Canadian Thoracic Society 2011 guideline update: diagnosis and treatment of sleep disordered breathing

Enhanced machine learning approaches for OSA patient screening: model development and validation study

Age, gender, body mass index (BMI), and mean heart rate during sleep were found to be risk factors for obstructive sleep apnea (OSA), and a variety of methods have been applied to predict the occurrence of OSA. This study aimed to develop and evaluate OSA prediction models using simple and accessible parameters, combined with multiple machine learning algorithms, and integrate them into a cloud-based mobile sleep medicine management platform for clinical use. The study data were obtained from the clinical records of 610 patients who underwent polysomnography (PSG) at the Sleep Medicine Center of the Second Affiliated Hospital of Fujian Medical University between January 2021 and December 2022. The participants were randomly divided into a training-test group (80%) and an independent validation group (20%). The logistic regression, artificial neural network, naïve Bayes, support vector machine, random forest, and decision tree algorithms were used with age, gender, BMI, and mean heart rate during sleep as predictors to build a risk prediction model for moderate-to-severe OSA. To evaluate the performance of the models, we calculated the area under the receiver operating curve (AUROC), accuracy, recall, specificity, precision, and F1-score for the independent validation set. In addition, the calibration curve, decision curve, and clinical impact curve were generated to determine clinical usefulness. Age, gender, BMI, and mean heart rate during sleep were significantly associated with OSA. The artificial neural network model had the best efficacy compared with the other prediction algorithms. The AUROC, accuracy, recall, specificity, precision, F1-score, and Brier score were 80.4% (95% CI 76.7-84.1%), 69.9% (95% CI 69.8-69.9%), 86.5% (95% CI 81.6-91.3%), 61.5% (95% CI 56.6-66.4%), 53.2% (95% CI 47.7-58.7%), 65.9% (95% CI 60.2-71.5%), and 0.165, respectively, for the artificial neural network model. The AUROCs for the LR, NB, SVM, RF, and DT models were 80.2%, 79.7%, 79.2%, 78.4%, and 70.4%, respectively. The six models based on four simple and easily accessible parameters effectively predicted moderate-to-severe OSA in patients with PSG screening, with the artificial neural network model having the best performance. These models can provide a reliable tool for early OSA diagnosis, and their integration into a cloud-based mobile sleep medicine management platform could improve clinical decision making.

Level 2 Polysomnography for the Diagnosis of Sleep Disorders: A Health Technology Assessment

Background

It is estimated that half of Canadians have insufficient sleep, which over time is associated with poor physical and mental health. Currently, the only publicly funded option for the diagnosis of sleep disorders in Ontario is an in-person overnight sleep study, performed in a hospital or independent health facility (known as a level 1 polysomnography). Level 2 polysomnography has been proposed as an alternative that can be conducted at home for the diagnosis of suspected sleep disorders, if considered to have sufficient diagnostic accuracy. We conducted a health technology assessment of level 2 polysomnography for the diagnosis of suspected sleep disorders in adults and children, which included an evaluation of the test performance, cost-effectiveness, and budget impact of publicly funding level 2 polysomnography, and the experiences, preferences, and values of people with suspected sleep disorders.

Methods

We performed a systematic literature search of the clinical evidence to identify diagnostic accuracy, test failures and subjective measures of patient preferences. We assessed the risk of bias of each included study (using the Quality Assessment of Diagnostic Accuracy Studies [QUADAS-2] tool) and the quality of the body of evidence (according to Grading of Recommendations Assessment, Development, and Evaluation [GRADE] Working Group criteria). We performed a systematic literature search of economic evidence and conducted a primary economic evaluation and budget impact analysis to determine the cost-effectiveness and additional costs of publicly funding level 2 polysomnography for adults and children with suspected sleep disorders in Ontario. To contextualize the potential value of using level 2 polysomnography, we spoke with people with sleep disorders.

Results

We included 10 studies that reported on diagnostic accuracy and found level 2 polysomnography had sensitivity ranging between 0.76-1.0 and specificity ranging between 0.40-1.0 (GRADE: Moderate to Very low) when compared with level 1 polysomnography. Studies reported test failure rates from 0% to 20%, with errors present in both level 1 and level 2 tests conducted (GRADE: Very low). As well, some of these studies reported patients were found to have mixed opinions about their experiences, with more people preferring their experience with level 2 testing at home and having better quality of sleep compared with when they underwent level 1 testing (GRADE not conducted).Our primary economic evaluation showed that for adults with suspected sleep disorders, the new diagnostic pathway with level 2 polysomnography was equally effective (outcome: confirmed diagnosis at the end of the pathway) as the current practice diagnostic pathway with level 1 polysomnography. With the assumption of a lower technical fee for level 2 polysomnography, the new diagnostic pathway with level 2 polysomnography was less costly than the current practice diagnostic pathway (a saving of $27 per person with a wide 95% credible interval [95% CrI, -$137 to $121]), indicating that the results are highly uncertain. For children, a new diagnostic pathway with level 2 polysomnography was associated with additional costs (mean, $9.70; 95% CrI, -$125 to $190), and similarly, this estimate was highly uncertain.We estimated that the budget impact of publicly funding level 2 polysomnography for adults is uncertain and could range from savings of $22 million to additional costs of $43 million. Publicly funding a diagnostic pathway with level 2 polysomnography for children could result in additional costs of about $0.005 million over the next 5 years.People with whom we spoke reported that their sleep disorder negatively impacted their day-to-day lives, mental health, social and family relationships, and work. Participants who had experience with in-clinic (level 1) polysomnography described negative experiences they had at the clinic. Most people said they would prefer at-home (level 2) polysomnography over in-clinic (level 1) polysomnography, citing comfort and convenience as the main reasons; however, some people who have physical limitations preferred level 1 (in-clinic) polysomnography because they needed assistance to set up the equipment.

Conclusions

Level 2 polysomnography may have good test performance for adults and children, with adequate diagnostic accuracy, compared with level 1 polysomnography. The economic analyses showed that level 2 polysomnography for adults with suspected sleep disorders could be potentially cost saving but there is high uncertainty in the cost-effectiveness results. Given very limited information, the cost-effectiveness of this technology is also highly uncertain for children and young adults with suspected sleep disorders. The budget impact of publicly funding level 2 polysomnography for adults could range from savings of $22 million to additional costs of $43 million. Publicly funding level 2 polysomnography in children would require additional costs of about $0.005 million over the next 5 years. A clearer understanding of uptake of the technology, test costs, and the implementation pathway for adopting the technology is needed to improve the certainty of the cost-effectiveness and budget impact estimates. People with sleep disorders highlighted how important getting a diagnosis had been in order to be able to seek proper treatment for their sleep disorder and improve their lives. For many people with suspected sleep disorders, undergoing a sleep study at home would be a more comfortable and convenient option than undergoing a sleep study in clinic.

Proposal of a diagnostic algorithm based on the use of pulse oximetry in obstructive sleep apnea

PURPOSE

The aims of this study were to assess the cut-off values for oxygen desaturation index ≥ 3% (ODI3) to confirm obstructive sleep apnea (OSA) in subjects undergoing polysomnography (PSG) and home-based respiratory polygraphy (RP), and to propose an algorithm based on pulse oximetry (PO) for initial management of patients with suspected OSA.

METHODS

This was an observational, cross-sectional, retrospective study. ODI3 was used to classify subjects as healthy (no OSA = AHI < 5 or < 15 events/h) or unhealthy (OSA = AHI ≥ 5 or ≥ 15 events/h). On the PSG or experimental group (Exp-G), we determined ODI3 cut-off values with 100% specificity (Sp) for both OSA definitions. ODI3 values without false positives in the Exp-G were applied to a validation group (Val-G) to assess their performance. A strategy based on PO was proposed in patients with suspected OSA.

RESULTS

In Exp-G (PSG) 1141 patients and in Val-G (RP) 1141 patients were included. In Exp-G, ODI3 > 12 (OSA = AHI ≥ 5) had a sensitivity of 69.5% (CI95% 66.1-72.7) and Sp of 100% (CI95% 99-100), while an ODI3 ≥ 26 had a 53.8% sensitivity (CI95% 49.3-58.2) and Sp of 100% (CI95% 99.4-100) for AHI ≥ 15. A high pretest probability for OSA by Berlin questionaire (≥ 2 categories) had a lower diagnostic performance than by STOP-BANG questionnaire ≥ 5 points (AHI ≥ 5: 0.856 vs. 0.899, p < 0.001; AHI ≥ 15: 0.783 vs. 0.807, p 0.026).

