Obstructive Sleep Apnea and Gastroesophageal Reflux: A Multivariate Population-Level Analysis

Nocturnal gastro-oesophageal reflux and respiratory symptoms are increased in sleep apnoea: comparison with the general population

AIM

To assess respiratory symptoms and nocturnal gastro-oesophageal reflux (nGER) among untreated obstructive sleep apnoea (OSA) patients, compared with the general population. Also, if nGER associates differently with respiratory symptoms among OSA patients.

METHODS

2 study cohorts were included: 822 newly diagnosed subjects with moderate-severe OSA and 738 Icelandic general population study participants. All participants answered the same questionnaires. Those reporting nGER symptoms at least once per week were defined as 'with nGER'; those without nGER symptoms and without nGER medication were defined as 'no nGER'; and other participants were defined as having 'possible nGER'. Propensity score-based weights were used to minimise confounding and selection bias and facilitate causal interpretations.

RESULTS

The prevalence of nGER among OSA patients was 14.1%, compared with 5.8% in the general population. This increased prevalence in OSA was not explained by differences in age, gender, body mass index, smoking, hypertension and diabetes (adjusted OR (95% CI)=3.79 (2.24 to 6.43)). OSA patients 'with nGER' and with 'possible nGER' reported more wheezing (44% and 44% vs 25%, respectively) and productive cough (47% and 42% vs 29%, respectively), compared with OSA patients with 'no nGER'. The same pattern was seen in the general population, although with a generally lower prevalence. The effect of nGER on respiratory symptoms was similar between the two cohorts.

CONCLUSION

nGER was more often reported among untreated moderate-severe OSA patients than in the general population. Participants with nGER had more wheezing and productive cough, both among untreated OSA patients and in the general population.

Causal association of gastroesophageal reflux disease with obstructive sleep apnea and sleep-related phenotypes: a bidirectional two-sample Mendelian randomization study

Background

The interactions and associations between obstructive sleep apnea (OSA), sleep-related phenotypes (SRPs), and gastroesophageal reflux disease (GERD) are complex, thus it is hard to explore the effect and direction of causalities.

Study objectives

A bidirectional Mendelian randomization (MR) study was performed to explore causal associations of GERD with OSA and SRPs (including insomnia, morningness, sleep duration, ease of getting up, daytime napping, daytime dozing, and snoring).

Methods

First, we gathered summary statistics from publicly available databases. Subsequently, we identified single-nucleotide polymorphisms without strong linkage (r2 ≤ 0.001) by referencing relevant genome-wide association studies that met genome-wide significance criteria. Our primary analysis relied on inverse variance weighted to estimate the causal relationship. To ensure the validity of our findings, we also conducted several sensitivity analyses. These included MR Pleiotropy RESidual Sum and Outlier to detect and correct for potential pleiotropic effects, MR-Egger to assess directional pleiotropy, and weighted median analysis to further evaluate heterogeneity and pleiotropy. For the initial MR analysis, when causality was indicated by the results, instrumental variables that were significantly linked to the aforementioned confounding factors were removed. We will re-analyze the data after excluding outcome-related single nucleotide polymorphisms to confirm that the results are still consistent with the previous results.

Results

GERD was found to increase the risk of OSA (OR = 1.53, 95% CI = 1.37-1.70, p = 5.3 × 10-15), insomnia (OR = 1.14, 95% CI = 1.10-1.19, p = 1.3 × 10-10), snoring (OR = 1.09, 95% CI = 1.04-1.13, p = 6.3 × 10-5) and less sleep duration (OR = 0.94, 95% CI = 0.91-0.97, p = 3.7 × 10-4). According to the reverse-direction analysis, there is an elevated risk of GERD associated with OSA (OR = 1.07, 95% CI = 1.02-1.12, p = 0.005), insomnia (OR = 1.95, 95% CI = 1.60-2.37, p = 1.92 × 10-11) and snoring (OR = 1.74, 95% CI = 1.37-2.21, p = 4.4 × 10-6).

Conclusion

Genetic susceptibility to GERD can elevate the likelihood of experiencing insomnia, snoring, and OSA, in addition to diminishing sleep duration. Conversely, a reverse MR analysis indicates that ameliorating any one of insomnia, snoring, or OSA can mitigate the risk of developing GERD.

