Assessment and treatment of obstructive sleep-disordered breathing

Resting-state fMRI network efficiency as a mediator in the relationship between the glymphatic system and cognitive function in obstructive sleep apnea hypopnea syndrome: Insights from a DTI-ALPS investigation

INTRODUCTION

Obstructive sleep apnea hypopnea syndrome (OSAHS) is associated with cognitive impairment and physiological complications, necessitating further understanding of its mechanisms. This study investigates the relationship between glymphatic system function, brain network efficiency, and cognitive impairment in OSAHS patients using diffusion tensor image analysis along the perivascular space (DTI-ALPS) and resting-state fMRI.

MATERIALS AND METHODS

This study included 31 OSAHS patients and 34 age- and gender-matched healthy controls (HC). All participants underwent GE 3.0T magnetic resonance imaging (MRI) with diffusion tensor image (DTI) and resting-state fMRI scans. The DTI-ALPS index and brain functional networks were assessed. Differences between groups and correlations with clinical characteristics were analyzed. Additionally, the mediating role of brain network efficiency was explored. Finally, receiver operating characteristics (ROC) analysis assessed diagnostic performance.

RESULTS

OSAHS patients had significantly lower ALPS-index (1.268 vs. 1.431, p < 0.0001) and moderate negative correlation with Apnea Hypopnea Index (AHI) (r = -0.389, p = 0.031), as well as moderate positive correlation with Montreal Cognitive Assessment (MoCA) (r = 0.525, p = 0.002). Moreover, global efficiency (Eg) of the brain network was positively correlated with the ALPS-index and MoCA scores in OSAHS patients (r = 0.405, p = 0.024; r = 0.56, p = 0.001, respectively). Furthermore, mediation analysis showed that global efficiency partially mediated the impact of glymphatic system dysfunction on cognitive impairment in OSAHS patients (indirect effect = 4.58, mediation effect = 26.9 %). The AUROC for identifying OSAHS and HC was 0.80 (95 % CI 0.69 to 0.91) using an ALPS-index cut-off of 1.35.

CONCLUSIONS

OSAHS patients exhibit decreased ALPS-index, indicating impaired glymphatic system function. Dysfunction of the glymphatic system can affect cognitive function in OSAHS by disrupting brain functional network, suggesting a potential underlying pathological mechanism. Additionally, preliminary findings suggest that the ALPS-index may offer promise as a potential indicator for OSAHS.

Sleep-disordered breathing on respiratory polygraphy in neonates with spina bifida

INTRODUCTION

Studies have shown a high prevalence of sleep-disordered breathing (SDB) in children with spina bifida. International standards for regular testing for SDB in this population are lacking. While there are studies investigating the prevalence of SDB in children with spina bifida, there are close to no studies in neonates.

AIM AND OBJECTIVE

To evaluate if routine respiratory polygraphy (RPG) testing is indicated for neonates with spina bifida and if yes, with what therapeutic consequence.

METHODS

We conducted a retrospective cohort study of all neonates with spina bifida at the University (Children's) Hospital Zurich after fetal spina bifida repair born between 2017 and 2022, who had undergone at least 1 RPG evaluation during hospitalization on the neonatal ward. RPG were evaluated by a blinded group of experienced pediatric pulmonologists. Based on the neonatal RPG results and pediatric pulmonologist's recommendation for caffeine therapy the spina bifida cohort was divided into two groups. Neonatal baseline RPG and follow-up RPG at the age of the 3 months were evaluated.

RESULTS

48 neonates with RPG were included. Compared to the standard values in healthy neonates, the RPG results of this spina bifida cohort showed findings of SDB with central apnea and hypopnea. 22 (45.8%) neonatal RPG evaluations detected central SDB, prompting caffeine therapy. Follow-up RPG conducted after 3 months showed significant improvement of SDB with (almost) no need for continuation of caffeine.

CONCLUSION

We recommend the implementation of routine RPG testing in neonates with spina bifida to detect SDB and facilitate early targeted treatment.

