous positive airway pressure (CPAP) treatment is currently the gold standard treatment of OSAH and could prevent the occurrence of such events. However, long-term adherence to CPAP is a problem where a significant rate stop device treatment use. OSAH patients suffering CV disease could be less compliant due to less diurnal symptoms. Methods: We performed a prospective study of 408 non-CV or CV disease patients suffering severe OSAH syndrome and followed them during the first 5 months as well as a mean of 3 years of CPAP treatment use. Results: We demonstrated that in adult OSAH patients that two variables were associated with a low compliance (<5 h/night): age <60 y and lower maximal positive airway pressure level used. There was no significant impact of the presence of CV disease on compliance of 5 months. After 3 years of CPAP, age <60 y as well as diabetes were independent factors of low compliance. There was no significant association between gender, mask types, 90th centile positive airway pressure level, apnea/hypopnea index and short- or long-term compliance in our population. Conclusions: We did not find lower compliance of CPAP in CV OSAH patients. Most of our population (68-73%) demonstrated an optimal night treatment duration at 3 years of follow-up, allowing a reduction of CV occurrence or recurrence. We hypothesize that an early and short education of OSAH as we routinely proposed could allow a significant increase in the optimal observance of CPAP in at-risk populations.

Joint effects of OSA and self-reported sleepiness on incident CHD and stroke

BACKGROUND

Although excessive daytime sleepiness (EDS) is a common symptom of obstructive sleep apnea (OSA), and both EDS and OSA have separately been associated with increased risk of cardiovascular disease (CVD), their joint association with CVD risk is unknown.

METHODS

Among 3874 Sleep Heart Health Study (SHHS) participants without prevalent CVD, moderate to severe OSA was defined by an apnea hypopnea index (AHI) ≥ 15 on an in-home polysomnography. EDS was defined as an Epworth Sleepiness Scale score ≥11. Incident CVD events included total CVD events (coronary heart disease (CHD) and stroke), as well as CHD and stroke separately. Cox proportional hazards models adjusted for age, sex, alcohol, smoking, and body mass index.

RESULTS

Compared to those with AHI <15, the hazard ratios (95% CI) for the association of moderate-severe OSA (AHI ≥15) were as follows: CVD 1.06 (0.85-1.33); CHD 1.08 (0.85-1.33); and stroke 1.18 (0.75-1.84). Weak associations between EDS and CVD risk = [1.22 (1.01-1.47)] and CHD risk [1.25 (1.02-1.53)] were present, however there were none for stroke risk [1.10 (0.75-1.63)]. When jointly modeled, both AHI ≥15 and EDS (compared with having AHI <15 and no EDS) was associated with HRs of 1.26 (0.91-1.73) for CVD, 1.24 (0.87-1.75) for CHD and 1.49 (0.78-2.86) for stroke. There were no statistically significant interactions between daytime sleepiness and OSA on the multiplicative or additive scales.

CONCLUSIONS

Having both EDS and moderate-severe OSA was not associated with an increased risk of CVD in the SHHS data.

Women with symptoms of sleep-disordered breathing are less likely to be diagnosed and treated for sleep apnea than men

BACKGROUND

Women are often underrepresented at sleep clinics evaluating sleep-disordered breathing (SDB). The aim of the present study was to analyze gender differences in sleep apnea diagnosis and treatment in men and women with similar symptoms of SDB.

METHODS

Respiratory Health in Northern Europe (RHINE) provided information about snoring, excessive daytime sleepiness (EDS), BMI and somatic diseases at baseline (1999-2001) and follow-up (2010-2012) from 4962 men and 5892 women. At follow-up participants were asked whether they had a diagnosis of and/or treatment for sleep apnea.

RESULTS

Among those with symptoms of SDB (snoring and EDS), more men than women had been given the diagnosis of sleep apnea (25% vs. 14%, p < 0.001), any treatment (17% vs. 11%, p = 0.05) and CPAP (6% vs. 3%, p = 0.04) at follow-up. Predictors of receiving treatment were age, BMI, SDB symptoms at baseline and weight gain, while female gender was related to a lower probability of receiving treatment (adj. OR 0.3, 95% CI 0.3-0.5). In both genders, the symptoms of SDB increased the risk of developing hypertension (adj OR, 95% CI: 1.5, 1.2-1.8) and diabetes (1.5, 1.05-2.3), independent of age, BMI, smoking and weight gain.

CONCLUSIONS

Snoring females with daytime sleepiness may be under-diagnosed and under-treated for sleep apnea compared with males, despite running a similar risk of developing hypertension and diabetes.

Occupational Health and Sleep Issues in Underserved Populations

Sleep disorders and occupational hazards, injuries, and illnesses impact an individual's overall health. In the United States, substantial racial, ethnic, and socioeconomic disparities exist in sleep and occupational health. Primary care physicians working in underserved communities should be aware of this disparity and target these higher-risk populations for focused evaluation and intervention.

Association Between Benzodiazepine Receptor Agonists and Snoring Among Women in the Nurses' Health Study

Importance

Snoring is highly prevalent among adults. The use of benzodiazepine receptor agonists is also common, with higher prevalence of use with more advanced age. Benzodiazepine receptor agonists cause muscle relaxation, which may affect muscle tone and airway dynamics and thereby increase snoring. Previous studies examining the association between use of benzodiazepine receptor agonists and snoring were underpowered to detect clinically meaningful differences or did not report the magnitude of association.

Objective

To investigate the association between use of benzodiazepine receptor agonists and snoring in women.