International Consensus Statement on Obstructive Sleep Apnea

BACKGROUND

Evaluation and interpretation of the literature on obstructive sleep apnea (OSA) allows for consolidation and determination of the key factors important for clinical management of the adult OSA patient. Toward this goal, an international collaborative of multidisciplinary experts in sleep apnea evaluation and treatment have produced the International Consensus statement on Obstructive Sleep Apnea (ICS:OSA).

METHODS

Using previously defined methodology, focal topics in OSA were assigned as literature review (LR), evidence-based review (EBR), or evidence-based review with recommendations (EBR-R) formats. Each topic incorporated the available and relevant evidence which was summarized and graded on study quality. Each topic and section underwent iterative review and the ICS:OSA was created and reviewed by all authors for consensus.

RESULTS

The ICS:OSA addresses OSA syndrome definitions, pathophysiology, epidemiology, risk factors for disease, screening methods, diagnostic testing types, multiple treatment modalities, and effects of OSA treatment on multiple OSA-associated comorbidities. Specific focus on outcomes with positive airway pressure (PAP) and surgical treatments were evaluated.

CONCLUSION

This review of the literature consolidates the available knowledge and identifies the limitations of the current evidence on OSA. This effort aims to create a resource for OSA evidence-based practice and identify future research needs. Knowledge gaps and research opportunities include improving the metrics of OSA disease, determining the optimal OSA screening paradigms, developing strategies for PAP adherence and longitudinal care, enhancing selection of PAP alternatives and surgery, understanding health risk outcomes, and translating evidence into individualized approaches to therapy.

Causal association between obstructive sleep apnea and gastroesophageal reflux disease: A bidirectional two-sample Mendelian randomization study

Objectives: Correlations between obstructive sleep apnea (OSA) and gastroesophageal reflux disease (GERD) have been detected in previous observational studies. However, this association remains uncertain due to the potential presence of selection and confounding biases. Therefore, this bidirectional two-sample Mendelian randomization (MR) study was conducted to evaluate the causal relationship between OSA and GERD.

Methods: In this study, instrumental variables (IVs) for OSA were selected from publicly available genetic summary data (27,207 cases and 280,720 controls). Summary statistics for GERD were obtained from a genome-wide association study of 602,604 individuals. The inverse variance weighted (IVW) method was used as the main MR method. The MR-Egger intercept test, MR pleiotropy residual sum and outlier, and leave-one-out analysis were used to detect pleiotropy. Heterogeneity was detected by Cochran’s Q test.

Results: The IVW results revealed that OSA [odds ratio (OR): 1.19, 95% confidence interval (CI): 1.11–1.28, p = 8.88E-07] was causally associated with the incidence of GERD. Moreover, there was evidence of GERD leading to OSA in the IVW analysis (OR: 1.44, 95%CI: 1.33–1.57, p = 7.74E-19). No directional pleiotropy was detected by the MR-Egger intercept test (all p > 0.05).

Conclusion: This study found that OSA is linked to a higher incidence of GERD, and vice versa. This finding might be helpful for the screening and prevention of these two diseases.

Independent association of preoperative Hill grade with gastroesophageal reflux disease 2 years after sleeve gastrectomy

BACKGROUND

The sleeve gastrectomy (SG) is associated with postoperative gastroesophageal reflux disease (GERD). Higher endoscopic Hill grade has been linked to GERD in patients without metabolic surgery. How preoperative Hill grade relates to GERD after SG is unknown.

OBJECTIVE

To explore the relationship between preoperative Hill grade and GERD outcomes 2 years after SG.

SETTING

Academic hospital, United States.

METHODS

All patients (n = 882) undergoing SG performed by 5 surgeons at a single academic institution from January 2015 to December 2019 were included. Complete data sets were available for 360 patients, which were incorporated in analyses. GERD was defined as the presence of a diagnosis in the medical record accompanied by pharmacotherapy. Patients with GERD postoperatively (n = 193) were compared with those without (n = 167). Univariable and multivariable analyses were conducted to explore independent associations between preoperative factors and GERD outcomes.