CONCLUSION

We propose the initial use of PO at home in cases of moderate-to-high pretest probability of OSA. This algorithm considers PO as well as RP and PSG for more challenging cases or in case of doubt.

Salivary biomarker C-reactive protein levels in children with sleep problems and Class II malocclusion before and after twin-block therapy

Context

Disturbances in sleep affects the overall quality of a child's life, with several short- and long-lasting consequences. Hence, early diagnosis and monitoring is crucial in the management of sleep disorders in children.

Aims

The aim of this study was to evaluate salivary C-reactive protein (CRP) levels in a group of children with Class II malocclusion and sleep problems before and after twin-block appliance therapy.

Settings and Design

The study was a prospective clinical study with a 9-month follow-up period.

Subjects and Methods

Eleven children aged 8-12 years with skeletal Class II malocclusion and at least one sleep disorder were enrolled in the study. All children were subjected to a recording of their sleep history and a clinical as well as radiographic examination. Pretreatment levels of salivary CRP were recorded. A twin-block appliance was custom made and delivered to every child. At the end of 9-month follow-up, all children were recalled for a re-evaluation of salivary biomarker levels.

Statistical Analysis

Pretreatment and posttreatment changes in biomarker levels were assessed statistically using the students paired t-test.

Results

Levels of salivary biomarker CRP were significantly decreased in children following myofunctional therapy using a twin-block appliance (P < 0.001). There was a considerable improvement in the clinical symptoms such as a decrease in snoring and noisy breathing in most children post-twin-block therapy.

Conclusion

The measurement of salivary biomarker CRP could be used as an alternative and noninvasive method to evaluate prognosis of oral myofunctional therapy for children with sleep disordered breathing.

Obstructive Sleep Apnea and Hearing Loss: Is There Any Correlation?

Introduction  Obstructive sleep apnea (OSA) is a breathing disorder related to sleep that has a negative effect on the behavior and health of people around the globe. Chronic hypoxemia and variations in the concentration of oxygen in the blood noticed in OSA individuals may have adverse effects on the process of auditory transduction and transmission. Objective  To assess the effect of OSA on hearing and to find out the parameters that have more influence on hearing recorded during polysomnography of patients with OSA. Methods  The present is a hospital-based, observational, analytical, cross-sectional study conducted over a period of one year. After application of the exclusion criteria, the patients were then submitted to the application of the Berlin questionnaire, as well as polysomnography, impedance, and pure tone audiometry (PTA). Results  A total of 58 individuals were studied. Age, gender, and height were comparable among cases and controls, while weight, body mass index (BMI), and neck circumference were significantly higher in cases in comparison to controls. The mean PTA was significantly higher at 10 kHz or higher frequencies in cases in comparison to controls. Conclusion  We observed that there is evidence that the auditory mechanism is affected in OSA patients. We recommend early auditory screening of OSA patients for timely diagnosis and to raise awareness about its prevention.

Cognitive Functions, Depressive and Anxiety Symptoms After One Year of CPAP Treatment in Obstructive Sleep Apnea

Objective

The study worked with depressive symptoms, anxiety score and cognitive functions in obstructive sleep apnea (OSA) patients treated with CPAP.

Methods

Eighty-one subjects with OSA and without psychiatric comorbidity were treated with CPAP for one year and completed the following scales and cognitive tests: Trail Making Test, Verbal Fluency Test, d2 Test, Beck Depression Inventory-II and Beck Anxiety Inventory. MINI ruled out psychiatric disorder. At the two months check-up, subjects were re-evaluated for depressive and anxiety symptoms, and after one year of CPAP treatment, subjects repeated cognitive tests and scales. Data about therapy adherence and effectiveness were obtained from the patient's CPAP machines.

Results

The study was completed by 59 CPAP adherent patients and eight non-adherent patients. CPAP therapy effectiveness was verified in all patients by decreasing the apnea-hypopnoea index below 5 and/or 10% of baseline values. The adherent patients significantly improved depressive and anxiety symptoms. There was also an improvement in overall performance in the attention test; however, performance in many individual items did not change. The adherent patients also improved verbal fluency and in the Part B of the Trail making test. The non-adherent group significantly increased the number of mistakes made in the d2 test; other results were non-significant.

Conclusion

According to our results, OSA patients' mood, anxiety and certain cognitive domains improved during the one-year therapy with CPAP.

Trial Registration Number

NCT03866161.

Cannabis and sleep disorders: not ready for prime time? A qualitative scoping review

STUDY OBJECTIVES

To perform a qualitative scoping literature review for studies involving the effects of cannabis on sleep and sleep disorders.

METHODS

Two electronic databases, MEDLINE and EMBASE, searched for comprehensive published abstracted studies that involved human participants. Inclusion criteria were article of any type, published in English, a target population of cannabis users, and reported data on cannabis effect on sleep and sleep disorders. The Joanna Briggs Institute's (JBI) approach was elected as the methodology framework guidance in the scoping review process.

RESULTS

A total of 40 unique publications were found. The majority (82.5%) were from the Americas with 60% published in the last decade. Of the 40 studies, only 25% were randomized control trials, and the sleep outcome measurements were similar and comparable in only 20%. Cannabis users studied were reported either 73% frequent users or 27% sporadic users. The utilization of cannabis showed improved sleep (21%), worse sleep (48%), mixed results (14%), or no impact at all (17%) in the studies published in the last 5 decades.

CONCLUSIONS

Our findings summarize the lack of robust evidence to support the use of cannabis for sleep disorders. The varied cannabis user-related characteristics may account for the inconsistent results identified. Further studies assessing cannabis and sleep are needed to discern what works in what context, how it works, and for whom.

CITATION

Amaral C, Carvalho C, Scaranelo A, Chapman K, Chatkin J, Ferreira I. Cannabis and sleep disorders: not ready for prime time? A qualitative scoping review. J Clin Sleep Med. 2023;19(5):975-990.

Level of Evidence of Guidelines for Perioperative Management of Patients With Obstructive Sleep Apnea: An Evaluation Using the Appraisal of Guidelines for Research and Evaluation II Tool

Currently, the quality of guidelines for the perioperative management of patients with obstructive sleep apnea (OSA) is unknown, leaving anesthesiologists to make perioperative management decisions with some degree of uncertainty. This study evaluated the quality of clinical practice guidelines regarding the perioperative management of patients with OSA. This study was reported in compliance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. A systematic search of the MedlineALL (Ovid) database was conducted from inception to February 26, 2021, for clinical practice guidelines in the English language. Quality appraisal of guidelines was evaluated using the Appraisal of Guidelines for Research and Evaluation II (AGREE II) framework. Descriptive statistical analysis of each of the 6 domains was expressed as a percentage using the formula: (obtained score - minimum possible score)/(maximum possible score - minimum possible score). Of 192 articles identified in the search, 41 full texts were assessed for eligibility, and 10 articles were included in this review. Intraclass correlation coefficients of the AGREE II scores across the 7 evaluators for each guideline were each >0.9, suggesting that the consistency of the scores among evaluators was high. Sixty percent of recommendations were based on evidence using validated methods to grade medical literature, while the remainder were consensus based. The median and range scores of each domain were: (1) scope and purpose, 88% (60%-95%); (2) stakeholder involvement, 52% (30%-82%); (3) rigor of development, 67% (40%-90%); (4) clarity of presentation, 74% (57%-88%); (5) applicability, 46% (20%-73%); and (6) editorial independence, 67% (19%-83%). Only 4 guidelines achieved an overall score of >70%. This critical appraisal showed that many clinical practice guidelines for perioperative management of patients with OSA used validated methods to grade medical literature, such as Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) and Oxford classification, with lower scores for stakeholder involvement due to lack of engagement of patient partners and applicability domain due to lack of focus on the complete perioperative period such as postdischarge counseling. Future efforts should be directed toward establishing higher focus on the quality of evidence, stakeholder involvement, and applicability to the wider perioperative patient experience.