Design, Setting, and Participants

Women aged 62 to 86 years provided information on snoring and covariates of interest in the 2008 survey of the Nurses' Health Study, a cross-sectional cohort study of female registered nurses in the United States. Potential effect modification of the association between use of benzodiazepine receptor agonists and snoring by age, body mass index, waist circumference, smoking, alcohol consumption, and physical activity was explored. Logistic regression was used to adjust for potential confounders. Data analysis was conducted from November 2015 to March 2016.

Main Outcomes and Measures

Self-reported habitual snoring, defined as a few nights a week or more.

Results

Of 52 504 participants (mean [SD] age, 72.4 [6.7] years), 14 831 (28.2%) reported habitual snoring. There was a slightly higher prevalence of benzodiazepine receptor agonist use among habitual snorers (11.4%) compared with nonhabitual snorers (10.6%) (absolute difference, 0.8%; 95% CI, 0.2%-1.4%). After multivariable adjustment, use of benzodiazepine receptor agonists was not associated with snoring (odds ratio, 1.01; 95% CI, 0.95-1.07) compared with women who did not use benzodiazepine receptor agonists. Although there was no significant interaction with smoking, there were higher odds of snoring with use of benzodiazepine receptor agonists among current smokers (odds ratio, 1.34; 95% CI, 1.04-1.73).

Conclusions and Relevance

Use of benzodiazepine receptor agonists is not associated with odds of snoring in middle-aged and elderly women.

Relationship of Snoring and Sleepiness as Presenting Symptoms in a Sleep Clinic Population

Objectives:

Sleepiness has traditionally been considered medically the cardinal symptom of obstructive sleep apnea syndrome. Snoring is perceived as a social or cosmetic complaint. Without independent medical morbidity, snoring identification and treatment is not a major focus in sleep medicine. We speculate that snoring is a major independent symptom. To evaluate how patients rated snoring symptom severity, we compared the relative significance of a sleep clinic population's presenting symptoms of snoring and sleepiness.

Methods:

We performed a retrospective analysis of 770 consecutive patients who completed sleep intake evaluation forms at the initial clinic visit, including standardized forms for both sleepiness and snoring using previously validated visual analog scales. Data on symptom magnitude (scale of 1 to 10), symptom importance (scale of 1 to 5), a combined symptom product score consisting of magnitude multiplied by importance (MIP; scale of 1 to 50), the Epworth Sleepiness Scale (ESS; n = 599), and the apnea-hypopnea index (AHI; n = 482; mean ± SD, 35.6 ± 31.9 events per hour) were collected.

Results:

The mean snoring measures (magnitude, importance, and MIP) were greater than those for sleepiness (MIPsnoring of 32.7 ± 14.8 versus MIPsleepiness of 22.4 ± 14.2, p <.001). Snoring scored higher than sleepiness in 72% of individuals. To assess whether sleep apnea or sleepiness severity affected symptom scores, we stratified the subgroup with sleep studies into quartiles by AHI and ESS score. Snoring consistently scored higher than sleepiness in most AHI and ESS quartiles (p <.01). Only in the most severe ESS quartile did any sleepiness measure (importance) score higher than the snoring measure (p <.05).

Conclusions:

The presenting symptoms of snoring are larger in magnitude, importance, and severity than those of sleepiness in a broad population of patients with sleep disorders and sleep-disordered breathing irrespective of severity of sleep apnea or sleepiness. Symptoms of major significance are clinically relevant to identifying, diagnosing, and treating patients. Failure of medical providers to appreciate the impact of snoring on this population may affect attempts to identify, diagnose, and treat patients with sleep-disordered breathing.

Sex differences in reported and objectively measured sleep in COPD

Background

The aim was to assess and compare reported sleep disturbances and objectively measured sleep in men and women with COPD compared with controls and also explore sex differences.

Methods

A total of 96 patients with COPD and 90 age- and sex-matched controls answered a sleep questionnaire, underwent ambulatory polysomnography, a post-bronchodilatory spirometry, and blood sampling.

Results

Of the patients with COPD, 51% reported sleep disturbances as compared with 31% in controls (P=0.008). Sleep disturbances were significantly more prevalent in males with COPD compared with controls, whereas there was no significant difference in females. The use of hypnotics was more common among patients with COPD compared with controls, both in men (15% vs 0%, P=0.009) and women (36% vs 16%, P=0.03). The men with COPD had significantly longer recorded sleep latency than the male control group (23 vs 9.3 minutes, P<0.001), while no corresponding difference was found in women. In men with COPD, those with reported sleep disturbances had lower forced vital capacity, higher C-reactive protein, myeloperoxidase, and higher prevalence of chronic bronchitis.

Conclusion

The COPD was associated with impaired sleep in men while the association was less clear in women. This was also confirmed by recorded longer sleep latency in male subjects with COPD compared with controls.

Obstructive sleep apnoea and risks of all-cause mortality: preliminary evidence from prospective cohort studies

PURPOSE

A meta-analysis of prospective cohort studies was conducted to clarify the association between obstructive sleep apnoea (OSA) and future risk of all-cause mortality.

METHODS

Eligible studies were identified by searching the PubMed and EMBASE databases up to July 2015. Pooled hazard ratios (HRs) and their corresponding 95 % confidence intervals (CIs) were calculated to estimate the association between OSA and risk of all-cause mortality. Sources of heterogeneity were identified by subgroup and meta-regression analyses.