RESULTS

The presence of any GERD increased at the postoperative follow-up of 25.2 (3.9) months compared with preoperative values (53.6% versus 41.1%; P = .0001). Secondary GERD outcomes at follow-up included de novo (41.0%), persistent (33.1%), resolved (28.4%), worsened (26.4%), and improved (12.2%) disease. Postoperative endoscopy and reoperation for GERD occurred in 26.4% and 6.7% of the sample. Patients with GERD postoperatively showed higher prevalence of Hill grade III-IV (32.6% versus 19.8%; P = .0062) and any hiatal hernia (HH) (36.3% versus 25.1%; P = .0222) compared with patients without postoperative GERD. Frequencies of gastritis, esophagitis A or B, duodenitis, and peptic ulcer disease were similar between groups. Higher prevalence of preoperative GERD (54.9% versus 25.1%; P < .0001), obstructive sleep apnea (66.8% versus 54.5%; P = .0171), and anxiety (25.4% versus 15.6%; P = .0226) was observed in patients with postoperative GERD compared with those without it. Baseline demographics, weight, other obesity-associated diseases, whether an HH was repaired at index SG, and follow-up length were statistically similar between groups. After adjusting for collinearity, preoperative GERD (odds ratio [OR] = 3.6; 95% confidence interval [CI], 2.2-5.7; P < .0001) and Hill grade III-IV (OR [95% CI]: 1.9 [1.1-3.1]; P = .0174) were independently associated with the presence of any GERD postoperatively. The preoperative presence of an HH >2 cm and whether an HH was repaired at index SG showed no independent association with GERD at follow-up.

CONCLUSIONS

More than 50% of patients experienced GERD 2 years after SG. Preoperative GERD confers the highest risk for GERD postoperatively. Hill grade III-IV is independently associated with GERD after SG. Whether a hiatal hernia repair was performed did not influence GERD outcomes. Preoperative esophagogastroduodenoscopy should be obtained before SG and Hill grade routinely captured and used to counsel patients about the risk of postoperative GERD after this procedure. Hill grade may help guide the choice of metabolic operation.

Updates in interaction of gastroesophageal reflux disease and extragastroesophageal digestive diseases

INTRODUCTION

Gastroesophageal reflux disease (GERD) is one of the common chronic diseases with prevalence increasing in the last decades. Because of its prevalence and chronicity, GERD affects the quality of life and increases health-care costs. Gastroesophageal diseases leading to GERD have been thoroughly studied, while extragastroesophageal digestive diseases (EGEDDs) may coexist with GERD and affect the occurrence and persistence of GERD symptoms and therapeutic effect.

AREAS COVERED

In this review, we aim to summarize the EGEDDs correlated with GERD and explore the potential mechanisms of this interaction.

EXPERT OPINION

Individuals with troublesome GERD symptoms may have some common gastroesophageal etiologies, but EGEDDs may also overlap and impact on the progression of GERD, which are often ignored in clinic. The lesions in the small intestine, colon, and hepatobiliary tract as well as functional bowel disorders had positive or negative associations with GERD through potential mechanisms. These diseases aggravate GERD symptoms, increase the esophageal acid burden, cause esophageal hypersensitivity, and finally affect the response to therapy in GERD patients. Therefore, it is necessary to clear the interaction between GERD and EGEDDs and their mechanisms.

Reduced gastroesophageal reflux disease symptom severity following upper airway surgery for comorbid obstructive sleep apnea

PURPOSE

To evaluate patient-reported quality of life pertaining to gastroesophageal reflux disease symptoms in patients undergoing upper airway surgery for comorbid obstructive sleep apnea.

MATERIALS AND METHODS

A prospective survey-based study was conducted on patients with gastroesophageal reflux disease and comorbid obstructive sleep apnea receiving surgery from July 2020-December 2020. Patients completed the Gastroesophageal Reflux Disease-Health Related Quality of Life Questionnaire at two time-points: one week before surgery and at 6 months following surgery. Disease-related symptoms were rated from 0 (no symptoms) to 5 (incapacitating symptoms). Patient survey scores, demographics, medications, and sleep study parameters were collected for analysis. A p-value <0.05 indicated statistical significance.

