Obstructive sleep apnea: personal, societal, public health, and legal implications

Impact of continuous positive airway pressure on cognitive functions in adult patients with obstructive sleep apnea: A systematic review and meta-analysis

BACKGROUND

Obstructive sleep apnea (OSA) is associated with the impairment of a range of cognitive functions. Whether treatment with continuous positive airway pressure (CPAP) improves these cognitive functions is still a matter of debate.

METHODS

We performed a systematic review and meta-analysis of randomized controlled trials (RCTs) that included OSA patients (apnea hypopnea index, AHI >10/h), naive to CPAP treatment, with a cognitive assessment before and after CPAP initiation. We compared CPAP versus sham-CPAP or placebo tablet or dietary rules or no treatment. This systematic review and meta-analysis were registered in PROSPERO (ID CRD42021275214).

RESULTS

Eleven RCTs encompassing 923 OSA patients were included. For most of them, CPAP initiation was ≤3 months. A significant post-treatment improvement was found for the Trail Making Test part B (TMT-B; SMD = -0.93, 95 % CI = [-1.60, -0.25], Z = -2.70, p = 0.007), but not for the other neuropsychological assessments. No global effects on other cognitive domains (information processing speed, executive functions, working memory) were found.

CONCLUSION

The significant improvement in the TMT-B supports a short-term enhancement in cognitive flexibility with CPAP treatment. Further studies that take into account OSA comorbidities, cognitive profiles, a more diverse range of cognition assessments and include long-term evaluations are needed.

Rostral fluid shifts and other mechanisms of interaction between obstructive sleep apnea and heart failure - a systematic review

<b>Introduction:</b> Obstructive sleep apnea (OSA) is a chronic inflammatory disorder characterized by episodes of total or partial upper airway obstruction during sleep. Untreated OSA leads to various cardiovascular complications, including heart failure (HF), both involving complex and detrimental pathophysiological processes.<b>Aim:</b> The aim of this study is to describe the role of rostral fluid shifts and other mechanisms responsible for the co-existence of OSA and HF, providing insight into potential diagnostic and therapeutic strategies.<b>Materials and methods:</b> Two authors independently searched the literature and assessed articles following PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analytics) guidelines.<b>Results:</b> Rostral fluid shifts, characterized by nocturnal redistribution from the lower limbs to the neck tissues, exacerbate upper airway obstruction by increasing neck circumference and predisposing individuals to respiratory events. This phenomenon is particularly significant in patients with HF due to impaired cardiovascular function leading to fluid retention. The repetitive collapse of the upper airway during sleep triggers abrupt changes in intrathoracic pressure negatively impacting cardiac tissue remodeling by promoting inflammation and fibrosis. Moreover, sleep fragmentation and arousals activate the sympathetic nervous system (SNS), imposing additional strain on the cardiovascular system. Accumulated data suggest that rostral fluid shifts are a clinically significant pathomechanism in the coexistence of OSA and HF. Therapeutic strategies, including the benefits of continuous positive airway pressure (CPAP) therapy and lifestyle modifications, have been discussed. This systematic review highlights the need for integrated treatment approaches to manage both OSA and HF effectively.<b>Conclusions:</b> Understanding and addressing these interconnected mechanisms is essential to offer an integrated diagnostic and therapeutic management of patients, highlighting the importance of multidisciplinary care to optimize patient health and quality of life.

Promoting identification of obstructive sleep apnea among patients with psychiatric conditions

ABSTRACT

Obstructive sleep apnea (OSA) is prevalent but remains underdiagnosed and undertreated. Recognizing OSA in patients with psychiatric disorders can be challenging due to the conditions' overlapping symptoms. To aid primary care NPs in identifying OSA among patients with psychiatric disorders, this article examines overlapping symptoms and outlines diagnostic reasoning. It also provides an overview of the anatomy and neurotransmitters involved in OSA, as well as OSA-specific screening tools and risk stratification, to promote the condition's identification among this population.

Machine-learning-based classification of obstructive sleep apnea using 19-channel sleep EEG data

OBJECTIVE

This study aimed to investigate the neurophysiological effects of obstructive sleep apnea (OSA) using multi-channel sleep electroencephalography (EEG) through machine learning methods encompassing various analysis methodologies including power spectral analysis, network analysis, and microstate analysis.

