Defining obstructive sleep apnoea syndrome: a failure of semantic rules

Study of Two Sedative Protocols for Drug-Induced Sleep Endoscopy: Propofol versus Propofol-Remifentanil Combination, Delivered in Target-Controlled Infusion Mode

Background and Objectives: Obstructive sleep apnea (OSA) is a prevalent sleep-disordered breathing pathology with significant clinical consequences, including increased cardiovascular risk and cognitive decline. Continuous positive airway pressure (CPAP) is the gold-standard treatment, but alternative strategies are sometimes needed for patients intolerant to CPAP. Drug-induced sleep endoscopy (DISE) is a key diagnostic tool for assessing upper airway obstruction in OSA patients and subsequently tailoring a surgical approach, with sedation protocols playing a crucial role in its efficacy and results accuracy. This study aimed to investigate the effect of adding remifentanil to a propofol target-controlled infusion (TCI) regimen on the sedation parameters and procedural outcomes of DISE. Materials and Methods: The study was conducted at the Central University and Emergency Military Hospital "Dr. Carol Davila" and Ria Clinic in Bucharest between July 2021 and October 2023. Thirty-one patients were enrolled and randomised into two groups: a propofol group (P group, n= 11) and a remifentanil-propofol group (R-P group, n = 20). DISE was performed using standardised protocols, sedative drugs were administered in TCI mode, and data on sedation levels, respiratory and cardiovascular parameters, and procedural incidents were collected. Results: The addition of remifentanil at 1 ng/mL effect-site concentration significantly reduced the effect-site concentration of propofol required for adequate sedation (3.4 ± 0.7 µg/mL in the P group vs. 2.8 ± 0.6 µg/mL in the R-P group, p = 0.035). The time to achieve adequate sedation was also shorter in the R-P group (7.1 ± 2.5 min vs. 9.5 ± 2.7 min, p = 0.017). The incidence of cough, hypoxemia, and cardiovascular events did not significantly differ between the two groups. Conclusions: Adding remifentanil to a propofol TCI regimen for DISE effectively reduces the required propofol effect-site concentration and shortens sedation time without increasing the risk of adverse events. This combination may enhance the safety and efficiency of DISE, offering a promising alternative for patients undergoing this procedure.

Analysis of the relationship between comorbid obstructive sleep apnea and clinical outcomes in patients with asthma in Japan

BACKGROUND

Asthma and obstructive sleep apnea (OSA) are prevalent chronic respiratory disorders, which often coexist and interact with each other. Obesity is an important risk factor shared by them. The rate of obesity is lower in Japan versus Western countries. Hence, the co-existence of asthma and OSA has not been investigated in Japan.

METHODS

Ninety-seven outpatients with asthma were recruited. Patients wore a portable monitor for sleep study. Background data, pulmonary function, blood tests, and patient-reported outcomes including gastroesophageal reflux disease, sleepiness, sleep quality, asthma control, cough and respiratory symptoms, and health status, were assessed.

RESULTS

Of the patients, 19 (19.6 %), 40 (41.2 %), 24 (24.7 %), and 14 (14.4 %) were classified into non-, mild, moderate, and severe OSA groups. Non-OSA patients were younger than those in other groups (p < 0.05). The BMI of patients with moderate and severe OSA, was higher than that of non-OSA patients (p < 0.05). Pulmonary function, FeNO, serum IgE, and the number of peripheral eosinophils were not significantly different between groups. Nonetheless, compared with the other groups, treatment step was the highest, and the Asthma Control Test, Leicester Cough Questionnaire, COPD Assessment Test, and Asthma Health Questionnaire-33 yielded worst scores in the severe OSA group, and predicted the severe OSA after adjustment by BMI.

CONCLUSIONS

Moderate and severe OSA are highly prevalent among patients with asthma in Japan. Pulmonary function did not differ between groups. However, patients with asthma and severe OSA were linked to more asthma treatment, worse asthma control, more symptoms and cough, and worse health status.

Sleep-disordered breathing in children and adults with intellectual disability: mind the gap!

BACKGROUND

In adults and children with intellectual disability (ID), sleep -disordered breathing (SDB) is thought to be common. However, large epidemiological studies are lacking, and there are few studies on optimal methods of investigation and even fewer randomised, controlled intervention trials of treatment.

METHOD

Peer-reviewed publications from various databases were examined in line with search terms relevant to ID and SDB spanning the years 200-2024.

RESULTS

Findings suggest that, due to comorbid conditions, children and adults with ID may experience both an increased risk of SDB, as well as lower frequency of diagnosis. SDB can compromise the emotional, physical and mental health of individuals with ID. Appropriate treatment when tolerated leads to an improvement in health and well-being and several studies emphasized the importance of consistent follow-up of people with ID - something that is not universally occurring during childhood, in the transition to adulthood and during adulthood itself. As the most frequently occurring form of ID worldwide, we use Down syndrome as a specific example of how diagnosing and treating SDB can lead to improved outcomes.