RESULTS

Twelve prospective cohort studies involving 34,382 participants were included in this meta-analysis. The pooled HR of all-cause mortality was 1.262 (95 % CI 1.093-1.431) with significant heterogeneity. Subgroup analyses indicated that the pooled HRs of all-cause mortality in patients with mild, moderate and severe OSA were 0.945 (95 % CI 0.810-1.081), 1.178 (95 % CI 0.978-1.378) and 1.601 (95 % CI 1.298-1.902), respectively. OSA severity could be a possible sources of heterogeneity. Existing publication bias produced a minor contribution to effect size.

CONCLUSION

Severe, but not mild to moderate, OSA is significantly associated with increased risk of all-cause mortality.

Predictors for Development of Excessive Daytime Sleepiness in Women: A Population-Based 10-Year Follow-Up

STUDY OBJECTIVES

To analyze predictors of excessive daytime sleepiness (EDS) and to analyze how changes within risk factors over time predict incident EDS in women.

DESIGN

Population-based prospective study.

SETTING

General population of the City of Uppsala, Sweden.

PARTICIPANTS

From a random, general population sample of 7,051 women from the Sleep and HEalth in women ("SHE") cohort, 4,322 women without EDS at baseline were followed up after 10 y.

INTERVENTIONS

N/A.

MEASUREMENTS AND RESULTS

At baseline and follow-up, women answered a questionnaire on sleeping habits, somatic disease, obesity, insomnia, anxiety and depression, lifestyle, and social factors. The risk of incident EDS was analyzed from changes over time in risk factors using logistic regression modeling. Of the women, EDS developed in 7.9%. Incident: insomnia (adjusted odds ratio = 5.01; 95% confidence interval 3.63-6.92), anxiety and/or depression (3.34; 2.22-5.02), somatic disease (1.73; 1.17-2.55), obesity (1.91; 1.14-2.57), snoring (1.91; 1.17-3.10) and smoking (4.31; 1.95-9.54) were all independent risk factors for the development of EDS. In addition, persistent: insomnia (4.44; 2.97-6.65) and anxiety and/or depression (4.91; 3.17-7.62) increased the risk of developing EDS. Apart from incident: snoring and obesity, similar results were obtained when only including women without somatic disease in the analyses.

CONCLUSION

Insomnia, anxiety and/or depression, and smoking were the most important factors for predicting incident excessive daytime sleepiness (EDS) and, in addition, somatic disease, obesity, and snoring predicted EDS. It is important not only to treat these conditions but also to inform women of the importance of a healthy lifestyle in order to prevent and reduce EDS in women.

Retrospective study of changes in pharyngeal airway space and position of hyoid bone after mandibular setback surgery by cephalometric analysis

Background

The posterior movement of mandible was known as the main cause of the changes in the pharyngeal airway space (PAS) and the postoperative obstructive sleep apnea (OSA). The purpose of this study was to know the changes of PAS and position of hyoid bone.

Methods

Lateral cephalographies of 13 patients who had undergone sagittal split ramus osteotomy (SSRO) setback surgery were taken preoperatively (T1), postoperatively within 2 months (T2), and follow-up after 6 months or more (T3). On the basis of F-H plane, diameters of nasopharynx, oropharynx, and hypopharynx were measured. The movements of the soft palate, tongue, and hyoid bone were also measured.

Results

The amount of mandible setback was 7.5 ± 3.8 mm. In the measurements of PAS, there was a statistically significant decrease of 2.8 ± 2.5 mm in nasopharynx (P < 0.01), and 1.7 ± 2.4 mm in oropharynx (P < 0.01) were observed after surgery. The hypopharynx decreased 1.0 ± 2.1 mm after surgery and continuously decreased 1.0 ± 2.8 mm at follow-up. The changes in hyoid bone position showed the posterior movement only after surgery and posteroinferior movement at follow-up.

Conclusions

The PAS such as nasopharynx, oropharynx, and hypopharynx showed relatively high correlation with the amount of mandibular setback. The change of resistance in upper airway may be important for the prevention of OSA after mandibular setback surgery.

Obstructive sleep apnea is a common disorder in the population-a review on the epidemiology of sleep apnea

The prevalence of obstructive sleep apnea (OSA) defined at an apnea-hypopnea index (AHI) ≥5 was a mean of 22% (range, 9-37%) in men and 17% (range, 4-50%) in women in eleven published epidemiological studies published between 1993 and 2013. OSA with excessive daytime sleepiness occurred in 6% (range, 3-18%) of men and in 4% (range, 1-17%) of women. The prevalence increased with time and OSA was reported in 37% of men and in 50% of women in studies from 2008 and 2013 respectively. OSA is more prevalent in men than in women and increases with age and obesity. Smoking and alcohol consumption are also suggested as risk factors, but the results are conflicting. Excessive daytime sleepiness is suggested as the most important symptom of OSA, but only a fraction of subjects with AHI >5 report daytime sleepiness and one study did not find any relationship between daytime sleepiness and sleep apnea in women. Stroke and hypertension and coronary artery disease are associated with sleep apnea. Cross-sectional studies indicate an association between OSA and diabetes mellitus. Patients younger than 70 years run an increased risk of early death if they suffer from OSA. It is concluded that OSA is highly prevalent in the population. It is related to age and obesity. Only a part of subjects with OSA in the population have symptoms of daytime sleepiness. The prevalence of OSA has increased in epidemiological studies over time. Differences and the increase in prevalence of sleep apnea are probably due to different diagnostic equipment, definitions, study design and characteristics of included subjects including effects of the obesity epidemic. Cardiovascular disease, especially stroke is related to OSA, and subjects under the age of 70 run an increased risk of early death if they suffer from OSA.