Obstructive sleep apnea affects the psychological and behavioural development of children-a case-control study

This study aims to investigate the effects of obstructive sleep apnea on paediatric psychological and behavioural abnormalities. A total of 1086 paediatric patients with obstructive sleep apnea and 728 sample snoring controls were enrolled in the study. Patients with obstructive sleep apnea underwent bilateral tonsillectomy plus adenoidectomy or adenoidectomy alone. Repeated Autism Behaviour Checklist, Spence Children's Anxiety Scale, and Children's Depression Inventory were performed to assess the autism symptoms, anxiety level and depressive symptoms before and after surgery. The score of Autism Behaviour Checklist in preschool children with obstructive sleep apnea was higher than that in control. In school children with obstructive sleep apnea, the score of Spence Children's Anxiety Scale was also higher. School children with obstructive sleep apnea with depressive symptoms were significantly higher than that in control. The scores of Autism Behaviour Checklist, Spence Children's Anxiety Scale, and Children's Depression Inventory in the obstructive sleep apnea group after surgery were significantly lower than that before surgery. Our study showed that the score of Spence Children's Anxiety Scale and Children's Depression Inventory had a close correlation with the illness course and hypoxia duration. The Spence Children's Anxiety Scale and Children's Depression Inventory scores are also closely associated with the Autism Behaviour Checklist score. These results suggest that obstructive sleep apnea may have a significant impact on autism symptoms, anxiety levels and depressive symptoms in children. We found that the longer the duration of the obstructive sleep apnea course and hypoxia, the greater the impact on anxiety level and depressive symptoms. The suspected autism symptoms, anxiety level and depressive symptoms in children with obstructive sleep apnea were also significantly correlated. Thus, early detection and timely treatment may often reverse the psychological and behavioural abnormalities caused by obstructive sleep apnea.

Translation and validation of the Arabic version of the sleep-related breathing disorder scale of the pediatric sleep questionnaire (PSQ-SRBD)

BACKGROUND/OBJECTIVES

The incidence of sleep-related breathing disorders is underestimated because polysomnography is required to confirm its diagnosis. The pediatric sleep questionnaire-sleep-related breathing disorder (PSQ-SRBD) scale is a self-reported questionnaire completed by a patient's guardian. There is no validated Arabic version of the PSQ-SRBD that can be used in the Arabic-speaking population. Therefore, we aimed to translate, validate, and culturally adapt the PSQ-SRBD scale. We also aimed to evaluate its psychometric properties for the diagnosis of obstructive sleep apnea (OSA).

METHODS

The cross-cultural adaptation method consisted of the following steps: forward-backward translation, appraisal of a sample of 72 children (aged between 2 and 16 years) by an expert group, and performing Cronbach's alpha coefficient testing, Spearman's rank correlation coefficient testing, Wilcoxon signed-rank testing, and sign testing. The reliability of the Arabic version of the PSQ-SRBD scale was assessed using a test-retest comparison, and a factor analysis of the items was used to verify construct validity. For statistical purposes, p-values <0.05 were considered to indicate significance.

RESULTS

All subscales had adequate internal consistency: 0.799 for snoring and breathing, 0.69 for sleepiness, 0.711 for behavioral problems, and 0.805 for the entire questionnaire. Comparing questionnaire responses administered 2 weeks apart revealed no statistically significant difference in total scores between the two groups (p-values >0.05 by Spearman's rank correlation coefficient test for all domains) and also no statistical difference among 20 out of 22 questions independently (p-value >0.05 by sign test). A factor analysis conducted to assess the structure of the Arabic-SRBD scale revealed good correlational patterns. The mean score before surgery was 0.464 ± 0.166, and this changed to 0.185 ± 0.142 after surgery with a reduction of 0.278 ± 0.184 which was statistically significant (p < 0.001).

CONCLUSION

The Arabic version of the PSQ-SRBD scale is a valid tool for the assessment of pediatric OSA patients and can be used to follow-up patients after surgery. Future research will determine this translated questionnaire's applicability.

Preliminary study on brain resting-state networks and cognitive impairments of patients with obstructive sleep apnea-hypopnea syndrome

BACKGROUND

To investigate functional changes in brain resting-state networks (RSNs) in patients with obstructive sleep apnea-hypopnea syndrome (OSAHS) and their correlations with sleep breathing disorders and neurocognitive performance.