RESULTS

Twenty-two patients completed the baseline preoperative and 6-month postoperative questionnaires. Median baseline vs. 6-month survey scores significantly decreased for symptoms including heartburn in general (3.0 vs. 2.0, p = 0.006), when lying down (2.5 vs. 1.5, p = 0.046), when standing (2.0 vs 1.0, p = 0.003), following meals (2.0 vs. 2.0, p = 0.042), and cumulative survey score (15.5 vs. 11.0, p = 0.029). Heartburn altering diet or sleep, odynophagia, dysphagia, and medication burden did not change following surgery (p > 0.05). More patients were satisfied with their postoperative condition compared to baseline, however this did not reach statistical significance (40.9% vs. 18.2%, p = 0.18).

CONCLUSIONS

Our results suggest that upper airway surgery to treat obstructive sleep apnea may have a positive impact on patient-reported symptoms of gastroesophageal reflux disease, and further investigation into the role of surgery in this setting for improvement of both quality of life and true clinical disease severity is merited.

Analysis of effects of laryngopharyngeal reflux disease and proton pump inhibitor treatment on Eustachian tube function in patients with obstructive sleep apnea hypopnea

OBJECTIVE

This study aims to explore the effects of laryngopharyngeal reflux disease (LPRD) and proton pump inhibitor (PPI) treatment on Eustachian tube function in patients with obstructive sleep apnea (OSA).

METHODS

The Eustachian tube score-7 (ETS-7) was observed before and after PPI treatment in the control group, OSA only group, and OSA + LPRD group.

RESULTS

Age, sex, smoking history, and drinking history showed no differences among 3 groups (P > .05). The body mass index (BMI) in the control group was lower than that in other groups (P < .017). Before PPI treatment, the abnormality rate of ETS-7 in the OSA + LPRD group statistically differed from that in the control group and the OSA only group (P < .017). After PPI treatment, the abnormality rate of ETS-7 in the OSA + LPRD group exhibited no significant differences compared with that in the control group and the OSA only group (P > .017), and it declined remarkably compared with that before PPI treatment (75% vs 35%, χ² = 13.334, P = .001). Moreover, the multivariate analysis revealed that only LPRD had an independent correlation with the abnormality of ETS-7 (OR = 1.245, 95% CI: 1.759-6.861, P = .000).

CONCLUSION

In view of its high incidence in OSA patients, LPRD may be a considerable factor for the high incidence of abnormality rate of ETS-7 in OSA patients, and PPI therapy is of significant value in improving Eustachian tube function in OSA patients with LPRD.

Effect of Continuous Positive Airway Pressure on Chronic Cough in Patients with Obstructive Sleep Apnea and Concomitant Gastroesophageal Reflux

BACKGROUND

Obstructive sleep apnea (OSA) and/or gastroesophageal reflux (GER) may be the contributors to chronic cough in patients with OSA and concomitant GER. This study aimed to explore whether continuous positive airway pressure (CPAP), antireflux treatment and lifestyle modifications improve chronic cough in patients with OSA and concomitant GER.

METHODS

Patients with OSA and concomitant GER who also experienced chronic cough were enrolled, and were divided into two groups. Patients who were treated with general treatment (antireflux treatment and lifestyle modifications) as the control group, and patients who were treated with CPAP and general treatment as the treatment group. Effects of different treatments on chronic cough were assessed, and the association among chronic cough, GER and OSA was evaluated by Pearson's correlation analysis.

RESULTS

The Pittsburgh Sleep Quality Index and Epworth Sleepiness Scale were better in the treatment group after 1 week of treatment; further, the improvement became stronger with the duration of therapy. The gastroesophageal reflux disease questionnaire, visual analog scale (VAS) for cough, and daytime and nighttime cough symptom scores significantly improved in both groups after treatment, whereas this improvement was more significant in the treatment group. Significant associations between the apnea-hypopnea index (AHI) and VAS, weak acid reflux and VAS, and weak acid reflux and AHI were observed.

CONCLUSION

CPAP improved the symptoms of chronic cough and GER in patients with OSA and concomitant GER. AHI and weak acid reflux may be important factors affecting the therapeutic effect of chronic cough in patients with OSA and concomitant GER.