Impaired functional capacity predicts mortality in patients with obstructive sleep apnea

BACKGROUND

Obstructive sleep apnea (OSA) is associated with increased mortality, for which impaired functional capacity (IFC) has been established as a surrogate. We sought to assess whether IFC is associated with increased mortality in patients with OSA and whether IFC is predictive of increased mortality after accounting for coronary artery disease.

METHODS

Patients with OSA who underwent both polysomnography testing and exercise stress echocardiogram were selected. Records were reviewed retrospectively for demographics, comorbidities, stress echocardiographic parameters, and polysomnography data. Univariable and multivariable logistic regression analysis was used to evaluate the association between IFC and overall mortality. We then evaluated the variables associated with IFC in the overall population and in the subgroup with normal Duke treadmill score (DTS).

RESULTS

In our cohort, 404 (26%) patients had IFC. The best predictors of IFC were female sex, history of smoking, ejection fraction less than 55, increased body mass index, presence of comorbidities, abnormal exercise echocardiogram, abnormal heart rate recovery, and abnormal DTS. Compared with those without IFC, patients with IFC were 5.1 times more likely to die (odds ratio [OR], 5.1; 95% confidence interval [CI], 2.5-10.5; P < 0.0001) by univariate analysis and 2.7 times more likely to die (OR, 2.7; 95% CI, 1.2-6.1; P = 0.02) by multivariate analysis, when accounting for heart rate recovery, DTS, and sleep apnea severity. Among those without coronary artery disease, patients with IFC were at significantly increased risk of mortality (OR, 4.3; 95% CI, 1.35-13.79; P = 0.0088) compared with those with preserved functional capacity.

CONCLUSIONS

In our OSA population, IFC was a strong predictor of increased mortality. Among those with normal DTS, IFC identified a cohort at increased risk of mortality.

Simple snoring: not quite so simple after all?

Simple snoring (SS), in the absence of obstructive sleep apnoea (OSA), is a common problem, yet our understanding of its causes and consequences is incomplete. Our understanding is blurred by the lack of consistency in the definition of snoring, methods of assessment, and degree of concomitant complaints. Further, it remains contentious whether SS is independently associated with daytime sleepiness, or adverse health outcomes including cardiovascular disease and metabolic syndrome. Regardless of this lack of clarity, it is likely that SS exists on one end of a continuum, with OSA at its polar end. This possibility highlights the necessity of considering an otherwise 'annoying' complaint, as a serious risk factor for the development and progression of sleep apnoea, and consequent poor health outcomes. In this review, we: 1) highlight variation in prevalence estimates of snoring; 2) review the literature surrounding the distinctions between SS, upper airway resistance syndrome (UARS) and OSA; 3) present the risk factors for SS, in as far as it is distinguishable from UARS and OSA; and 4) describe common correlates of snoring, including cardiovascular disease, metabolic syndrome, and daytime sleepiness.

Self-reported habitual snoring and risk of cardiovascular disease and all-cause mortality

OBJECTIVE

Inconsistent findings have reported the association between self-reported habitual snoring and risk of cardiovascular disease (CVD) and all-cause mortality. We conducted a meta-analysis to investigate whether self-reported habitual snoring was an independent predictor for CVD and all-cause mortality using prospective observational studies.

METHODS

Electronic literature databases (PubMed, Medline, Embase, Cochrane Library, Wanfang database, and China National Knowledge Infrastructure) were searched for publications prior to September 2013. Only prospective studies evaluating baseline habitual snoring and subsequent risk of CVD and all-cause mortality were selected. Pooled adjust hazard risk (HR) and corresponding 95% confidence intervals (CI) were calculated for categorical risk estimates.

RESULTS

Eight studies with 65,037 subjects were analyzed. Pooled adjust HR was 1.26 (95% CI 0.98-1.62) for CVD, 1.15 (95% CI 1.05-1.27) for coronary heart disease (CHD), and 1.26 (95% CI 1.11-1.43) for stroke comparing habitual snoring to non-snorers. Pooled adjust HR was 0.98 (95% CI 0.78-1.23) for all-cause mortality in a random effect model comparing habitual snoring to non-snorers. Habitual snoring appeared to increase greater stroke risk among men (HR 1.54; 95% CI: 1.09-2.17) than those in women (HR 1.22; 95% CI: 1.05-1.41).

CONCLUSIONS

Self-reported habitual snoring is a mild but statistically significant risk factor for stroke and CHD, but not for CVD and all-cause mortality. However, whether the risk is attributable to obstructive sleep apnea syndrome or snoring alone remains controversial.

The association between the phenotype of excessive daytime sleepiness and blood pressure in patients with obstructive sleep apnea-hypopnea syndrome

OBJECTIVE

Investigate the clinical features and the blood pressure (BP) pattern of the phenotype of excessive daytime sleepiness (EDS) in OSAHS.

METHODS

A total of 508 Chinese adults with suspected OSAHS were referred to our sleep laboratory from October 2009 to May 2012. On the same night of polysomnography (PSG), the levels of blood pressure were measured before sleeping (bedtime BP) and immediately after waking up in the next morning (morning BP). EDS was recognized as Epworth Sleepiness Scale (ESS)≥9. Subjects were classified into four groups based on the apnea-hypopnea index (AHI) from PSG as follows: control (simple snoring) group (control, n=104) with AHI<5; mild group (mild, n=89) with AHI≥5 and <15; moderate group (moderate, n=70) with AHI≥15 and<30; and severe group (severe, n=245) with AHI ≥30. The differences and correlations between BP and PSG parameters in EDS and non-EDS group of OSAHS patients were analyzed.