Effects of Soft Tissue Sleep Surgery on Morbidly Obese Patients

INTRODUCTION

Morbidly obese patients with obstructive sleep apnea (OSA) are often intolerant of continuous positive airway pressure (CPAP). The effects of sleep surgery in this population is not well documented, and sleep surgery is generally avoided due to the expectation of poor outcomes, leaving these patients untreated.

METHODS

This retrospective study included 42 patients with a body mass index (BMI) ≥40.0 and OSA with a preoperative apnea hypopnea index (AHI) ≥5. Preoperative BMI ranged from 40.0 to 69.0 kg/m². Preoperative AHI ranged from 7.2 to 130.0. Of 42 patients, 12 (28.6%) underwent concurrent pharyngeal and retrolingual surgery. Subgroup analysis of change in AHI was measured with respect to preoperative OSA severity, change in preoperative BMI, and BMI severity. Univariate linear and logistic regression was performed assessing change in AHI and surgical success with respect to age, sex, preoperative AHI, preoperative BMI, change in BMI, total procedures, palatal procedure, retrolingual procedure, nasal procedure, and multilevel procedures.

RESULTS

The mean AHI improved from 45.9 ± 31.8 to 31.9 ± 31.6 (P = .007). Epworth sleepiness score (ESS) improved from 13.2 ± 5.5 to 9.6 ± 5.4 (P = .00006). Lowest oxygen saturation (LSAT) improved from 74.4 ± 10.7 to 79.9 ± 10.4 (P = .002). About 33.3% of patients had surgical success (AHI < 20 with at least 50% reduction in AHI). Preoperative AHI was the most significant factor for change in AHI in univariate and multivariate models (P = .015).

CONCLUSION

Sleep surgery is effective in reducing OSA burden in most morbidly obese patients and can result in surgical cure for a third of patients.

Patient-reported Differences in Obstructive Sleep Apnea Care between Jurisdictions with and without Government Funding for Continuous Positive Airway Pressure

Rationale: Funding for obstructive sleep apnea (OSA) treatment may impact how patients access care, wait times, and costs of care. Objectives: The aim of this study was to compare differences in diagnosis and treatment of OSA between Canadian jurisdictions with and without public funding for continuous positive airway pressure (CPAP). Methods: We administered an anonymous internet survey to Canadian adults reporting a physician diagnosis of OSA. Responses were categorized on the basis of whether the respondent's province provided full or partial funding for CPAP therapy for all patients. We assessed wait times for diagnosis and treatment, patient-borne costs, and model of care delivery compared between jurisdictions with and without universal CPAP funding. Results: We received 600 responses representing all Canadian provinces and territories. The median (interquartile range) age was 59 (49-66) years; 57% were male, and 21% were from rural settings. Patients living in provinces without public CPAP funding (n = 419) were more likely to be diagnosed using home sleep apnea testing (69% vs. 20%; P = 0.00019). Wait times were similar after adjustment for demographics, disease characteristics, and model of care. Although patient-borne costs of care were similar between jurisdictions, patients from regions without CPAP funding reported that cost had a greater influence on the choice of therapy. Sleep specialists were more commonly involved in OSA care in regions with CPAP funding. There was no difference in the current use of therapy between jurisdictions with and without public funding. Conclusions: This survey study demonstrates that public funding for CPAP therapy impacts how Canadians access OSA care but is not associated with differences in wait times or costs. Future research is required to determine the impact of different funding models for OSA care on clinical outcomes.

Impact of wait times for treatment on clinical outcomes in patients with obstructive sleep apnoea: protocol for a randomised controlled trial

Background

Obstructive sleep apnoea (OSA) is a common chronic condition that is associated with significant morbidity and economic cost. Prolonged wait times are increasingly being recognised as a barrier to diagnosis and treatment of many chronic diseases; however, no study to date has prospectively evaluated the impact of wait times on health outcomes in OSA.

Objective

The purpose of this study is to determine whether treatment outcomes for individuals with OSA differ between patients managed using an expedited versus standard pathway.

Methods

A pragmatic randomised controlled trial design will be used with a target sample size of 200 adults. Participants with clinically significant uncomplicated OSA will be recruited through referrals to a large tertiary care sleep centre (Calgary, AB, Canada) and randomised to either early management (within 1 month) or usual care (∼6 months) with a 1:1 allocation using a concealed computer-generated randomisation sequence. The primary outcome will be adherence to positive airway pressure (PAP) therapy at 3 months after treatment initiation. Secondary outcomes will include change in sleepiness, quality of life, patient satisfaction, and patient engagement with therapy from baseline to 3 months after PAP initiation, measured using validated questionnaires and qualitative methods.

Anticipated results

This study will determine whether expedited care for OSA leads to differences in PAP adherence and/or patient-reported outcomes. More broadly, the findings of this study may improve the understanding of how wait time reductions impact health outcomes for other chronic diseases.

This study will determine whether expedited care for OSA leads to differences in PAP adherence and/or patient-reported outcomeshttps://bit.ly/38TrkwS

Sleep Apnea Syndrome (SAS) Clinical Practice Guidelines 2020

The prevalence of sleep disordered breathing (SDB) is reportedly very high. Among SDBs, the incidence of obstructive sleep apnea (OSA) is higher than previously believed, with patients having moderate-to-severe OSA accounting for approximately 20% of adult males and 10% of postmenopausal women not only in Western countries but also in Eastern countries, including Japan. Since 1998, when health insurance coverage became available, the number of patients using continuous positive airway pressure (CPAP) therapy for sleep apnea has increased sharply, with the number of patients about to exceed 500,000 in Japan. Although the "Guidelines for Diagnosis and Treatment of Sleep Apnea Syndrome (SAS) in Adults" was published in 2005, a new guideline was prepared in order to indicate the standard medical care based on the latest trends, as supervised by and in cooperation with the Japanese Respiratory Society and the "Survey and Research on Refractory Respiratory Diseases and Pulmonary Hypertension" Group, of Ministry of Health, Labor and Welfare and other related academic societies, including the Japanese Society of Sleep Research, in addition to referring to the previous guidelines. Because sleep apnea is an interdisciplinary field covering many areas, this guideline was prepared including 36 clinical questions (CQs). In the English version, therapies and managements for SAS, which were written from CQ16 to 36, were shown. The Japanese version was published in July 2020 and permitted as well as published as one of the Medical Information Network Distribution Service (Minds) clinical practice guidelines in Japan in July 2021.

Sleep Apnea Syndrome (SAS) Clinical Practice Guidelines 2020

The prevalence of sleep-disordered breathing (SDB) is reportedly very high. Among SDBs, the incidence of obstructive sleep apnea (OSA) is higher than previously believed, with patients having moderate-to-severe OSA accounting for approximately 20% of adult males and 10% of postmenopausal women not only in Western countries but also in Eastern countries, including Japan. Since 1998, when health insurance coverage became available, the number of patients using continuous positive airway pressure (CPAP) therapy for sleep apnea has increased sharply, with the number of patients about to exceed 500,000 in Japan. Although the "Guidelines for Diagnosis and Treatment of Sleep Apnea Syndrome (SAS) in Adults" was published in 2005, a new guideline was prepared to indicate the standard medical care based on the latest trends, as supervised by and in cooperation with the Japanese Respiratory Society and the "Survey and Research on Refractory Respiratory Diseases and Pulmonary Hypertension" Group, of Ministry of Health, Labor and Welfare and other related academic societies, including the Japanese Society of Sleep Research, in addition to referring to the previous guidelines. Since sleep apnea is an interdisciplinary field covering many areas, this guideline was prepared including 36 clinical questions (CQs). In the English version, therapies and managements for SAS, which were written from CQ16 to 36, were shown. The Japanese version was published in July 2020 and permitted as well as published as one of the Medical Information Network Distribution Service (Minds) clinical practice guidelines in Japan in July 2021.