METHODS

In this study, 18 OSAHS patients and 18 matched healthy controls underwent neurocognitive assessment and magnetic resonance imaging (MRI). Group-level independent component analysis (ICA) and statistical analyses were used to explore between-group differences in RSNs and the relationship between functional changes in RSNs, sleep breathing disorders and neurocognitive performance.

RESULTS

The OSAHS patients performed worse on neuropsychological tests than the healthy controls. Eight RSNs were identified, and between-group analyses showed that OSAHS patients displayed significantly decreased functional connectivity in the bilateral posterior cingulate gyri (PCC) within the default mode network (DMN), the right middle frontal gyrus (MFG) within the dorsal attention network (DAN), and the left superior temporal gyrus (STG) within the ventral attention network (VAN), and increased functional connectivity in the right superior frontal gyrus (SFG) within the salience network (SN). Further correlation analyses revealed that the average ICA z-scores in the bilateral PCC were correlated with sleep breathing disorders.

CONCLUSIONS

Our findings demonstrate that the DMN, SN, DAN, and VAN are impaired during the resting state and are associated with decreased functionally distinct aspects of cognition in patients with OSAHS. Moreover, the intermittent hypoxia and sleep fragmentation caused by OSAHS are likely to be the main influencing factors.

Saliva Analysis of pH and Antioxidant Capacity in Adult Obstructive Sleep Apnea Patients

BACKGROUND

Obstructive sleep apnea syndrome (OSAS) may be associated with and activates the stress response system, and variation in the physiological antioxidant capacity of body fluids. Our aim was to evaluate the variation of pH and antioxidant capacity on the saliva of obstructive sleep apnea subjects (OG) compared to a control group (CG).

METHOD

Fifty subjects with moderate/severe OSAS were recruited in Tor Vergata Hospital and compared with 20 healthy subjects CG. The buffer and the antioxidant capacity of the samples were quantified measuring the pH and the percentage of total salivary antioxidant capacity (%TAC), which refers to the reduced glutathione salivary concentration (GSH). Moreover, the protein concentration and the gelatinolytic activity of metalloproteinases were quantified.

RESULTS

The data showed that the pH value is slightly more alkaline in OSAS subjects; however, it is not directly related to the severity of OSAS. The %TAC was found to be significantly reduced by 86.2% in the OG. Proteins of saliva from the OG were found 1.5 times more concentrated than in the healthy sample. The gelatinolytic activity of metalloproteinases of healthy and OSA did not show statistically significant changes.

CONCLUSIONS

The salivary samples from OSAS compared to CG show an alteration of the oxidative state, the pH buffering power, and protein concentrations, inducing conditions that can easily evolve chronic gingivitis. Further investigations are necessary to evaluate the feasibility of using salivary fluid for the early diagnosis of oral or systemic problems in OSAS subjects.

Sleep-disordered breathing in patients with Chiari malformation type II: a case-control study and review of the literature

STUDY OBJECTIVES

The main aim was to evaluate the prevalence of sleep-disordered breathing (SDB) in patients with Chiari II malformation (CM-II). The secondary objectives were to evaluate the association between SDB, morphological abnormalities, and neurological symptoms and to review the literature on patients with SDB and CM-II.

METHODS

The study has a cross-sectional, case-control design. Patients with CM-II (patients) were compared to control patients referred for clinical polysomnography in the Sleep Medicine Unit, matched for age and sex. All patients underwent brain and spinal cord magnetic resonance imaging, and polysomnography was conducted for all participants. A review of the literature about SDB in patients with CM-II was performed.

RESULTS

Forty patients were included (20 patients vs 20 control patients). SDB was identified in 45% of patients, a significantly higher prevalence compared to control patients. Three patients presented with purely obstructive SDB, 3 patients with purely central SDB, and 3 patients with both obstructive and central SDB. Compared with control patients, patients with CM-II showed a higher oxygen desaturation index (median: CM-II, 3.7; interquartile range, 1.6-19.5; control patients: 1.1; interquartile range, 0.3-3.2) and obstructive apnea-hypopnea index (median: CM-II, 1.5; interquartile range, 0.5-5.1; control patients, 0.1; interquartile range, 0.0-0.7). A logistic regression showed that the risk of developing SDB in patients affected by CM-II was 14.7 times higher than in the control population.