RESULTS

In all subjects, ESS was positively correlated with morning diastolic blood pressure (DBP), Mean arterial pressure (MAP) and bedtime DBP (r=0.144, 0.102 and 0.114, respectively, each P value<0.05). In OSAHS patients, ESS was only positively correlated with morning DBP (r=0.137, P<0.05). OSAHS patients with EDS phenotype were younger and were more likely to have the symptom of waking up feeling tired (36.1% vs. 23.2%, p=0.023), who had lower MSaO2, longer SIT90 (the ratio of time of SpO2 below 90% in total sleep time) and higher DBP (bedtime as well as morning). In patients with AHI≥15, ESS was correlated positively with both bedtime and morning DBP after controlling the confounding effects of age, sex, BMI, AHI and nadir nocturnal oxygen saturation( r=0.126,0.143, respectively, both P values<0.05). And in OSAHS patients of EDS phenotype, the bedtime DBP, bedtime MAP, morning DBP, and morning MAP were 3~5 mm Hg higher than that in patients of non-EDS phenotype(P<0.05). In the moderate and severe OSAHS group, patients with EDS phenotype were younger and had a lower mean blood oxygen saturation (MSaO2), longer time of SpO2 below 90% and higher SIT90 than patients with non-EDS phenotype (P<0.05). In hypertensive OSAHS patients, patients with EDS were also younger and had higher micro-arousal index (MiI), as well as higher morning DBP, morning MAP and bedtime DBP than that in non-EDS group (P<0.05).

CONCLUSIONS

EDS in OSAHS patients is a special phenotype, which was characterized by younger age, higher DBP and more severe hypoxic load. This feature is mainly manifested in moderate and severe OSAHS patients. It is very important to identify the phenotype of EDS in patients with OSAHS, who may meet more benefits from effective treatment of OSAHS by correcting the intermittent nocturnal hypoxia and sleep fragmentation.

Weight reduction improves nocturnal respiration in obese sleep apnoea patients-A randomized controlled pilot study

SUMMARY

OBJECTIVES

Randomized controlled pilot study of the effect of weight reduction on nocturnal respiratory parameters in obese patients with obstructive sleep apnoea syndrome (OSAS).

METHODS

Twenty consecutive obese male patients fulfilling OSAS criteria at Karolinska University Hospital were randomized into two groups. Intervention with an 8-week weight reduction programme consisting of a low-calorie diet, together with group meetings, was evaluated compared to expectancy alone for the control group, followed by a crossover. Follow-up at 3 months included anthropometrics and ambulant sleep apnoea recordings.

RESULTS

Eleven of twenty men completed the protocol. There were significant differences between the intervention group (n = 6) and the control group (n = 5) in changes of weight (p < 0.01) and oxygen desaturation index (ODI4) (p < 0.05). We also found a significant positive correlation in these 11 males after the crossover between their reduction in weight and their reduction in ODI4 (p < 0.05).

CONCLUSIONS

This pilot study indicates that weight reduction improves nocturnal respiration in obese OSAS patients after 3 months' dietary treatment compared to expectancy.

Weight reduction improves sleep, sleepiness and metabolic status in obese sleep apnoea patients

SUMMARY

METHOD

In this prospective intervention study, 33 obese patients with obstructive sleep apnoea syndrome (OSAS) (24 men, 9 women) were consecutively enrolled for a weight reduction program at the Obesity Unit, Karolinska University Hospital. 23 of 33 patients used OSAS-device, 19 with Continuous Positive Airway Pressure and 4 with Mandibular Retaining Device. The patients were investigated with questionnaires, blood tests and ambulant nocturnal polysomnography before and after a 6-month program. Patients with OSAS-device slept without it during the sleep studies. The intervention consisted of 8 weeks low calorie diet and group meetings, followed by a day-care program of behaviour change support.

RESULTS

27 of 33 patients (82%, 21 men and 6 women) completed the study. After the intervention there were highly significant decreases (p < 0.001) in Body Mass Index from mean(S.D.) 40(5) to 34(3), apnoea-hypopnoea index from 43(24) to 26(20) and Epworth Sleepiness Scale (ESS)-score from 9(4) to 6(4). Sleep quality (arousal index, sleep efficiency, percentage deep sleep) and metabolic status (blood pressure, blood glucose levels, lipidemia) were also significantly improved. There was a significant correlation between increased percentage deep sleep and reduced ESS-score. There were no differences due to gender or use/no use of OSAS-device.

CONCLUSION

The results suggest that weight loss, induced by low calorie diet and behaviour change support, significantly improves nocturnal respiratory parameters, sleep quality, daytime sleepiness and metabolic status in obese OSAS patients after 6 months.

Snoring, daytime sleepiness, and incident cardiovascular disease in the health, aging, and body composition study

OBJECTIVES

To examine the association between snoring and incident cardiovascular disease (CVD).

DESIGN SETTINGS AND PARTICIPANTS

This is a prospective study in which community dwelling older adults were evaluated at baseline, and followed up for an average of 9.9 years.