Revisiting level II sleep studies in the era of COVID-19: a theoretical economic decision model in patients with suspected obstructive sleep apnea

Background

The recent pandemic has made it more challenging to assess patients with suspected obstructive sleep apnea (OSA) with in laboratory polysomnography (PSG) due to concerns of patient and staff safety. The purpose of this study was to assess how Level II sleep studies (LII, full PSG in the home) might be utilized in diagnostic algorithms of suspected OSA using a theoretical decision model.

Methods

We examined four diagnostic algorithms for suspected OSA: an initial PSG approach, an initial LII approach, an initial Level III approach (LIII, limited channel home sleep study) followed by PSG if needed, and an initial LIII approach followed by LII if needed. Costs per patient assessed was calculated as a function of pretest OSA probability and a variety of other variables (e.g. costs of tests, failure rate of LIII/LII, sensitivity/specificity of LIII). The situation in British Columbia was used as a case study.

Results

The variation in cost per test was calculated for each algorithm as a function of the above variables. For British Columbia, initial LII was the least costly across a broad range of pretest OSA probabilities (< 0.80) while initial LIII followed by LII as needed was least costly at very high pretest probability (> 0.8). In patients with a pretest OSA probability of 0.5, costs per patient for initial PSG, initial LII, initial LIII followed by PSG, and initial LIII followed by LII were: $588, $417, $607, and $481 respectively.

Conclusions

Using a theoretical decision model, we developed a preliminary cost framework to assess the potential role of LII studies in OSA assessment. Across a broad range of patient pretest probabilities, initial LII studies may provide substantial cost advantages. LII studies might be especially useful during pandemics as they combine the extensive physiologic information characteristic of PSG with the ability to avoid in-laboratory stays. More empiric studies need to be done to test these different algorithms.

Supplementary Information

The online version contains supplementary material available at 10.1186/s41606-021-00063-5.

Upper airway collapsibility in patients with OSA treated with continuous positive airway pressure: a retrospective preliminary study

STUDY OBJECTIVES

To investigate the prevalence of mildly collapsible upper airways (defined by therapeutic continuous positive airway pressure [CPAP] values ≤ 8 cm H₂O) in moderate to severe obstructive sleep apnea patients treated with CPAP and to determine their clinical, functional, and nocturnal polysomnographic characteristics.

METHODS

Eighty-seven patients with moderate to severe obstructive sleep apnea consecutively treated with CPAP were retrospectively investigated. Two nocturnal home sleep portable monitoring studies were performed at baseline and during treatment. Participants were categorized according to therapeutic CPAP values: ≤ 8 cm H₂O (group 1), 8-12 cm H₂O (group 2), ≥ 12 cm H₂O (group 3). Anthropometric, awake respiratory function, symptoms, comorbidities, and nocturnal home sleep portable monitoring studies data were collected.

RESULTS

Mild upper airway collapsibility (therapeutic CPAP values ≤ 8 cm H₂O) was present in 25.3% of patients. They showed more favorable apnea-hypopnea index, oxygen desaturation index, mean nocturnal saturation, sleep time with oxygen saturation < 90%, desaturation nadir, and supine position. Oxygen desaturation index showed a weak association with anatomical collapsibility. Using the receiver operating characteristic curve, the area under the curve for the oxygen desaturation index vs CPAP pressure requirements ≤ 8 cm H₂O was low and oxygen desaturation index ≤ 40.8/h showed a sensitivity of 63.3% and a specificity of 69.2% to detect patients with mild collapsibility.

CONCLUSIONS

A quarter of moderate to severe patients under CPAP therapy had mild collapsibility and were likely to also be good candidates for alternative and better tolerated non-CPAP therapies. Baseline anthropometric, clinical, and respiratory function characteristics did not predict mild upper airway collapsibility determined by CPAP pressure requirements ≤ 8 cm H₂O.

Case-Ascertainment Models to Identify Adults with Obstructive Sleep Apnea Using Health Administrative Data: Internal and External Validation

Background

There is limited evidence on whether obstructive sleep apnea (OSA) can be accurately identified using health administrative data.

Study Design and Methods

We derived and validated a case-ascertainment model to identify OSA using linked provincial health administrative and clinical data from all consecutive adults who underwent a diagnostic sleep study (index date) at two large academic centers (Ontario, Canada) from 2007 to 2017. The presence of moderate/severe OSA (an apnea–hypopnea index≥15) was defined using clinical data. Of 39 candidate health administrative variables considered, 32 were tested. We used classification and regression tree (CART) methods to identify the most parsimonious models via cost-complexity pruning. Identified variables were also used to create parsimonious logistic regression models. All individuals with an estimated probability of 0.5 or greater using the predictive models were classified as having OSA.

Results

The case-ascertainment models were derived and validated internally through bootstrapping on 5099 individuals from one center (33% moderate/severe OSA) and validated externally on 13,486 adults from the other (45% moderate/severe OSA). On the external cohort, parsimonious models demonstrated c-statistics of 0.75–0.81, sensitivities of 59–60%, specificities of 87–88%, positive predictive values of 79%, negative predictive values of 73%, positive likelihood ratios (+LRs) of 4.5–5.0 and –LRs of 0.5. Logistic models performed better than CART models (mean integrated calibration indices of 0.02–0.03 and 0.06–0.12, respectively). The best model included: sex, age, and hypertension at the index date, as well as an outpatient specialty physician visit for OSA, a repeated sleep study, and a positive airway pressure treatment claim within 1 year since the index date.

Interpretation

Among adults who underwent a sleep study, case-ascertainment models for identifying moderate/severe OSA using health administrative data had relatively low sensitivity but high specificity and good discriminative ability. These findings could help study trends and outcomes of OSA individuals using routinely collected health care data.

Predictive Performance of Oximetry to Detect Sleep Apnea in Patients Taking Opioids

BACKGROUND

Long-term use of opioids for treatment of chronic pain is associated with significant risks including worsening unrecognized or untreated sleep apnea that may increase morbidity and mortality. Overnight oximetry has been validated for predicting sleep apnea in surgical and sleep clinic patients. The objective of the study was to assess the predictive accuracy of oxygen desaturation index (ODI 4%) from home overnight oximetry when compared to apnea hypopnea index (AHI) from polysomnography for predicting sleep apnea in patients taking opioids for chronic pain.

METHODS

This was a planned post hoc analysis of a prospective cohort study conducted at 5 pain clinics. Patient characteristics and daily morphine milligram equivalent (MME) dose were recorded. All consented patients underwent home overnight oximetry (PULSOX-300i, Konica Minolta Sensing, Inc, Osaka, Japan) and in-laboratory polysomnography. The predictive performance of ODI 4% from oximetry was assessed against AHI from polysomnography.

RESULTS

Among 332 consented patients, 181 with polysomnography and overnight oximetry data were analyzed. The mean age and body mass index of 181 patients were 52 ± 13 years and 29 ± 6 kg/m2, respectively, with 40% men. The area under the receiver operating curve for ODI to predict moderate-to-severe sleep apnea (AHI ≥15 events/h) and severe sleep apnea (AHI ≥30 events/h) was 0.82 (95% confidence interval [CI], 0.75-0.88) and 0.87 (95% CI, 0.80-0.94). ODI ≥5 events/h had a sensitivity of 85% (95% CI, 74-92) and specificity of 57% (95% CI, 52-61) to predict moderate-to-severe sleep apnea. ODI ≥15 events/h had a sensitivity of 71% (95% CI, 55-83) and specificity of 88% (95% CI, 84-91) to predict severe sleep apnea.

CONCLUSIONS

Overnight home oximetry has a high predictive performance in predicting moderate-to-severe and severe sleep apnea in patients on opioids for chronic pain. It is a useful additional tool for health care providers for the screening of sleep apnea in this high-risk group.

Variations in funding for treatment of obstructive sleep apnoea in England

OBJECTIVES

This study aimed to review the funding policies of clinical commissioning groups for treatment of obstructive sleep apnoea in England.

METHODS

Published policies from a randomly selected sample of 60 out of 190 clinical commissioning groups were reviewed.

RESULTS

Continuous positive airway pressure was funded based on a clinical assessment or according to criteria that were in line with national guidelines in most clinical commissioning groups (49 of 60), with 11 clinical commissioning groups offering no policy. Mandibular advancement devices, tonsillectomy and nasal surgery were funded based on a clinical assessment or certain criteria in 16, 25 and 16 clinical commissioning groups, respectively. In contrast, only one clinical commissioning group provided funding for soft palate, tongue base or mandibular surgery. Hypoglossal nerve stimulation was not mentioned in any clinical commissioning group's policy.