CONCLUSIONS

Our study and literature review showed a high prevalence of SDB in patients with CM-II. These patients are often asymptomatic at diagnosis, suggesting that PSG should be routinely provided in this population.

CITATION

Lazzareschi I, Curatola A, Massimi L, et al. Sleep-disordered breathing in patients with Chiari malformation type II: a case-control study and review of the literature. J Clin Sleep Med. 2022;18(9):2143-2154.

Disease characteristics and neuropathological changes associated with cognitive dysfunction in obstructive sleep apnea

Obstructive sleep apnea (OSA) is a common sleep-disordered breathing disease that often leads to many comorbidities (e.g., cognitive dysfunction), which adversely affect the quality of life for patients with OSA. Thus far, the underlying mechanisms of this dysfunction remain unclear. Many studies have focused on OSA-related characteristics, including intermittent hypoxemia and sleep fragmentation. There is increasing emphasis on neuroimaging studies to explore underlying relationships between neuropathological changes and cognitive dysfunction. This article reviews recent research progress concerning cognitive dysfunction associated with OSA to reveal potential mechanisms that contribute to this dysfunction.

Efficacy of a Pediatric Sleep Questionnaire for the Diagnosis of Obstructive Sleep Apnea in Children

BACKGROUND

Obstructive sleep apnea (OSA) is a source of significant morbidity in children. Polysomnography (PSG), the gold standard diagnostic tool for OSA, is often unavailable due to patient financial and geographic constraints. Our objective is to analyze the relationship between a patient's subjective complaints and the results from their PSG to determine the diagnostic value of the Pediatric Sleep Questionnaire (PSQ) for detecting OSA in children.

METHODS

A retrospective chart review was conducted for pediatric patients with suspected OSA from March 2012 to January 2014. Preoperative PSQ scores were compared with the results from PSG in the form of Apnea-Hypopnea Index (AHI) and Respiratory Disturbance Index (RDI) values. AHI and RDI values ranging from 1 to 5 were classified as mild OSA while values ranging from 5 to 10 were classified as moderate OSA.

RESULTS

A total of 161 patients were recruited for this study with 63 patients (39%) both completing the PSQ and undergoing PSG. Sensitivity of the positive questionnaire was higher in patients with AHI and RDI values indicative of moderate OSA (95% and 100% respectively) versus values indicative of mild OSA (83% and 86% respectively). Conversely, the positive predictive value of the positive questionnaire (n=49) was lower in patients with AHI and RDI values indicative of moderate OSA (39% and 46% respectively) versus values indicative of mild OSA (70% and 80% respectively).

CONCLUSION

The PSQ has high diagnostic value for screening patients with suspected OSA. We recommend the use of the PSQ in the primary care setting for children with suspected OSA.

Outcomes of Adenotonsillectomy for Obstructive Sleep Apnea in Prader-Willi Syndrome: Systematic Review and Meta-analysis

OBJECTIVES

Prader-Willi syndrome (PWS) increases the risk of obstructive sleep apnea (OSA) due to obesity, hypotonia, and abnormal ventilatory responses. We evaluated post-adenotonsillectomy complications, polysomnography changes, and quality of life in children with OSA and PWS.

STUDY DESIGN

Systematic review and meta-analysis.

METHODS

We conducted a systematic review and meta-analysis by searching PubMed, Embase, Cochrane, Web of Science, and Scopus. Two researchers independently reviewed studies about adenotonsillectomy for OSA in patients <21 years with PWS. We extracted study design, patient numbers, age, complications, polysomnography, and quality of life. We pooled postoperative changes in apnea hypopnea index (AHI) for meta-analysis. We applied Methodological Index for Nonrandomized Studies (MINORS) criteria to assess study quality.

RESULTS

The initial search yielded 169 studies. We included 68 patients from eight studies with moderate to high risk of bias. Six studies reported on complications and 12 of 51 patients (24%) had at least one. Velopharyngeal insufficiency was the most commonly reported complication (7/51, 14%). We included seven studies in meta-analysis. Mean postoperative improvement in AHI was 7.7 (95% CI: 4.9-10.5). Postoperatively 20% (95% CI: 3%-43%) had resolution of OSA with AHI < 1.5 while 67% (95% CI: 50%-82%) had improvement from severe/moderate OSA to mild/resolved (AHI < 5). Two studies evaluated quality of life and demonstrated improvement.