MEASUREMENTS

Data on snoring, daytime sleepiness, as well as demographic and clinical characteristics of study participants was collected at baseline, and participants were followed up every six months for an average of 9.9 years. Based on snoring and sleepiness status, 4 groups of participants were created: (1) No Snoring, No Sleepiness; (2) No Snoring, Sleepiness; (3) Snoring, No Sleepiness; (4) Snoring, Sleepiness. Incident CVD was defined as a diagnosis of myocardial infarction, angina pectoris, or congestive heart failure that resulted in overnight hospitalization during the follow-up period. Cox proportional hazard was used to estimate the risk of incident cardiovascular disease during follow-up by baseline snoring and sleepiness status.

RESULTS

A total of 2,320 participants with a mean age of 73.6 (2.9) years at baseline were included in the analysis. Fifty-two percent were women, and 58% were white. A total of 543 participants developed CVD events during the follow-up period. Participants who reported snoring associated with daytime sleepiness had significantly increased hazard ratio for CVD events (HR = 1.46 [1.03-2.08], P = 0.035) after adjusting for demographic and clinical confounding factors.

CONCLUSION

The results suggest that self-reported snoring and daytime sleepiness status are associated with an increased risk of future cardiovascular disease among older adults.

Mortality of patients with obstructive sleep apnea in Korea

BACKGROUND

Obstructive sleep apnea (OSA) is associated with diverse health risks, including death. However, the role of OSA as a risk factor for death has never been studied in Asians. This study is aimed at evaluating the influence of OSA on the mortality in Korean sleep clinic population.

METHODS

A total of 2,240 patients who underwent in-laboratory full-night polysomnography due to snoring or sleep apnea were included. The patients were categorized based on apnea-hypopnea index (AHI)/hour. Death records were provided from the Statistics Korea. A Cox-proportional hazard regression model and Kaplan-Meier survival curve were used for analysis and demonstration of the all-cause mortality and cardiovascular mortality.

RESULTS

The all-cause mortality risk adjusted for age, sex, body mass index, diabetes, hypertension, cardiovascular diseases, and previous history of stroke was significantly associated with the increased severity of OSA. The adjusted hazard ratio (HR) for all-cause mortality in the severe OSA group (AHI ≥ 30) vs. reference group (5 < AHI) was 2.47 (95% confidence interval [CI], 1.09-5.57) and the adjusted HR for cardiovascular mortality was 4.66 (CI 1.03-21.08). After adjusting for whether the patients were treated or untreated, the HR for all-cause and cardiovascular mortality in the severe OSA group vs. reference group were 2.14 (p = 0.079) and 4.19 (p = 0.076), respectively.

CONCLUSIONS

The present study showed that the increased mortality was also associated with the increased severity of OSA in Koreans as shown in the studies performed in the Western countries.

Does 'weight reduction' help all adult snorers?

BACKGROUND

Obesity is now a global epidemic. Obese people are at higher risk of snoring. Weight reduction could influence the prevalence of snoring. Present study tried to find out, whether weight reduction is of benefit in all adult snorers.

MATERIALS AND METHODS

It is a cross sectional study, on 349 subjects (196 males and 153 females). They and their spouses were asked for snoring habits. Their neck circumference, height and weight was measured and Body mass index (BMI) was calculated, and they were classified into low normal, high normal, pre-obese and obese BMI groups. Prevalence rates of snoring in different groups were compared, to find out any statistically significant difference, between them.

RESULTS

Statistically significant difference, in prevalence rates of snoring was found, when obese and pre-obese group were compared with normal BMI group, separately. No significant difference was found in prevalence rates, when comparison was made between obese and pre-obese group. Difference in prevalence of snoring, was also not significant, when comparison was made between low normal and high normal BMI groups. Neck circumference of snorers was significantly more than the neck circumference of non-snorers in all BMI groups. Gender wise difference, in prevalence of snoring was also not significant.

CONCLUSION

Body mass index target needs to be set at 25 kg/m(2), in weight reduction programmes, to achieve clinically relevant response in a snorer. There is no need to put extra emphasis, on further reduction of BMI. Weight reduction, is not helpful in all adult snorers, especially those with normal BMI, where other causes of snoring, like fat around upper airways, need to be considered.

The effect of obstructive sleep apnea on amputation site healing

Obstructive sleep apnea (OSA) is an independent risk for hypertension, cerebral artery stenosis, stroke and hypercoagulability.(1) Our research objective was to assess whether sleep disordered breathing affects the peripheral circulation, decreases perfusion as measured by TcPO2 and decreases the odds that a partial-foot amputation site will heal. We hypothesized that OSA would be an independent risk factor causing delayed healing of partial-foot amputations. We conducted a retrospective, observational study on a total of 307 patients who had TcPO2 measurements and underwent partial-foot amputation. Twenty-five of these patients had OSA. In our study, patients with OSA had a 3.7-fold increase in odds of healing within 3 months in comparison with patients without OSA. Of note, 16 patients (64%) with OSA were not treated with continuous positive airway pressure (CPAP) and healed within 3 months. Our results do not support our hypothesis that the presence of sleep apnea may impair healing of partial foot amputations. Further studies are needed to fully determine the effect of OSA and its treatment on TcPO2s and healing.

Snoring is not associated with all-cause mortality, incident cardiovascular disease, or stroke in the Busselton Health Study

STUDY OBJECTIVES

To ascertain whether objectively measured snoring increases mortality, cardiovascular disease, or stroke risk over the effects of obstructive sleep apnea and other established risk factors.

DESIGN

Community-based cohort.

PARTICIPANTS

400 residents of the Western Australian town of Busselton.