CONCLUSION

Although most clinical commissioning groups provide funding for the use of continuous positive airway pressure, the availability of funding for other obstructive sleep apnoea treatment modalities is heterogeneous, leaving continuous positive airway pressure intolerant patients with limited therapeutic options in some regions.

Prevalence of Obstructive Sleep Apnea in Orthodontic Patients with Different Skeletal Classes Using STOP-BANG Questionnaire: An Observational Study

AIM: The aim of the study was to determine the prevalence of obstructive sleep apnea (OSA) in orthodontic adult patients with different skeletal classes and no pathology in the airway as detected from the lateral cephalometric radiographs using the STOP-BANG questionnaire. METHODS: The sample comprised 309 subjects (152 males and 157 females) collected from the Egyptian population presented to the orthodontic follicular unit extraction for treatment. The sample was divided into three groups based on the anteroposterior relationship between maxilla and mandible (ANB angle) as evident from pretreatment lateral cephalometric. Patients were asked to fill out general medical history, sign a consent form, and fill in the STOP-BANG questionnaire. Patient’s neck size and height were measured using tape measuring tool and weighing scale, respectively. Body mass index (BMI) was obtained. After submission of the questionnaire, scores were measured for each patient to evaluate the severity of OSA. RESULTS: Comparison between OSA risk in the three classes showed no statistically significant difference (p = 0.791, effect size = 0.052). CONCLUSIONS: STOP-BANG questionnaire showed that there was no statistically significant difference in the prevalence of OSA between different skeletal classes.

Impact of continuous positive airway pressure mode on adherence to treatment in obstructive sleep apnea patients awaiting bariatric surgery

Obstructive sleep apnea is prevalent in the bariatric population, and is associated with various complications. Despite increasing popularity, automatic positive airway pressure has not yet been studied in this population. The objective was to compare treatment adherence between automatic positive airway pressure and fixed positive airway pressure (continuous positive airway pressure) in obstructive sleep apnea patients awaiting bariatric surgery. This randomized controlled trial involved obese patients newly diagnosed with severe obstructive sleep apnea and awaiting bariatric surgery. The primary outcome was the difference in adherence between automatic positive airway pressure and continuous positive airway pressure pre-operatively. Secondary outcomes included positive airway pressure efficacy, adherence at 1 month, adverse effects, quality of life and peri-operative complications. Analyses were conducted using a modified intention-to-treat methodology. Fifty patients were randomized. Baseline characteristics and duration of positive airway pressure therapy were comparable between groups. At the time of surgery, the percentage of overall nights positive airway pressure used was 96.9% [95% confidence interval: 93.5-100] and 86.0% [95% confidence interval: 66.9-100] in the automatic positive airway pressure and continuous positive airway pressure groups, respectively (p = .047). Average use was 6.3 hr per night [95% confidence interval: 5.1-7.2] and 5.9 hr per night [95% confidence interval: 3.0-8.8], with a difference of 0.4 hr favouring automatic positive airway pressure (p = .75). Nightly use ≥ 4 hr per night was 86.4% and 74.0% in the automatic positive airway pressure and fixed continuous positive airway pressure groups, respectively (p = .22). There were no statistically significant differences regarding adherence at 1 month, efficacy parameters, adverse effects, quality of life and peri-operative complications. With no difference on the safety profile and efficiency parameters, treatment adherence is not improved with automatic positive airway pressure compared with fixed continuous positive airway pressure in obstructive sleep apnea patients awaiting bariatric surgery.

Surgical management of obstructive sleep apnoea: A position statement of the Australasian Sleep Association. Respirology 2020;25:1292-1308. [PMID: 33190389 PMCID: PMC7839593 DOI: 10.1111/resp.13967]

Surgery for adult obstructive sleep apnoea (OSA) plays a key role in contemporary management paradigms, most frequently as either a second‐line treatment or in a facilitatory capacity. This committee, comprising two sleep surgeons and three sleep physicians, was established to give clarity to that role and expand upon its appropriate use in Australasia. This position statement has been reviewed and approved by the Australasian Sleep Association (ASA) Clinical Committee.

Telehealth, Telemedicine, and Obstructive Sleep Apnea

Obstructive sleep apnea (OSA) telehealth management may improve initial and chronic care access, time to diagnosis and treatment, between-visit care, e-communications and e-education, workflows, costs, and therapy outcomes. OSA telehealth options may be used to replace or supplement none, some, or all steps in the evaluation, testing, treatments, and management of OSA. All telehealth steps must adhere to OSA guidelines. OSA telehealth may be adapted for continuous positive airway pressure (CPAP) and non-CPAP treatments. E-data collection enhances uses for individual and group analytics, phenotyping, testing and treatment selections, high-risk identification and targeted support, and comparative and multispecialty therapy studies.

Evaluating the feasibility of implementing a Telesleep pilot program using two-tiered external facilitation

BACKGROUND

Obstructive sleep apnea (OSA) can negatively impact patients' health status and outcomes. Positive airway pressure (PAP) reverses airway obstruction and may reduce the risk of adverse outcomes. Remote monitoring of PAP (as opposed to in-person visits) may improve access to sleep medicine services. This study aimed to evaluate the feasibility of implementing a clinical program that delivers treatment for OSA through PAP remote monitoring using external facilitation as an implementation strategy.

METHODS

Participants included patients with OSA at a Veteran Affairs Medical Center (VAMC). PAP adherence and clinical disease severity on treatment (measured by the apnea hypopnea index [AHI]) were the preliminary effectiveness outcomes across two delivery models: usual care (in-person) and Telehealth nurse-delivered remote monitoring. We also assessed visit duration and travel distance. A prospective, mixed-methods evaluation examined the two-tiered external facilitation implementation strategy.

RESULTS

The pilot project included N = 52 usual care patients and N = 38 Telehealth nurse-delivered remote monitoring patients. PAP adherence and disease severity were similar across the delivery modalities. However, remote monitoring visits were 50% shorter than in-person visits and saved a mean of 72 miles of travel (median = 45.6, SD = 59.0, mode = 17.8, range 5.4-220). A total of 62 interviews were conducted during implementation with a purposive sample of 12 clinical staff involved in program implementation. Weekly external facilitation delivered to both front-line staff and supervisory physicians was necessary to ensure patient enrollment and treatment. Synchronized, "two-tiered" facilitation at the executive and coordinator levels proved crucial to developing the clinical and administrative infrastructure to support a PAP remote monitoring program and to overcome implementation barriers.

CONCLUSIONS

Remote PAP monitoring had similar efficacy to in-person PAP services in this Veteran population. Although external facilitation is a widely-recognized implementation strategy in quality improvement projects, less is known about how multiple facilitators work together to help implement complex programs. Two-tiered facilitation offers a model well-suited to programs where innovations span disciplines, disrupt professional hierarchies (such as those between service chiefs, clinicians, and technicians) and bring together providers who do not know each other, yet must collaborate to improve access to care.

Educational, supportive and behavioural interventions to improve usage of continuous positive airway pressure machines in adults with obstructive sleep apnoea

BACKGROUND

Although highly effective in the treatment of obstructive sleep apnoea (OSA), continuous positive airway pressure (CPAP) is not universally accepted by users. Educational, supportive and behavioural interventions may help people with OSA initiate and maintain regular and continued use of CPAP.

OBJECTIVES

To assess the effectiveness of educational, supportive, behavioural, or mixed (combination of two or more intervention types) strategies that aim to encourage adults who have been prescribed CPAP to use their devices.

SEARCH METHODS

Searches were conducted on the Cochrane Airways Group Specialised Register of trials. Searches are current to 29 April 2019.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) that assessed intervention(s) designed to inform participants about CPAP/OSA, to support them in using CPAP, or to modify their behaviour to increase use of CPAP devices.

DATA COLLECTION AND ANALYSIS

We assessed studies to determine their suitability for inclusion in the review. Data were extracted independently and were entered into RevMan for analysis. 'Risk of bias' assessments were performed, using the updated 'Risk of bias 2' tool, for the primary outcome, CPAP usage. Study-level 'Risk of bias' assessments were performed using the original 'Risk of bias' tool. GRADE assessment was performed using GRADEpro.