CONCLUSIONS

This review highlights the importance of identifying SDB in this heterogenous population, recognising the multi-faceted, deleterious consequences of untreated SDB in people with ID, and presents some strategies that can be harnessed to improve diagnosis and management. Until further ID-specific research is available, we urge flexibility in the approach to people with ID and SDB based in guidelines and standard practice developed for the typically developing population.

Towards automatic home-based sleep apnea estimation using deep learning

Apnea and hypopnea are common sleep disorders characterized by the obstruction of the airways. Polysomnography (PSG) is a sleep study typically used to compute the Apnea-Hypopnea Index (AHI), the number of times a person has apnea or certain types of hypopnea per hour of sleep, and diagnose the severity of the sleep disorder. Early detection and treatment of apnea can significantly reduce morbidity and mortality. However, long-term PSG monitoring is unfeasible as it is costly and uncomfortable for patients. To address these issues, we propose a method, named DRIVEN, to estimate AHI at home from wearable devices and detect when apnea, hypopnea, and periods of wakefulness occur throughout the night. The method can therefore assist physicians in diagnosing the severity of apneas. Patients can wear a single sensor or a combination of sensors that can be easily measured at home: abdominal movement, thoracic movement, or pulse oximetry. For example, using only two sensors, DRIVEN correctly classifies 72.4% of all test patients into one of the four AHI classes, with 99.3% either correctly classified or placed one class away from the true one. This is a reasonable trade-off between the model's performance and the patient's comfort. We use publicly available data from three large sleep studies with a total of 14,370 recordings. DRIVEN consists of a combination of deep convolutional neural networks and a light-gradient-boost machine for classification. It can be implemented for automatic estimation of AHI in unsupervised long-term home monitoring systems, reducing costs to healthcare systems and improving patient care.

Comparing efficacy of the mandibular advancement device after drug-induced sleep endoscopy and continuous positive airway pressure in patients with obstructive sleep apnea

PURPOSE

The purpose of this study was to compare objective and self-reported outcomes of two treatments for managing mild, moderate, and severe obstructive sleep apnea (OSA) in adults: a mandibular advancement device (MAD) and continuous positive airway pressure (CPAP).

METHODS

Patients diagnosed with OSA by means of polysomnography (PSG) included one group treated with a custom-made, two-piece, adjustable MAD and a second group treated with CPAP for 8 weeks. Before the initiation of the treatment, all patients assigned to MAD underwent drug-induced sleep endoscopy (DISE), and all CPAP group patients underwent manual titration of CPAP after PSG. Objective (PSG) and self-reported (Epworth Sleepiness Scale [ESS] and Short Form Health Survey [SF-36]) data were used to assess outcomes. Collected data included apnea-hypopnea index (AHI), mean capillary oxygen saturation (SpO2), oxygen desaturation index (ODI), arousal index (AI), degree of daytime sleepiness, and quality of life. A PSG follow-up after 8 weeks with MAD in situ, and data from the CPAP data card were used to assess the effect of the two treatments.

RESULTS

A total of 59 patients included 30 treated with MAD and 29 treated with CPAP. Between baseline and the 8-week follow-up, the mean AHI score decreased significantly from 35.1 to 6.8 episodes/h (p < 0.001) in patients treated with MAD and from 35.2 to 3.0 episodes/h (p < 0.001) in patients treated with CPAP. The mean AHI score at the 8-week follow-up was significantly lower in CPAP group than in MAD group (p = 0.003). The two groups did not differ significantly at follow-up regarding SpO2 (p = 0.571), ODI (p = 0.273), AI (p = 0.100), ESS score (p = 0.648), and SF-36 score (p = 0.237).

CONCLUSION

In the short term, patients on CPAP attained better PSG outcomes in terms of AHI reduction. Both MAD after DISE evaluation and CPAP resulted in similar improvements in clinical symptoms and health-related quality of life, even in patients with severe OSA.

Increased Levels of VCAM-1 in Patients with High Cardiovascular Risk and Obstructive Sleep Apnea Syndrome

(1) Background: Although obstructive sleep apnea (OSA) is associated with increased cardiovascular morbidity, the link between OSA and cardiovascular disease (CVD) is not completely elucidated. Thus, we aim to assess cardiovascular risk (CVR) using SCORE 2 and SCORE 2 for older persons (SCORE 2OP), and to evaluate the association between the endothelial biomarkers VCAM-1, ICAM-1, epicardial fat, and sleep study parameters in order to improve current clinical practices and better understand the short-and long-term CVRs in OSA patients. (2) Methods: 80 OSA patients and 37 healthy volunteers were enrolled in the study. SCORE2 and SCORE 2 OP regional risk charts (validated algorithms to predict the 10-year risk of first-onset CVD) were used for the analysis of CVR. Two-dimensional echocardiography was performed on all patients and epicardial fat thickness was measured. VCAM-1 and ICAM-1 serum levels were assessed in all patients. (3) Results: OSA patients were classified as being at high CVR, regardless of the type of score achieved. Increased EFT was observed in the OSA group. VCAM-1 was associated with a high CVR in OSA patients, but no significant correlation was observed between adhesion molecules and epicardial fat thickness. (4) Conclusions: OSA patients have a high CVR according to the SCORE 2 and SCORE 2OP risk scores. VCAM-1 may be associated with a high CVR in OSA patients. Extending conventional risk stratification scores by adding other potential biomarkers improves the risk stratification and guide treatment eligibility for CVD prevention in the OSA population.