Sorting out the Relationship between Gastroesophageal Reflux Disease and Sleep

PURPOSE OF REVIEW

Gastroesophageal reflux disease is one of the most common conditions encountered by primary care physicians, gastroenterologists, foregut surgeons and otolaryngologists. While approximately 50% of patients experience nocturnal reflux symptoms, the relationship between gastroesophageal reflux disease and sleep is often overlooked. The aim of this review is to provide an update on the current understanding of this relationship and its clinical implications. Recent studies pertaining to the association between GERD and sleep with focus on sleep disturbances, obstructive sleep apnea, extraesophageal manifestations of GERD and treatment are discussed.

RECENT FINDINGS

There is a close relationship between GERD and sleep disturbances, but the nature of this relationship remains to be elucidated. Similarly, new data supports the association between GERD and obstructive sleep apnea, but whether this association is independent of confounding risk factors remains unresolved. Extraesophageal manifestations due to nocturnal GERD are primarily respiratory and can be explained by microaspiration and vagally-induced bronchospasm. Treatment of nocturnal GERD, both pharmacologically and surgically, improves sleep quality. Conversely, pharmacologic treatment of sleep disorders can improve nocturnal GERD symptoms. There is a bi-directional relationship between GERD and sleep. GERD is associated with various sleep disturbances. Sleep deficiency can exacerbate GERD. There is an association between extraesophageal manifestations and nocturnal GERD. Treatment directed towards GERD can improve sleep experience, and treatment directed to improve sleep can improve GERD symptoms.

The Effectiveness of Nasal Airway Stent Therapy for the Treatment of Mild-to-Moderate Obstructive Sleep Apnea Syndrome

BACKGROUND

Patients with obstructive sleep apnea syndrome (OSAS) experience excessive daytime sleepiness and insomnia and they are at risk of developing cardiovascular disease and stroke. Continuous positive airway pressure therapy could improve symptoms and decrease these risks; however, adherence is problematic. Although the oral appliance is another therapeutic option, patient satisfaction is limited and the effect of the nasal airway stent - a new device - remains unclear.

OBJECTIVES

The aim of this study was to evaluate the effect of NAS therapy in patients with mild-to-moderate OSAS in a prospective, single-arm, interventional pilot study.

METHOD

Patients with mild/moderate sleep apnea (n = 71; Apnea-Hypopnea Index [AHI], 5-20 events/h on polysomnography) were recruited. Sleep-associated events were measured using a portable device (WatchPAT200) pre- and immediately post-treatment and at 1 month follow-up. AHI (including supine and non-supine AHI), Oxygen Desaturation Index (ODI), Respiratory Disturbance Index (RDI), percutaneous oxygen saturation, heart rate, and snore volume were evaluated. Symptoms were assessed using the Epworth Sleepiness Scale, Pittsburgh Sleep Quality Index, and Hospital Anxiety and Depression Scale.

RESULTS

NAS use significantly improved AHI, supine AHI, RD, ODI, and snore volume compared to pre-intervention (r = 0.44, 0.48, 0.3, 0.42, and 0.34; p < 0.001, p < 0.001, p = 0.011, p < 0.001, and p = 0.048, respectively). Additionally, 25 and 10% of patients showed complete and partial response for AHI, respectively; these improvements remained significant 1 month later. Pittsburgh Sleep Quality Index scores improved from 6.0 to 5.3 (r = 0.46, p = 0.022).

CONCLUSIONS

NAS therapy reduced severity and snoring in patients with mild-to-moderate OSAS. Approximately 30% of patients did not tolerate NAS due to side effects.

Gastroesophageal Reflux Disease: A Cause for Eustachian Tube Dysfunction in Obstructive Sleep Apnea

OBJECTIVES

To explore the effect of gastroesophageal reflux disease (GERD) on Eustachian tube function in patients with obstructive sleep apnea (OSA).

METHODS

This was a cross-sectional study. The patients were divided into 4 groups according to OSA and GERD: OSA+GERD group; OSA-only group; GERD-only group; and normal control group.