MAIN RESULTS

Forty-one studies (9005 participants) are included in this review; 16 of these studies are newly identified with updated searches. Baseline Epworth Sleepiness Scale (ESS) scores indicate that most participants suffered from excessive daytime sleepiness. The majority of recruited participants had not used CPAP previously. When examining risk of bias for the primary outcome of hourly machine usage/night, 58.3% studies have high overall risk (24/41 studies), 39.0% have some concerns (16/41 studies), and 2.4% have low overall risk (1/41 studies). We are uncertain whether educational interventions improve device usage, as the certainty of evidence was assessed as very low. We were unable to perform meta-analyses for number of withdrawals and symptom scores due to high study heterogeneity. Supportive interventions probably increase device usage by 0.70 hours/night (95% confidence interval (CI) 0.36 to 1.05, N = 1426, 13 studies, moderate-certainty evidence), and low-certainty evidence indicates that the number of participants who used their devices ≥ 4 hours/night may increase from 601 to 717 per 1000 (odds ratio (OR), 1.68, 95% CI 1.08 to 2.60, N = 376, 2 studies). However, the number of withdrawals may also increase from 136 to 167 per 1000 (OR 1.27, 95% CI 0.97 to 1.66, N = 1702, 11 studies, low-certainty evidence). Participants may experience small improvements in symptoms (ESS score -0.32 points, 95% CI -1.19 to 0.56, N = 470, 5 studies, low-certainty evidence), and we are uncertain whether quality of life improves with supportive interventions, as the certainty of evidence was assessed as very low. When compared with usual care, behavioural interventions produce a clinically-meaningful increase in device usage by 1.31 hours/night (95% CI 0.95 to 1.66, N = 578, 8 studies, high-certainty evidence), probably increase the number of participants who used their machines ≥ 4 hours/night from 371 to 501 per 1000 (OR 1.70, 95% CI 1.20 to 2.41, N = 549, 6 studies, high-certainty evidence), and reduce the number of study withdrawals from 146 to 101 per 1000 (OR 0.66, 95% CI 0.44 to 0.98, N = 939, 10 studies, high-certainty evidence). Behavioural interventions may reduce symptoms (ESS score -2.42 points, 95% CI -4.27 to -0.57, N = 272, 5 studies, low-certainty evidence), but probably have no effect on quality of life (Functional Outcomes of Sleep Questionnaire (FOSQ), standardised mean difference (SMD) 0.00, 0.95% CI -0.26 to 0.26, N = 228, 3 studies, moderate-certainty evidence). We are uncertain whether behavioural interventions improve apnoea hypopnoea index (AHI), as the certainty of evidence was assessed as very low. We are uncertain if mixed interventions improve device usage, increase the number of participants using their machines ≥ 4 hours/night, reduce study withdrawals, improve quality of life, or reduce anxiety symptoms, as the certainty of evidence for these outcomes was assessed to be very low. Symptom scores via the ESS could not be measured due to considerable heterogeneity between studies.

AUTHORS' CONCLUSIONS

In CPAP-naïve people with OSA, high-certainty evidence indicates that behavioural interventions yield a clinically-significant increase in hourly device usage when compared with usual care. Moderate certainty evidence shows that supportive interventions increase usage modestly. Very low-certainty evidence shows that educational and mixed interventions may modestly increase CPAP usage. The impact of improved CPAP usage on daytime sleepiness, quality of life, and mood and anxiety scores remains unclear since these outcomes were not assessed in the majority of included studies. Studies addressing the choice of interventions that best match individual patient needs and therefore result in the most successful and cost-effective therapy are needed.

Effects of Wait Times on Treatment Adherence and Clinical Outcomes in Patients With Severe Sleep-Disordered Breathing: A Secondary Analysis of a Noninferiority Randomized Clinical Trial

IMPORTANCE

Sleep-disordered breathing (SDB) is common and associated with substantial adverse health consequences. Long wait times for SDB care are commonly reported; however, it is unclear whether wait times for care are associated with clinical outcomes.

OBJECTIVE

To evaluate the association of wait times for care with clinical outcomes for patients with severe SDB.

DESIGN, SETTING, AND PARTICIPANTS

This study is a secondary analysis of a randomized clinical noninferiority trial comparing management by alternative care practitioners (ACPs) with traditional sleep physician-led care between October 2014 and May 2017. The study took place at Foothills Medical Centre Sleep Centre, a tertiary care multidisciplinary sleep clinic at the University of Calgary. Patients with severe SDB (defined as a respiratory event index ≥30 events per hour during home sleep apnea testing, mean nocturnal oxygen saturation ≤85%, or suspected sleep hypoventilation syndrome) were recruited for the study. Patients were excluded if they were suspected of having a concomitant sleep disorder other than SDB or had previously been treated with positive airway pressure (PAP) therapy for SDB. Data were analyzed from October 2017 to January 2020.

MAIN OUTCOMES AND MEASURES

Outcomes were assessed 3 months after treatment initiation with adherence to PAP therapy as the primary outcome. Secondary outcomes included Epworth Sleepiness Scale score, health-related quality of life, and patient satisfaction measured using the Visit-Specific Satisfaction Instrument-9. Multiple regression models were used to assess the associations between wait times and each of the outcomes. t tests were used to compare wait times for patients who were adherent to PAP therapy (≥4 hours per night for 70% of nights) with those for nonadherent patients.

RESULTS

One hundred fifty-six patients (112 [71.8%] men; mean [SD] age, 56 [12] years) were included in the analysis. The mean time from referral to initial visit was 88 days (95% CI, 79 to 96 days), and the mean time to treatment was 123 days (95% CI, 112 to 133 days). Shorter wait time to treatment initiation was associated with adherence to PAP therapy (odds ratio, 0.99; 95% CI, 0.98 to 0.99; P = .04), greater improvement in Epworth Sleepiness Scale score (mean coefficient, -9.37; 95% CI, -18.51 to -0.24; P = .04), and higher Visit-Specific Satisfaction Instrument-9 score (mean coefficient, -0.024; 95% CI, -0.047 to -0.0015; P = .04) at 3 months. Compared with nonadherent patients, those who were adherent to treatment waited a mean of 15 fewer days (95% CI, 12 to 19 days) for initial assessment (P = .07) and 30 fewer days (95% CI, 23 to 35 days) for treatment initiation (P = .008).

CONCLUSIONS AND RELEVANCE

Earlier initiation of treatment for severe SDB was associated with better PAP adherence and greater improvements in daytime sleepiness and patient satisfaction. These findings suggest that system interventions to improve timely access may modify patient behavior and improve clinical outcomes.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02191085.

Point-of-Care Ultrasound for Obstructive Sleep Apnea Screening: Are We There Yet? A Systematic Review and Meta-analysis

BACKGROUND

Perioperative diagnosis of obstructive sleep apnea (OSA) has important resource implications as screening questionnaires are overly sensitive, and sleep studies are expensive and time-consuming. Ultrasound (US) is a portable, noninvasive tool potentially useful for airway evaluation and OSA screening in the perioperative period. The objective of this systematic review was to evaluate the correlation of surface US with OSA diagnosis and to determine whether a point-of-care ultrasound (PoCUS) for OSA screening may help with improved screening in perioperative period.

METHODS

A search of all electronic databases including Medline, Embase, and Cochrane Database of Systematic Reviews was conducted from database inception to September 2017. Inclusion criteria were observational cohort studies and randomized controlled trials of known or suspected OSA patients undergoing surface US assessment. Article screening, data extraction, and summarization were conducted by 2 independent reviewers with ability to resolve conflict with supervising authors. Diagnostic properties and association between US parameters (index test) and OSA diagnosis using sleep study (reference standard) were evaluated. The US parameters were divided into airway and nonairway parameters. A random-effects meta-analysis was planned, wherever applicable.