METHODS

Twenty participants with apnea-hypopnea index (AHI) ≥ 15 and 18 participants with AHI <15 were recruited. Overnight polysomnography was conducted concurrently with 19-channel EEG. Preprocessed EEG data underwent computation of relative spectral power. A weighted network based on graph theory was generated; and indices of strength, path length, eigenvector centrality, and clustering coefficient were calculated. Microstate analysis was conducted to derive four topographic maps. Machine learning techniques were employed to assess EEG features capable of differentiating two groups.

RESULTS

Among 71 features that showed significant differences between the two groups, seven exhibited good classification performance, achieving 88.3 % accuracy, 92 % sensitivity, and 84 % specificity. These features were power at C4 theta, P3 theta, P4 theta, and F8 gamma during NREM1 sleep and at Pz gamma during REM sleep from power spectral analysis; eigenvector centrality at F7 gamma during REM sleep from network analysis; and duration of microstate 4 during NREM2 sleep from microstate analysis. These seven EEG features were significantly correlated with polysomnographic parameters reflecting the severity of OSA.

CONCLUSIONS

The application of machine learning techniques and various EEG analytical methods resulted in a model that showed good performance in classifying moderate to severe OSA and highlights the potential of EEG to serve as a biomarker of functional changes in OSA.

The Emergence of Inpatient Sleep Medicine: Screening for Sleep Disordered Breathing to Reduce the Burden of Cardiovascular Disease

Purpose of Review

Treatment of obstructive sleep apnea (OSA) has historically been centered on outpatients given sleep testing is performed on an outpatient basis. Much of this practice originates from insurers only covering sleep testing on an outpatient basis. Over the last decade, there have been innovations made in the portability of sleep monitors which have allowed sleep testing on inpatients to be facilitated. There is also emerging data that inpatient sleep testing may reduce readmissions and healthcare costs in certain cardiovascular conditions. Accordingly, this review aims to provide comprehensive coverage of recent advances in the practice of inpatient sleep medicine and its effect on reducing the burden of cardiovascular disease.

Recent Findings

Chief cardiovascular diseases that intersect with OSA in inpatients are stroke, atrial fibrillation, and heart failure. There is data from the National Inpatient Sample comparing arrhythmia burdens in patients with OSA and HFpEF showing that OSA patients have higher mortality rates, hospital durations, and medical costs. Also, OSA is associated with higher burdens of arrhythmia. It is currently unknown whether treatment of inpatients with PAP therapy lowers the occurrence of arrhythmias. Recent data suggests that costs for heart failure patients with OSA that are readmitted are higher than those for heart failure patients without OSA. A recent analysis of patients with HFpEF (heart failure with preserved ejection fraction) and OSA showed that the PAP adherent patients had fewer healthcare related costs, lower readmission rates, and fewer emergency room visits than those that were nonadherent. In broader terms, rapid initiation of PAP therapy in a large administration database query of 23 million Medicare patients appears to reduce annual healthcare costs and reduce readmissions although further study is required.

Summary

OSA is globally underdiagnosed, with an estimated one billion individuals affected. OSA's pathogenesis involves a combination of risk factors, such as obesity, age, and increased neck circumference that contribute to fragmented sleep patterns and in turn, numerous cardiovascular comorbidities, such as stroke, atrial fibrillation, and coronary artery disease. Recently, inpatient sleep medicine programs have emerged as a promising avenue for improving diagnosis, patient safety, and potentially reducing readmissions. Integrating inpatient sleep medicine into healthcare systems to address the significant health and economic burden associated with undiagnosed OSA. Improved coverage of inpatient sleep testing and services will be a key driver of addressing inpatient gaps in sleep medicine care. The current research findings provide a bedrock from which further investigations may proceed in a prospective and randomized, controlled fashion to further clarify the effects of treatment of OSA on cardiovascular outcomes of inpatients.