Update on the genetic basis of obstructive sleep apnoea - hype or hope?

PURPOSE OF REVIEW

The obstructive sleep apnoea syndrome (OSAS) is a chronic, common condition in western societies which can lead to adverse cardiometabolic effects if left untreated and is one of the commonest causes of excessive daytime somnolence.

RECENT FINDINGS

The presentation of OSAS is diverse and is thought to comprise of different intermediate phenotypes and endotypes in varying proportions in each individual. Unfortunately, due to its heterogeneity and the changing definitions of the disorder by workers in the field, attempts at revealing the genetic basis of OSAS has been fraught with difficulty.

SUMMARY

This brief review presents a short update on the achievements of the past three decades in this understudied and underfunded area of endeavour in respiratory sleep medicine. The genetic underpinnings of OSAS remain elusive.

Systematic review and meta-analysis of the prevalence of obstructive sleep apnea in Indian adults

Obstructive sleep apnea (OSA) is a common sleep disorder associated with considerable morbidity. However, there is an underrepresentation of data from India and other developing countries in global reviews of OSA prevalence. This systematic review and meta-analysis examined the prevalence of OSA in India. The MEDLINE, Embase, and Scopus databases were searched for articles that reported the prevalence of OSA in the general Indian adult population using sleep studies. Eight studies were included comprising 11,009 subjects with mean age ranging from 35.5 to 47.8 years. On the Joanna Briggs Institute (JBI) checklist for prevalence studies, the study quality ranged from 3/9 to 9/9. Meta-analysis was performed using the random-effects model. The pooled prevalence of OSA (AHI ≥5 events/hour) was 11% overall (95% CI: 7%-15%; I2 = 98.0%, p<0.001), 13% in males (95% CI: 7%-18%; I2 = 96.0%, p<0.001), and 5% in females (95% CI: 3%-7%; I2 = 73.3%, p = 0.01). The pooled prevalence of moderate-to-severe OSA (AHI ≥15 events/hour) was 5% (95% CI: 2%-8%, I2 = 95.3%; p = 0.01). Based on these findings, approximately 104 million Indians of working age suffer from OSA, of whom 47 million have moderate-to-severe OSA. This represents a major public health problem in India with important implications for the global burden of the disease.

Aiming to Improve Equity in Lung Health: Sex and Gender

Sex and gender impact risk factors, presentations of, and response to therapy in lung diseases such as chronic obstructive pulmonary disease, asthma, lung cancer, interstitial lung disease, and obstructive sleep apnea. Many physicians lack training in the impact of sex and gender on lung disease, resulting in diagnostic delays. Scales and indices taught in the health care system are largely validated in male populations, thereby limiting their application to females. For transgender and lesbian, gay, bisexual, transgender, and questioning + patients, high rates of bias in health care may limit patients' willingness to seek health care.

ERS technical standards for using type III devices (limited channel studies) in the diagnosis of sleep disordered breathing in adults and children

For more than three decades, type III devices have been used in the diagnosis of sleep disordered breathing in supervised as well as unsupervised settings. They have satisfactory positive and negative predictive values for detecting obstructive and central sleep apnoea in populations with moderately high pre-test probability of symptoms associated with these events. However, standardisation of commercially available type III devices has never been undertaken and the technical specifications can vary widely. None have been subjected to the same rigorous processes as most other diagnostic modalities in the medical field. Although type III devices do not include acquisition of electroencephalographic signals overnight, the minimum number of physical sensors required to allow for respiratory event scoring using standards outlined by the American Academy of Sleep Medicine remains debatable. This technical standard summarises data on type III studies published since 2007 from multiple perspectives in both adult and paediatric sleep practice. Most importantly, it aims to provide a framework for considering current type III device limitations in the diagnosis of sleep disordered breathing while raising research- and practice-related questions aimed at improving our use of these devices in the present and future.

Disease definitions in respiratory and sleep medicine: changes in diagnostic criteria and categories over time and clinical implications

The latest issue of Breathe focuses on disease definitions in respiratory and sleep medicine: read the introductory editorial by Chief Editor @ClaudiaCDobler https://bit.ly/3A7CeYj.