RESULTS

Of the initial 3865 screened articles, 21 studies (7 airway and 14 nonairway) evaluating 3339 patients were included. Majority of studies were conducted in the general population (49%), respirology (23%), and sleep clinics (12%). No study evaluated the use of US for OSA in perioperative setting. Majority of included studies had low risk of bias for reference standard and flow and timing. Airway US parameters having moderate-good correlation with moderate-severe OSA were distance between lingual arteries (DLAs > 30 mm; sensitivity, 0.67; specificity, 0.59; 1 study/66 patients); mean resting tongue thickness (>60 mm; sensitivity, 0.85; specificity, 0.59; 1 study/66 patients); tongue base thickness during Muller maneuver (MM; sensitivity, 0.59; specificity, 0.78; 1 study/66 patients); and a combination of neck circumference and retropalatal (RP) diameter shortening during MM (sensitivity, 1.0; specificity, 0.65; 1 study/104 patients). Nonairway US parameters having a low-moderate correlation with moderate-severe OSA were carotid intimal thickness (pooled correlation coefficient, 0.444; 95% confidence interval [CI], 0.320-0.553; P value = .000, 8 studies/727 patients) and plaque presence (sensitivity, 0.24-0.75; specificity, 0.13-1.0; 4 studies/1183 patients).

CONCLUSIONS

We found that a number of airway and nonairway parameters were identified with moderate to good correlation with OSA diagnosis in the general population. In future studies, it remains to be seen whether PoCUS screening for a combination of these parameters can address the pitfalls of OSA screening questionnaires.

Guidelines on the surgical management of sleep disorders: A systematic review

OBJECTIVE

To facilitate the development of U.K. guidelines for sleep surgery and to guide sleep surgeons to existing guidelines relevant to their practice, we provide a systematic review and quality assessment of all existing guidelines on the surgical management of sleep disorders.

METHODS

Systematic review using preferred reporting items for systematic reviews and meta-analyses (PRISMA) recommendations. Medline and Embase databases were searched from inception to April 2018. Publications were included if they described a guideline for the surgical management of sleep disorders. Three assessors used the Appraisal of Guidelines for Research and Evaluation II (AGREE II) instrument to evaluate included guidelines.

RESULTS

The systematic search revealed 1,161 publications. Twenty-two guidelines from eight countries were included. Fourteen focused on adults, five on children, and three on both. The guidelines discussed nasal, tonsillar, palatal, tongue, hyoid, maxillomandibular, tracheal, bariatric, and multilevel surgeries. The mean overall AGREE II quality score of included guidelines was 3.5 (range = 2 to 5.3; maximum possible score = 7).

CONCLUSION

This article provides a summary and quality assessment of all published guidelines on the surgical management of sleep disorders. No U.K. guidelines were identified, and existing guidelines have several shortcomings. This highlights the need for robust U.K. national guidelines on sleep surgery to promote clinical and cost-effective care in this field. Our findings can be used by stakeholders as a foundation for the development of new guidelines and can be used by sleep surgeons to direct them to existing guidelines relevant to their practice, promoting evidence-based clinical care. Laryngoscope, 130:1070-1084, 2020.

Distance to Specialist Medical Care and Diagnosis of Obstructive Sleep Apnea in Rural Saskatchewan

Obstructive sleep apnea (OSA) is the most common sleep-disordered breathing condition. Patients with OSA symptoms are often not diagnosed clinically, which is a concern, given the health and safety risks associated with unmanaged OSA. The availability of fewer practicing medical specialists combined with longer travel distances to access health care services results in barriers to diagnosis and treatment in rural communities. This study aimed to (1) determine whether the proportion of adults reporting OSA symptoms in the absence of a sleep apnea diagnosis in rural populations varied by travel distance to specialist medical care and (2) assess whether any distance-related patterns were attributable to differences in the frequency of diagnosis among adults who likely required this specialist medical care. We used a cross-sectional epidemiologic study design, augmented by analysis of follow-up survey data. Our study base included adults who completed a 2010 baseline questionnaire for the Saskatchewan Rural Health Study. Follow-up occurred until 2015. 6525 adults from 3731 households constituted our sample. Statistical models used log-binomial regression. Rural adults who reported the largest travel distances (≥250 km) to specialist medical care were 1.17 (95% CI: 1.07, 1.29) times more likely to report OSA symptoms in the absence of a sleep apnea diagnosis than those who reported the smallest (<100 km; referent) distances. However, the proportion of sleep apnea diagnoses was low and unaffected by reported travel distance among adults who likely required this specialist medical care. Our findings suggest factors other than travel distance may be contributing to the low sleep apnea diagnostic rate. This remains important as undiagnosed and untreated OSA has serious implications on the health of people and populations, but effective treatments are available. Health care access barriers to the diagnosis and treatment of OSA require evaluation to inform health care planning and delivery.

CPAP indication based on clinical data and oximetry for patients with suspicion of obstructive sleep apnea: A multicenter trial

BACKGROUND AND OBJECTIVE

The usefulness of pulse oximetry for the management of obstructive sleep apnea is controversial. The aim of this study was to assess the accuracy for indication of Continuous Positive Airway Pressure (CPAP) treatment in patients with suspected obstructive sleep apnea (OSA) based on clinical and oximetry data as compared to polysomnography (PSG).

METHODS

This multicenter observational study involved seven sleep laboratories. Patients with suspicion of OSA who completed a standardized sleep questionnaire and a diagnostic PSG were enrolled. Eight observers logged on to a website independently and blindly. Seven observers only accessed the clinical data, curve and pulse oximetry results (Os-SO2-test method), while the eighth observer had full access to all indicators of PSG (O-PSG-reference method). Once observers assessed the information available on the website, they had to choose between three CPAP treatment options (yes/no/do not know) based on their knowledge and criteria.

RESULTS

411 subjects (228 men), median age 54 years, were available for evaluation. Os-SO2 had lower sensitivity (S), greater specificity (Sp) and positive likelihood ratio (PLR) to prescribe CPAP in patients more symptomatic (Epworth Sleepiness Scale-ESS > 10 or comorbidities) than those with fewer symptoms (ESS < 11 without comorbidities) (S 45-75% versus 45-91%, p 0.028); Sp 93.8-100% versus 68.5-96.6%, p 0.004; PLR > 10 versus 2.9-17, p<0.01).

CONCLUSIONS

Due to its low false positive rate, a strategy based on pulse oximetry and clinical data was a consistent tool to indicate CPAP treatment in most symptomatic patients with a suspicion of OSA.

International consensus (ICON) on the ENT role in diagnosis of obstructive sleep apnea syndrome

During the 2017 IFOS ENT World Congress, an international expert panel was asked to clarify the role of ENT in the diagnosis process of the obstructive sleep apnea syndrome (OSA) in adults around the world. OSA is a major public health issue throughout the world. OSA is a highly prevalent disease with heavy clinical, social and economical outcomes. This high prevalence raises serious difficulties of diagnosis accessibility if only somnologists are able to confirm OSA diagnosis. First of all, the panellists reviewed the impact of OSA. Secondly, they defined the ENT role stressing ENT legitimacy, professional expertise and academic and institutional tasks. They also defined when somnologists were necessary. For the international panel, the ENT is a major player in the OSA diagnosis process.

Defining the Core Components of a Clinical Review of People Using Continuous Positive Airway Pressure Therapy to Treat Obstructive Sleep Apnea: An International e-Delphi Study

STUDY OBJECTIVES

Guidelines recommend regular review of individuals using continuous positive airway pressure (CPAP) to treat obstructive sleep apnea but do not agree on the core components and frequency. We aimed to achieve consensus on essential components and frequency of review.

METHODS

We used an e-Delphi approach, recruiting a multidisciplinary international expert panel to identify components based on a list compiled from guidelines and to score these on a scale 1 to 5 over three rounds. Consensus was defined as ≥ 75% agreement for scores of 4 or higher. Free-text comments were thematically analyzed.

RESULTS

Forty participants completed 3 rounds scoring 36 potential components. Seventeen components achieved consensus: treatment acceptability, sleep quality, symptom resolution (including reduction in apnea-hypopnea index), assessment of sleepiness (including when driving), technical CPAP issues (mask fit/humidification/cleaning/filters), recording CPAP adherence, and quality of life. Participants suggested 12 to 18 monthly reviews (more frequent when commencing CPAP) or "on demand." Free-text comments highlighted that reviews should be multidisciplinary, flexible (including telehealth), and focus on symptom control.