Validity of Modified STOP-Bang Questionnaire as a Screening Tool for Obstructive Sleep Apnea

OBJECTIVES

The aim of this study was to evaluate the validity of a modified STOP-Bang questionnaire with different body mass index reference as a screening tool for obstructive sleep apnea in Korean population.

METHODS

The medical records of 1417 participants who underwent overnight Level I polysomnography were retrospectively analyzed. Predictive parameters were calculated for each of the 3 groups classified by obstructive sleep apnea severity with a cut-off value of 3 or 4. Responses to modified and traditional questionnaires were comparatively analyzed by receiver-operator characteristic curves and area under the receiver-operator characteristic curves.

RESULTS

The optimal cut-off values of the modified and traditional questionnaires were both 3.5. The area under the receiver-operator characteristic curve of modified STOP-Bang questionnaire for any obstructive sleep apnea group was 0.786 ± 0.018, which was significantly higher than that of the traditional questionnaire. The modified STOP-Bang questionnaire with a cut-off value ≥4 showed significantly higher sensitivity than the traditional one for any obstructive sleep apnea group. The diagnostic accuracy of the modified questionnaire was also significantly higher for the any obstructive sleep apnea group when the cut-off value was 4.

CONCLUSION

The modified STOP-Bang questionnaire, with a cut-off value of 4, can be used as an alternative to the traditional screening tool for the Korean population.

Patient-Reported Outcomes of Maxillomandibular Surgery for Obstructive Sleep Apnea Treatment: A Scoping Review

(1) Background: The present scoping review aims to scrutinize all existing patient-reported outcomes and assess the perspectives of obstructive sleep apnea patients after maxillomandibular surgery. (2) Methods: The review was carried out according to the extensions for scoping reviews using the PRISMA-ScR guidelines. Several databases were used to carry out the initial search. This study included randomized controlled trials, cohort studies, cross-sectional and case-control studies. The included studies considered patients with obstructive sleep apnea who were submitted to orthognathic surgery as the main subjects, and the patient's perception of quality of life, satisfaction, treatment experience and side effects were assessed. (3) Results: From 1407 examined articles, a total of 16 were included. Most of the included studies used more than one questionnaire to assess quality of life, except for five articles. The most commonly referred instruments were the Epworth Sleepiness Scale, SF-36, the Functional Outcomes of Sleep and Ottawa Sleep Apnea. The most commonly assessed outcomes were sleep quality, daytime function, facial aesthetics, dental function and emotional health. (4) Conclusions: The number of variables that can be evaluated from a patient's perspective are endless, as are the tools available to assess them. Not all of these tools, which are generally questionnaires, assess all the various outcomes, and some do not compare the pre- and post-surgical situations. Most of them are generic and lack specificity for obstructive sleep apnea.

The mediating role of coping styles in illness perception and self-management in patients with obstructive sleep apnea

STUDY OBJECTIVES

Obstructive sleep apnea (OSA) has become a chronic disease that threatens human health. Self-management in patients with OSA can influence their quality of life, and illness perception and coping styles are relevant facilitators of self-management, but this specific relationship has not been adequately studied. The purpose of this study was to investigate the current status and relationship between illness perception, coping styles, and self-management behaviors in patients with OSA, and how coping styles mediate this relationship.

METHODS

This is a cross-sectional study. Conducted between September 2022 and March 2023, the study involved patients aged ≥18 years old in two hospitals who were diagnosed with OSA. The survey was conducted using the demographic characteristics questionnaire, the Brief Illness Perception Questionnaire, the Simple Coping Style Questionnaire, and the Self-management Behavior Questionnaire of patients with obstructive sleep apnea. Spearman's correlation analysis was used for correlation analysis and multiple linear regression and structural equation models were used for mediation effect testing.

RESULTS

There were 282 valid questionnaires, with a 94 % valid response rate. Higher levels of self-management behaviors were associated with low negative illness perceptions, high positive coping, and low negative coping. The study also demonstrated that the mediating effect accounted for 25.65 % (-0.049/-0.191) of the overall effect.

CONCLUSION

Illness perceptions in OSA patients were negatively related to positive coping styles, positively related to negative coping styles, and negatively related to self-management. This study suggests that coping styles of OSA patients mediate illness perception and self-management.