RESULTS

There were no differences among the 4 groups regarding age, sex, smoking history, and alcohol history (all P > .05). The patients in the OSA and OSA+GERD groups had a significantly larger body mass index than those in the control and GERD-only groups (all P < .05). The proportions of patients with abnormal ETS-7 and ETD-Q results were higher in the GERD and OSA+GERD groups compared to the control group (P < .008). There were no significant differences in ETS-7 and ETD-Q between the control and the OSA-only groups (P > .008). The multivariable analysis showed that only GERD was independently associated with abnormal ETS-7 results (odds ratio = 3.090, 95% CI: 1.332-7.169, P = .009).

CONCLUSION

Given the high concomitance rate in patients with OSA, GERD might be an important association factor of Eustachian tube dysfunction in patients with OSA.

Phenotypes of Obstructive Sleep Apnea

Obstructive sleep apnea (OSA) is a multisystem breathing disorder associated with increased morbidity and mortality. Clinical and operative assessment tools improve surgical approaches to treat airway obstruction. The primary sites of anatomic obstruction are at the levels of the nasal, palatal, and hypopharyngeal airway. The literature suggests a relationship between reduced neuromuscular tone and the age-related increase in OSA prevalence for normal-weight adults. Pharyngeal soft tissue collapse due to reduced airway pressure is defined as the critical closing pressure. Respiratory biochemistry homeostasis is an additional factor in maintaining airway patency.

Dysphagia in patients with moderate and severe obstructive sleep apnea

Introduction

There is evidence that trauma caused by snoring in the pharynx could result in dysphagia in patients with obstructive sleep apnea, but the literature is still scarce to define the factors associated with the presence of dysphagia in these patients.

Objectives

To analyze the occurrence of dysphagia and its clinical and polysomnographic features in patients with moderate and severe obstructive sleep apnea, in addition to verifying the impact of dysphagia on the quality of life of these patients.

Methods

Seventy patients with moderate or severe apnea (apnea and hypopnea index – AHI > 15/hour) were selected. The patients underwent a sleep questionnaire, a quality of life in dysphagia questionnaire and a fiberoptic endoscopic evaluation of swallowing.

Results

A total of 70 patients were included in the study, of which 49 were men (70 %), with a mean age of 48.9 years. The fiberoptic endoscopic evaluation of swallowing was altered in 27.3 % and the most frequent alteration was the premature oral leakage with fluid. Comparing the groups with and without dysphagia, the female gender was the only clinical parameter that showed a trend of statistical significance in the group with dysphagia (p = 0.069). There was no statistical difference regarding the polysomnographic features and in the global quality of life score in dysphagia in the comparison between the groups.

Conclusions

The presence of dysphagia in patients with moderate to severe apnea is frequent and subclinical, reinforcing the need to investigate this symptom in this group of patients. However, the presence of dysphagia did not result in worsening in patients' quality of life, suggesting that, although frequent, its effect is mild. There was no relevance regarding the association of clinical and polysomnographic parameters with the presence of dysphagia.

Individualized medicine of gastroesophageal reflux disease

Gastroesophageal reflux disease (GERD) is a common disease worldwide, and its prevalence is increasing in both developed and developing countries. GERD is divided into three subtypes, namely, erosive esophagitis, nonerosive reflux disease (NERD), and Barrett's esophagus. The etiology, pathogenesis, clinical manifestations, and response to treatment of GERD invariably show high heterogeneity or significant individual difference, especially NERD and refractory GERD. On the other hand, advanced technology has currently provided a wide range of methods for the diagnosis and treatment of GERD patients; however, the long-term efficacy and quality of life of some patients are unsatisfactory. Therefore, each GERD patient needs a specialized management strategy aiming at his/her own condition, which is known as individualized medicine or personalized medicine. The goal of GERD treatment is to relieve the symptoms, while symptomatic remission is directly related to the quality of life. In other words, health-related quality of life and patient satisfaction may be reasonable criteria for GERD. In this paper, we will discuss the individualized medicine of GERD.