CONCLUSIONS

Children with PWS undergoing adenotonsillectomy for OSA have a substantial risk of postoperative complications that may require additional interventions, especially velopharyngeal insufficiency. Despite improvements in polysomnography and quality of life, many patients had residual OSA. This information can be used to counsel families when considering OSA treatment options. Laryngoscope, 131:898-906, 2021.

Associations Between Morning Salivary and Blood Cortisol Concentrations in Individuals With Obstructive Sleep Apnea Syndrome: A Meta-Analysis

BACKGROUND

Obstructive sleep apnea syndrome (OSAS) may be associated with an increase in hypothalamic-pituitary-adrenocortical axis activity (HPA AA). We reviewed research comparing morning salivary and blood (serum and plasma) cortisol concentrations of individuals with OSAS to those of healthy controls.

METHODS

We made a systematic search without any restrictions of the PubMed/Medline, Scopus, Cochrane Library, and Web of Science databases for relevant articles published up to August 25, 2019.

RESULTS

Sixteen studies were analyzed in this meta-analysis; five studies compared morning salivary concentrations, five compared serum concentrations, four compared plasma cortisol concentrations, and two compared both salivary and plasma concentrations. In pediatric samples, compared to healthy controls, those with OSAS had significantly lower saliva morning cortisol concentrations (MD = -0.13 µg/dl; 95% CI: 0.21, -0.04; P = 0.003). In contrast, no significant differences were observed for serum cortisol concentrations, plasma cortisol concentrations, or salivary morning cortisol concentrations between adults with and without OSAS (p = 0.61, p = 0.17, p = 0.17).

CONCLUSION

Cortisol concentrations did not differ between adults with OSAS and healthy controls. In contrast, morning salivary cortisol concentrations were lower in children with OSAS, compared to healthy controls. Given that a reduced HPA AA is observed among individuals with chronic stress, it is conceivable that children with OSAS are experiencing chronic psychophysiological stress.

Upper airway visualization in pediatric obstructive sleep apnea

Pediatric Obstructive Sleep Apnea (OSA) is a condition that may lead to a variety of comorbidities in adolescence and adulthood. The gold standard of diagnosing OSA is polysomnography (PSG). Over the past fifteen years numerous publications have explored how to better visualize the upper airway to further assess OSA in the pediatric population, and eventually institute personalized treatment. Lateral neck radiograph, cephalometry, computed axial tomography, and magnetic resonance imaging are all unique imaging techniques that are used in the diagnosis of OSA. Drug Induced Sleep Endoscopy is a direct visualization technique that is gathering momentum in pediatrics. Each approach has respective benefits and weaknesses. However, none of them at this time can replace PSG. They are a helpful supplement in those patients with complicated upper airway anatomy and in those with residual OSA.

Adenoidectomy in Children: What Is the Evidence and What Is its Role?

Purpose of Review

Review the current state of the adenoidectomy procedure in the pediatric population with up-to-date indications for surgery, operative techniques, adverse events, non-surgical management of adenoid hypertrophy, and future directions.

Recent Findings

Adenoidectomy is indicated in children for the treatment of sleep-disordered breathing, nasal airway obstruction, recurrent acute otitis media, and chronic rhinosinusitis. A new recommendation was released in 2016, not supporting adenoidectomy for a primary indication of otitis media in children under 4 years old, including those with prior tympanostomy tubes, unless a distinct indication exists such as nasal obstruction or chronic adenoiditis. Although adenotonsillectomy is the mainstay of treatment for obstructive sleep apnea (OSA), recent studies have identified that non-obese patients with moderate OSA and small tonsils have comparable benefits with adenoidectomy alone with less complications. While conventional approaches such as indirect mirror-assisted curette and suction coagulation are still utilized, direct transnasal endoscope-assisted removal of the adenoids has proven to be a safe technique, with good short- and long-term outcomes. Novel non-surgical therapies including immunotherapy have been evaluated.