INTERVENTIONS

N/A.

MEASUREMENTS

Snoring and obstructive sleep apnea were quantified via the percentage of the night spent snoring and the respiratory disturbance index as measured by a single night recording in November-December 1990 by a home sleep apnea monitoring device (MESAM IV), along with a range of cardiovascular disease risk factors. Follow-up for deaths and cardiovascular hospitalizations was ascertained via record linkage until the end of 2007.

RESULTS

Our analytical sample of 380 people was made up of the 397 people for whom the authors had follow-up data, minus 17 people who reported a previous stroke or heart attack at baseline (n = 380/400 = 95% of cohort). Snoring was observed for a mean/median of 32.0/27.4% of the night (standard deviation = 23.9%; range = 0-97.2%). There were 46 deaths, 68 cardiovascular events, and 24 strokes during 17 yr of follow-up. Snoring as either a categoric or continuous variable was not significantly associated with death, incident cardiovascular disease, or stroke in both unadjusted Cox regression models and in models that adjusted for obstructive sleep apnea and other risk factors.

CONCLUSIONS

No measure of snoring was associated with all-cause mortality, or incident cardiovascular disease or stroke over 17 yr in this community-based sample.

Epworth Sleepiness Scale may be an indicator for blood pressure profile and prevalence of coronary artery disease and cerebrovascular disease in patients with obstructive sleep apnea

OBJECTIVE

This study seeks to determine whether scores of a short questionnaire assessing subjective daytime sleepiness (Epworth Sleepiness Scale [ESS]) are associated with blood pressure (BP) level, BP profile, and prevalence of related coronary artery disease (CAD) and cerebrovascular disease (CVD) in obstructive sleep apnea (OSA) patients diagnosed by polysomnography (PSG).

METHODS

Twenty university hospital sleep centers in China mainland were organized by the Chinese Medical Association to participate in this study. Between January 2004 and April 2006, 2,297 consecutive patients (aged 18-85 years; 1,981 males and 316 females) referred to these centers were recruited. BP assessments were evaluated at four time points (daytime, evening, nighttime, and morning) under standardized conditions. Anthropometric measurements, medical history of hypertension, CAD, and CVD were collected. ESS score was calculated for each participant and at the night of BP assessment, nocturnal PSG was performed and subjects were classified into four groups based on the apnea-hypopnea index (AHI) from PSG as follows: control group (control, n = 213) with AHI < 5; mild sleep apnea (mild, n = 420) with AHI ≥ 5 and <15; moderate sleep apnea (moderate, n = 460) with AHI ≥ 15 and <30; and severe sleep apnea (severe, n = 1,204) with AHI ≥ 30. SPSS 11.5 software package was used for the relationships between ESS and BP profile and prevalence of CAD and CVD.

RESULTS

ESS is correlated positively with average daytime, nighttime, evening, and morning BP before and even after controlling for confounding effects of age, sex, BMI, AHI, and nadir nocturnal oxygen saturation (before--r = 0.182, 0.326, 0.245, and 0.329, respectively, all P values < 0.001; after--r = 0.069, 0.212, 0.137, and 0.208, respectively, all P values < 0.001). In the severe group, nighttime, evening, morning average BPs (ABPs), the ratio of nighttime/daytime average BP (ratio of nighttime average BP to daytime average BP), and prevalence of hypertension, drug-resistant hypertension (R-HTN), isolated nighttime hypertension (IN-HTN), CAD, and CVD in excessive daytime sleepiness (EDS, ESS ≥ 11) subjects are higher than those in non-EDS (ESS 0-10; t/χ(2) = -8.388, -6.207, -8.607, -5.901, 12.742, 38.980, 16.343, 59.113, and 67.113, respectively; all P values < 0.05). For EDS subjects in the moderate group but not in the control and mild group, nighttime ABP and the ratio of nighttime/daytime average BP are higher (t = -2.086 and -3.815, respectively, all P values < 0.05). Linear fitting with ESS and the ratio of nighttime/daytime average BP shows a positive correlation (r(2) = 0.049, P < 0.001).

CONCLUSIONS

In severe OSA patients with comparable AHI, EDS may identify a subset of individuals with OSA at higher risk of hypertension, R-HTN, IN-HTN, CAD, and CVD. Overall, nighttime ABP seems to be more sensitive to be influenced by EDS than other ABP parameters. Future studies should investigate the potential dose-effect relationship between EDS and hypertension and the possibility that diagnosis and treatment of EDS could aid in BP reduction and ultimately in decreased morbidity and mortality from cardiovascular and cerebrovascular complications (TMUIRB20010002 at www.clinicaltrials.gov ).

Elective tracheostomy is an alternative treatment in patients with severe obstructive sleep apnoea syndrome and CPAP failure

CONCLUSIONS

Elective tracheostomy with custom-made tubes was tolerated in a majority of patients with severe obstructive sleep apnoea syndrome (OSAS), as it reduced daytime symptoms and served as a link to other treatments.

OBJECTIVES

To evaluate the tolerability of elective tracheostomy and changes in excessive daytime sleepiness and nocturnal oxygen desaturations (ODI) in patients with severe OSAS and obesity.

PATIENTS AND METHODS

The medical records of 10 patients, median age 53.5 years (range 31-77), BMI 36 kg/m(2) (31-50), ODI 81 (55-126) during a 5-year period were reviewed. Inclusion criteria were failure of continuous positive airway pressure (CPAP), acceptance of tracheostomy, excessive daytime sleepiness and ODI > 50. All patients received a custom-made tube. Sleep apnoea recordings and questionnaires with Epworth sleepiness scale (ESS) were performed before and after tracheostomy.