Comorbid "treatable traits" in difficult asthma: Current evidence and clinical evaluation

The care of patients with difficult-to-control asthma ("difficult asthma") is challenging and costly. Despite high-intensity asthma treatment, these patients experience poor asthma control and face the greatest risk of asthma morbidity and mortality. Poor asthma control is often driven by severe asthma biology, which has appropriately been the focus of intense research and phenotype-driven therapies. However, it is increasingly apparent that extra-pulmonary comorbidities also contribute substantially to poor asthma control and a heightened disease burden. These comorbidities have been proposed as "treatable traits" in chronic airways disease, adding impetus to their evaluation and management in difficult asthma. In this review, eight major asthma-related comorbidities are discussed: rhinitis, chronic rhinosinusitis, gastroesophageal reflux, obstructive sleep apnoea, vocal cord dysfunction, obesity, dysfunctional breathing and anxiety/depression. We describe the prevalence, impact and treatment effects of these comorbidities in the difficult asthma population, emphasizing gaps in the current literature. We examine the associations between individual comorbidities and highlight the potential for comorbidity clusters to exert combined effects on asthma outcomes. We conclude by outlining a pragmatic clinical approach to assess comorbidities in difficult asthma.

Recognition of Sleep Apnea Is Increasing. Analysis of Trends in Two Large, Representative Databases of Outpatient Practice

RATIONALE

Little is known about recent trends in physician reporting of sleep apnea during outpatient practice visits.

OBJECTIVES

To assess trends in the frequency of adult outpatient visits for sleep apnea in the United States, the clinicians who provided those visits, and the characteristics of patients reported to have sleep apnea; and to assess whether the reporting of a diagnosis of sleep apnea varies across regions of the country as a function of body weight and insurance status.

METHODS

We reviewed annual stratified samples of patients identified as having sleep apnea during physician office visits in the U.S. National Ambulatory Medical Care Survey database, and during visits to hospital outpatient practices in the U.S. National Hospital Ambulatory Medical Care Survey database, between 1993 and 2010. The aggregate data set included records of 838,000 ambulatory practice visits.

MEASUREMENTS AND MAIN RESULTS

During this 17-year period, survey reports of a diagnosis of sleep apnea increased 14.6- fold, from 420,000 to 6.37 million per year (P = 0.0002). Thirty-three percent were reported by primary care providers, 17% by pulmonologists, and 10% by otolaryngologists. Over the period of observation, reports of a diagnosis of sleep apnea by "other groups" increased considerably (P < 0.001). The per capita rate of sleep apnea diagnoses per 1,000 persons per year differed across regions of the United States (P < 0.0001). Regions that reported a higher rate of sleep apnea appeared to be influenced by obesity (P < 0.001) and health insurance status (P < 0.005).

CONCLUSIONS

Diagnoses of sleep apnea during outpatient visits to hospital-based and non-hospital-based practices in the United States were much more frequent in 2010 than in 1993, as reported by outpatient practice clinicians participating in national surveys. Although the majority of diagnoses of sleep apnea were reported by primary care providers, pulmonologists, and otolaryngologists (60%), there was a substantial increase in reports of sleep apnea by clinicians practicing other specialties during the study period. Reporting of a diagnosis of sleep apnea varied by obesity prevalence and health insurance status across U.S. geographic regions.

A possible association between dysphonia and sleep duration: A cross-sectional study based on the Korean National Health and nutrition examination surveys from 2010 to 2012

BACKGROUND

Sleep is important in terms of good general health and appropriate sleep duration has been linked to quality-of-life. Dysphonia may impair communication and social relationships, and is thus also closely related to quality-of-life. No large-scale, cross-sectional epidemiological study of a sample representative of the population of an entire country has yet assessed the possible existence of a relationship between sleep duration and dysphonia.

METHODS

We investigated a possible association between subjective voice problems and self-reported sleep duration in South Korean subjects using 2010-2012 data from the Korean National Health and Nutrition Examination Survey (KNHANES). Cross-sectional data on 17,806 adults (7,578 males and 10,228 females) over the age of 19 years who completed the KNHANES were analyzed. All participants reported voice problems (if present) and their daily average sleep duration using a self-reporting questionnaire. Sleep duration was classified into five categories as follows: ≤5, 6, 7, 8, and ≥9 h/day.