CONCLUSIONS

We mapped 17 prioritized components to a suggested template that may support clinical reviews. Reviews should be flexible, frequently in the early stages of commencing CPAP, shifting to "on demand" and/or remote follow-up for maintenance. Our findings may inform future guideline recommendations for reviewing CPAP users.

Obstructive sleep apnoea-hypopnoea and arrhythmias: new updates

AIMS

Obstructive sleep apnoea-hypopnoea (OSAH) is a prevalent condition characterized by repetitive pharyngeal collapse during sleep, leading to hypoxemia, hypercapnia, and persistent inspiratory efforts against an occluded airway until arousal. Several studies demonstrated that OSAH exerts acute and chronic effects on the cardiovascular system. Thus, although being a respiratory problem, the most important consequences of OSAH are cardiovascular, among which there are arrhythmias. The purpose of this review is to systematically analyse what has been recently published about the relationship between OSAH and every cardiac arrhythmia separately.

METHODS

We searched Pubmed, Scopus, Web of Science and Cochrane Collaboration databases for 'OSAHS arrhythmias', 'OSAH arrhythmias' and 'OSA arrhythmias'. We analyse 1298 articles and meta-analyses, excluding already edited reviews.

RESULTS

Arrhythmias, especially of ventricular origin, are frequent in OSAH. Ventricular premature beats, couplets and ventricular tachycardia runs are even more frequent in patients suffering from heart failure. They may be due to left heart remodelling, overwork and ischaemia and can explain at least some sudden deaths occurring between midnight and 6 a.m. Sinus pauses and atrioventricular blocks are increased according to the severity of the disturbance and may be reduced by continuous positive airway pressure therapy, preventing pace-maker implantation. Finally, atrial fibrillation, resistance against antiarrhythmic drugs and recurrences after surgical procedures are strongly related to OSAH.

CONCLUSION

Arrhythmias are frequent in OSAH. Treatment of OSAH may reduce some of them. An implantable cardioverter-defibrillator and continuous positive airway pressure should be considered in some patients.

Interpretation of sleep studies for patients with sleep-disordered breathing: What the anesthesiologist needs to know

There is increased interest in the perioperative management of patients with sleep-disordered breathing (SDB). Anesthesiologists must distill information from clinical reports to make key decisions for optimizing perioperative care. A patient with SDB may present with a sleep study report at the time of surgery. Knowledge of the essential components of such a report can help the anesthesiologist evaluate the patient and optimize the perioperative management. In this narrative review, we describe how level I (i.e., laboratory-based) polysomnography (PSG) data are collected and scored using the recommended scoring guidelines, as well as the basic information and salient features of a typical PSG report relevant to the anesthesiologist. In addition, we briefly review the indications for sleep studies, including the types of laboratory-based studies, as well as the role and limitations of portable monitors (level II-IV studies) and examples of PSG reports in the clinical context.

Prevalence of sleep apnea and cardiovascular risk factors in patients with hypertension in a day hospital model

INTRODUCTION

To identify patients at risk for obstructive sleep apnea (OSA) syndrome at a specialized hypertension center, we administered questionnaires and used respiratory polygraphy (RP).

RESULTS

We studied 168 patients (64.8% men and 35.2% women). Patients' body mass index (BMI) was 34.7 ± 6.79 and Epworth Sleepiness Scale (ESS) scores were 8.01 for male and 8.92 for women (p = 0.69). RP recordings revealed AHI (Apnea-Hypopnea Index) of 18.03 ± 15.7, an ODI (Oxygen Desaturation Index) of 18.6 ± 15.2, and a time oxygen saturation <90% (%) of 20.8 ± 24.3. Around 44% of patients had an AHI of >15 events/h, and continuous positive airway pressure (CPAP) was recommended to 69 patients (41.07%). Pulse wave velocity (PWV) showed high values in AHI > 15/h (p = 0.050), and carotid intima-media thickness (IMT) did not correlate with AHI > 15; right IMT: 0.83 ± 1.3 versus 0.78 ± 0.13 mm (p = 0.41) and 0.82 ± 0.16 versus 0.78 ± 0.19 mm (p = 0.40). However, we find correlation with carotid plaque (p = 0.046). The ACC/AHA calculator revealed a gradual increase in the risk of cardiovascular events: 8.7% with AHI < 5/h, and 30.3% in severe OSA.

CONCLUSIONS

In hypertension (HT) patients, RP revealed a high prevalence of OSA associated with carotid artery disease, high PWV, and increased cardiovascular risk.

Repercusiones cardiovasculares del síndrome de apnea-hipopnea obstructiva del sueño (SAHOS)

En la población de sujetos con síndrome de apnea-hipopnea obstructiva del sueño se describen entidades clínicas cardiovasculares asociadas con esta entidad y que afectan su curso y pronóstico. Dentro de estas se encuentran hipertensión arterial, arritmias, enfermedad coronaria, insuficiencia cardíaca, hipertensión pulmonar y tromboembolismo venoso. Del mismo modo, se describen los mecanismos fisiopatológicos de estas asociaciones, su prevalencia e impacto. Dado que afectan el curso de la enfermedad y, por tanto, la severidad de la misma, estas entidades juegan un papel muy importante en la toma de decisiones al momento de ofrecer el mejor manejo en cada caso, el cual debe ser abordado de forma multidisciplinaria.

Investigating Cost Implications of Incorporating Level III At-Home Testing into a Polysomnography Based Sleep Medicine Program Using Administrative Data

Objective

Obstructive sleep apnea is a common problem, requiring expensive in-lab polysomnography for proper diagnosis. Home monitoring can provide an alternative to in-lab testing for a subset of OSA patients. The objective of this project was to investigate the effect of incorporating home testing into an OSA program at a large, tertiary sleep disorders centre.

Methods

The Sleep Disorders Centre in Saskatoon, Canada, has been incorporating at-home testing into their diagnostic pathways since 2006. Administrative data from 2007 to 2013 were extracted (10030 patients) and the flow of patients through the program was followed from diagnosis to treatment. Costs were estimated using 2014 pricing and were stratified by disease attributes and sensitivity analysis was applied.

Results

The overall costs per patient were $627.40, with $419.20 for at-home testing and $746.20 for in-lab testing. The cost of home management would rise to $515 if all negative tests were required to be confirmed by an in-lab PSG.

Discussion

Our review suggests that at-home testing can be cost-effective alternative to in-lab testing when applied to the correct population, specifically, those with a high pretest probability of obstructive sleep apnea and an absence of significant comorbidities.

Evaluation of an alternative care provider clinic for severe sleep-disordered breathing: a study protocol for a randomised controlled trial

INTRODUCTION

Despite the high prevalence of sleep-disordered breathing (SDB) and the significant health consequences associated with untreated disease, access to diagnosis and treatment remains a challenge. Even patients with severe SDB (severe obstructive sleep apnoea or hypoventilation), who are at particularly high risk of adverse health effects, are subject to long delays. Previous research has demonstrated that, within a sleep clinic, management by alternative care providers (ACPs) is effective for patients with milder forms of SDB. The purpose of this study is to compare an ACP-led clinic (ACP Clinic) for patients with severe SDB to physician-led care, from the perspective of clinical outcomes, health system efficiency and cost.

METHODS AND ANALYSIS

The study is a randomised, controlled, non-inferiority study in which patients who are referred with severe SDB are randomised to management by a sleep physician or by an ACP. ACPs will be supervised by sleep physicians for safety. The primary outcome is positive airway pressure (PAP) adherence after 3 months of therapy. Secondary outcomes include: long-term PAP adherence; clinical response to therapy; health-related quality of life; patient satisfaction; healthcare usage; wait times from referral to treatment initiation and cost-effectiveness. The economic analysis will be performed using the perspective of a publicly funded healthcare system.

ETHICS AND DISSEMINATION

Ethics approval was obtained from the Conjoint Health Research Ethics Board (ID: REB13-1280) at the University of Calgary. Results from this study will be disseminated through presentations at scientific conferences and publication in peer-reviewed journals.

TRIAL REGISTRATION NUMBER

NCT02191085; Pre-results.