RESULTS

Eight of 10 patients tolerated the tube for more than 6 months. The ESS score was reduced from median 18 (range 8-23) to 5 (0-7) and the ODI values from 81 (55-126) to 13 (1-87). Two patients insisted on decannulation because they had nocturnal breathing problems, two underwent palatal surgery and were decannulated, and five still have their tubes. Severe cough, sputum infections and stoma granuloma were seen in all patients.

Sleep-disordered breathing and mortality: a prospective cohort study

BACKGROUND

Sleep-disordered breathing is a common condition associated with adverse health outcomes including hypertension and cardiovascular disease. The overall objective of this study was to determine whether sleep-disordered breathing and its sequelae of intermittent hypoxemia and recurrent arousals are associated with mortality in a community sample of adults aged 40 years or older.

METHODS AND FINDINGS

We prospectively examined whether sleep-disordered breathing was associated with an increased risk of death from any cause in 6,441 men and women participating in the Sleep Heart Health Study. Sleep-disordered breathing was assessed with the apnea-hypopnea index (AHI) based on an in-home polysomnogram. Survival analysis and proportional hazards regression models were used to calculate hazard ratios for mortality after adjusting for age, sex, race, smoking status, body mass index, and prevalent medical conditions. The average follow-up period for the cohort was 8.2 y during which 1,047 participants (587 men and 460 women) died. Compared to those without sleep-disordered breathing (AHI: <5 events/h), the fully adjusted hazard ratios for all-cause mortality in those with mild (AHI: 5.0-14.9 events/h), moderate (AHI: 15.0-29.9 events/h), and severe (AHI: >or=30.0 events/h) sleep-disordered breathing were 0.93 (95% CI: 0.80-1.08), 1.17 (95% CI: 0.97-1.42), and 1.46 (95% CI: 1.14-1.86), respectively. Stratified analyses by sex and age showed that the increased risk of death associated with severe sleep-disordered breathing was statistically significant in men aged 40-70 y (hazard ratio: 2.09; 95% CI: 1.31-3.33). Measures of sleep-related intermittent hypoxemia, but not sleep fragmentation, were independently associated with all-cause mortality. Coronary artery disease-related mortality associated with sleep-disordered breathing showed a pattern of association similar to all-cause mortality.

CONCLUSIONS

Sleep-disordered breathing is associated with all-cause mortality and specifically that due to coronary artery disease, particularly in men aged 40-70 y with severe sleep-disordered breathing. Please see later in the article for the Editors' Summary.

Heavy snoring is a risk factor for case fatality and poor short-term prognosis after a first acute myocardial infarction

STUDY OBJECTIVES

Sleep disordered breathing has been associated with an increased risk for developing coronary heart disease. Data on the effects of sleep disordered breathing on case fatality and prognosis of a myocardial infarction are sparse. The present study aimed to investigate a possible relationship of snoring and case fatality and mortality after an acute myocardial infarction. DESIGN, SETTINGS, PATIENTS, AND MEASUREMENTS: In this study, we enrolled 1660 first acute myocardial infarction cases and examined the effects of self- or relative-reported heavy snoring on case fatality and prognosis. The average follow-up time was 8 years, SD = 262 days.

RESULTS

There was a variation in the association between snoring and mortality with time, with a strong association in the first 28 days after infarction but not later during the follow-up. Occasional and regular heavy snorers, when compared to those never having heavy snoring, had a 2.04 (95% confidence interval, 1.50 to 2.79) and 3.30 (95% confidence interval, 2.37 to 4.58) hazard ratio for mortality within the first 28 days after controlling for age, gender, obesity, history of diabetes and hypertension, physical activity, smoking, and education, respectively. There was no association between snoring and new myocardial infarction, stroke, or hospitalization for heart failure during the follow-up.

CONCLUSIONS

Heavy snoring is associated with case fatality and short-term mortality in patients with a first acute myocardial infarction.

Early life environment and snoring in adulthood

BACKGROUND

To our knowledge, no studies of the possible association of early life environment with snoring in adulthood have been published. We aimed to investigate whether early life environment is associated with snoring later in life.

METHODS

A questionnaire including snoring frequency in adulthood and environmental factors in early life was obtained from 16,190 randomly selected men and women, aged 25-54 years, in Sweden, Norway, Iceland, Denmark and Estonia (response rate 74%).

RESULTS

A total of 15,556 subjects answered the questions on snoring. Habitual snoring, defined as loud and disturbing snoring at least 3 nights a week, was reported by 18%. Being hospitalized for a respiratory infection before the age of two years (adjusted odds ratio (OR) = 1.27; 95% confidence interval (CI) 1.01-1.59), suffering from recurrent otitis as a child (OR = 1.18; 95%CI 1.05-1.33), growing up in a large family (OR = 1.04; 95%CI 1.002-1.07) and being exposed to a dog at home as a newborn (OR = 1.26; 95%CI 1.12-1.42) were independently related to snoring later in life and independent of a number of possible confounders in adulthood. The same childhood environmental factors except household size were also related with snoring and daytime sleepiness combined.

CONCLUSION

The predisposition for adult snoring may be partly established early in life. Having had severe airway infections or recurrent otitis in childhood, being exposed to a dog as a newborn and growing up in a large family are environmental factors associated with snoring in adulthood.