RESULTS

The overall prevalence of dysphonia was 6.8%; 5.7% in males and 7.7% in females. The prevalence for dysphonia by sleep duration exhibited a U-shape, with the lowest point being at sleep duration of 7-8h. After adjustment for covariates (age, sex, smoking status, alcohol consumption, regular exercise, low income, high-level education), a sleep duration of ≤5 h (OR = 1.454; 95% CI, 1.153-1.832) and a sleep duration of ≥9 h (OR = 1.365; 95% CI, 1.017-1.832) were significantly associated with dysphonia, compared to a sleep duration of 7 h. In terms of gender, males who slept for ≥9 h were at a 2-fold (OR = 2.028; 95% CI, 1.22-3.35) higher odds for dysphonia (p<0.05) compared to those who slept for 7 h. A sleep duration ≤5 h was associated with a 1.6-fold (OR = 1.574; 95% CI, 1.203-2.247) higher odds of dysphonia ≥3 weeks in duration (long-term dysphonia).

CONCLUSIONS

This is the first study to show that both short and long sleep duration were significantly associated with the development of dysphonia. The association between sleep duration and dysphonia was more marked in males than females. A sleep duration ≤5 h had a significant impact on the prevalence of long-term dysphonia.

Does an Otolaryngology-Specific Database Have Added Value? A Comparative Feasibility Analysis

OBJECTIVES

There are multiple nationally representative databases that support epidemiologic and outcomes research, and it is unknown whether an otolaryngology-specific resource would prove indispensable or superfluous. Therefore, our objective was to determine the feasibility of analyses in the National Ambulatory Medical Care Survey (NAMCS) and National Hospital Ambulatory Medical Care Survey (NHAMCS) databases as compared with the otolaryngology-specific Creating Healthcare Excellence through Education and Research (CHEER) database.

STUDY DESIGN

Parallel analyses in 2 data sets.

SETTING

Ambulatory visits in the United States.

SUBJECTS AND METHODS

To test a fixed hypothesis that could be directly compared between data sets, we focused on a condition with expected prevalence high enough to substantiate availability in both. This query also encompassed a broad span of diagnoses to sample the breadth of available information. Specifically, we compared an assessment of suspected risk factors for sensorineural hearing loss in subjects 0 to 21 years of age, according to a predetermined protocol. We also assessed the feasibility of 6 additional diagnostic queries among all age groups.

RESULTS

In the NAMCS/NHAMCS data set, the number of measured observations was not sufficient to support reliable numeric conclusions (percentage standard error among risk factors: 38.6-92.1). Analysis of the CHEER database demonstrated that age, sex, meningitis, and cytomegalovirus were statistically significant factors associated with pediatric sensorineural hearing loss (P < .01). Among the 6 additional diagnostic queries assessed, NAMCS/NHAMCS usage was also infeasible; the CHEER database contained 1585 to 212,521 more observations per annum.

CONCLUSION

An otolaryngology-specific database has added utility when compared with already available national ambulatory databases.

Physicians Report Sleep Apnea Infrequently in Older and Older Vulnerable Adults

OBJECTIVES

To determine how often outpatient physician visits detect sleep apnea (SA) in older persons in the United States.

DESIGN

Retrospective Analysis.

SETTING

US non hospital and hospital based clinics.

PARTICIPANTS

US physicians.

MEASUREMENTS

National Ambulatory Medical Care Survey and National Hospital Ambulatory Medical Care Survey data from 1993 to 2011 were used to assess the frequency of physicians' coding diagnoses of SA in persons aged 65 and older. Which specialties are most likely to report SA, the most-common comorbid conditions reported with SA, and the likelihood of reporting SA in patient visits for dementia and preoperative care were assessed.

RESULTS

From 1993 to 2011, physicians reported SA in 0.3% of all office visits in persons aged 65 and older. SA reported in visits increased from 130,000 in 1993 to 2,070,000 in 2011, with an annual per capita visit reporting rate of 0.07% to 0.74%. In older populations, the proportion of documented SA visits by specialists rose, and that of primary care providers decreased. Older adults with a diagnosis of SA had higher average number of comorbidities than those without SA (1.8 vs 1.3). Reporting SA was low in visits with a diagnosis of dementia and classified as a preoperative visits.

CONCLUSION

In two nationwide surveys, SA reporting by physicians in elderly adults was 16 as greater in 2001 as in 1993, although reporting of SA remains infrequent (<1% of visits) even in vulnerable populations.