Summary

Adenoidectomy is a safe procedure in the pediatric population and leads to excellent outcomes. Adverse events are rare, and hospitalization is uncommon. Children with sleep disturbance from nasal airway obstruction, ear disease, or chronic rhinosinusitis are the best operative candidates for this procedure.

The Efficacy of Adenotonsillectomy for Obstructive Sleep Apnea in Children with Down Syndrome: A Systematic Review

Objective

Determine the efficacy of adenotonsillectomy in children with Down syndrome.

Data Sources

Databases included PubMed, EMBASE, CINAHL, and Google Scholar. The search was inclusive of all references available through January 5, 2017.

Review Methods

A systematic review of the medical literature addressing adenotonsillectomy in treating obstructive sleep apnea in children with Down syndrome was performed following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses. Data were pooled using a random-effects model where possible. The quality of studies was graded using the Methodological Index for Nonrandomized Studies criteria.

Results

Of the 957 articles screened, 5 met inclusion for the qualitative analysis and 3 met criteria for the quantitative analysis. The findings of the qualitative analysis were that adenotonsillectomy has a positive effect on children with Down syndrome but in many cases is noncurative, up to 75% need postoperative breathing support, there is a high rate of immediate postoperative airway needs, and there is no change in sleep efficiency or architecture. The articles consistently reported moderate success in improving polysomnographic parameters, and limited pooling of the data demonstrated a mean decrease of the apnea-hypopnea index by 51% (95% confidence interval [CI], 46%-55%).

Conclusion

A 51% reduction in the preoperative apnea-hypopnea index can be expected with the intervention of adenotonsillectomy alone in children with Down syndrome. This information is useful for counseling and managing patient and family expectations. It also serves as a reminder to clinicians to obtain a postoperative sleep study, as many of these patients will need nighttime airway support or secondary sleep surgery.

Sleep-disordered breathing in patients with myelomeningocele

OBJECT A paucity of literature examines sleep apnea in patients with myelomeningocele, Chiari malformation Type II (CM-II), and related hydrocephalus. Even less is known about the effect of hydrocephalus treatment or CM-II decompression on sleep hygiene. This study is an exploratory analysis of sleep-disordered breathing in patients with myelomeningocele and the effects of neurosurgical treatments, in particular CM-II decompression and hydrocephalus management, on sleep organization. METHODS The authors performed a retrospective review of all patients seen in their multidisciplinary spina bifida clinic (approximately 435 patients with myelomeningocele) to evaluate polysomnographs obtained between March 1999 and July 2013. They analyzed symptoms prompting evaluation, results, and recommended interventions by using descriptive statistics. They also conducted a subset analysis of 9 children who had undergone polysomnography both before and after neurosurgical intervention. RESULTS Fifty-two patients had polysomnographs available for review. Sleep apnea was diagnosed in 81% of these patients. The most common presenting symptom was "breathing difficulties" (18 cases [43%]). Mild sleep apnea was present in 26 cases (50%), moderate in 10 (19%), and severe in 6 (12%). Among the 42 patients with abnormal sleep architecture, 30 had predominantly obstructive apneas and 12 had predominantly central apneas. The most common pulmonology-recommended intervention was adjustment of peripheral oxygen supplementation (24 cases [57%]), followed by initiation of peripheral oxygen (10 cases [24%]). In a subset analysis of 9 patients who had sleep studies before and after neurosurgical intervention, there was a trend toward a decrease in the mean number of respiratory events (from 34.8 to 15.9, p = 0.098), obstructive events (from 14.7 to 13.9, p = 0.85), and central events (from 20.1 to 2.25, p = 0.15) and in the apnea-hypopnea index (from 5.05 to 2.03, p = 0.038, not significant when corrected for multiple measures). CONCLUSIONS A large proportion of patients with myelomeningocele who had undergone polysomnography showed evidence of disordered sleep on an initial study. Furthermore, 31% of patients had moderate or severe obstructive sleep apnea. Myelomeningocele patients with an abnormal sleep structure who had undergone nonoperative treatment with peripheral oxygen supplementation showed improvement in the apnea-hypopnea index. Results in this study suggested that polysomnography in patients with myelomeningocele may present an opportunity to detect and classify sleep apnea, identify low-risk interventions, and prevent future implications of sleep-disordered breathing.