Characterization of risk factors for obstructive sleep apnea and its association with absenteeism among nurses

PURPOSE

To characterize risk factors associated with obstructive sleep apnea (OSA) and its relationship with nurses' absenteeism.

METHODS

A cross-sectional study was conducted from 2018 to 2020 at a 1,000-bed academic hospital complex and biomedical research facility in Tehran, Iran. Participants were selected through consecutive sampling after obtaining ethical approval and informed consent. Data on demographics, medical conditions, occupational characteristics, and absenteeism were collected through face-to-face interviews. The STOP-Bang questionnaire was utilized to assess the probability of OSA. Statistical tests included the Mann-Whitney U, t-test, Chi-square, and multivariable regression.

RESULTS

In this study involving 304 nurses, the majority were female (81.3%), with an average age of 35. About 27 participants (8.9%) had a high probability of OSA, with male sex, older age, higher body mass index, neck circumference, and diastolic BP identified as the main determinants of OSA. Additionally, shift work and night shifts were associated with increased absenteeism, while sex showed no significant association with absenteeism rates among nurses.

CONCLUSION

Male sex, neck circumference (obesity), night shifts, and diastolic BP can predict OSA risk. However, unauthorized absence from work is not associated with a high risk for OSA (STOP-BANG ≥3) or the individual risk factors of OSA.

Brazilian Consensus on Sleep-Focused Speech-Language-Hearing Sciences - 2023 Brazilian Sleep Association

Introduction  This consensus aimed to develop a structured document presenting the role of sleep-focused Speech-Language-Hearing (SPH) Sciences (SPHS). The recommendations were based on the expertise of specialists and on evidence in the literature, aiming to guide the coverage of this area and the consequent improvement in the quality of the professionals' approach. Methods  A Delphi method was conducted with 49 SLH pathologists (SLHP), four sleep physicians, one dentist, one physical therapist, and one methodologist. Four Delphi panel rounds were conducted in Google Forms. The items were analyzed based on the panelists' percentage of agreement; consensuses were reached when ⅔ (66.6%) of valid responses were on a same on a same answer (either "agree" or "disagree"). Results  Participants voted on 102 items. The mean consensus rate was 89.9% ± 10.9%. The essential topics were the importance of professional training, the SLH diagnosis, and the SLH treatment of sleep disorders. It was verified that all fields of the SLHS are related to the area of sleep; that sleep-focused SLH pathologists (SLHP) are the responsible for assessing, indicating, and conducting specific orofacial myofunctional therapy for sleep-disordered breathing alone or in combination with other treatments; that SLHP are included in interdisciplinary teams in the area of sleep in public and private services. Discussion  The Brazilian consensus on sleep-focused SLHS is a landmark in this area. This consensus described the scope of action of sleep-focused SLHP and systematized recommendations being useful as a reference for the professional practice in the area of sleep.

Longitudinal risk factors for obstructive sleep apnea: A systematic review

Despite substantial disease burden, existing evidence on the risk factors for obstructive sleep apnea (OSA) have been derived primarily from cross-sectional studies without determining temporality. Therefore, we aimed to systematically synthesize the literature on longitudinal risk factors for sleep study-assessed OSA and questionnaire-assessed probable OSA from cohort studies in the general adult population settings. We systematically searched Embase and Medline (on OVID) databases. Eleven studies met the inclusion criteria. Meta-analyses were not conducted due to methodological heterogeneity of exposure and outcome measurements. There was consistent evidence that weight gain was associated with incident (n = 2) and greater severity (n = 2) of OSA. One study each observed an association of higher baseline body-mass index, male sex, asthma, a specific genetic polymorphism in rs12415421, and insulin resistance/hyperglycemia, with incident OSA. Long-term exposure to ambient air pollution (NO2, n = 1) was associated with OSA, and menopausal transitions (n = 1) with higher apnea-hypopnea index. There were no eligible studies on long-term smoking or alcohol use. In conclusion, approximately 10% increase in weight, especially in males, might alert clinicians to consider potential or worsening OSA. Large, well-designed longitudinal studies are needed to consolidate knowledge on other associations with OSA development, especially on potentially modifiable risk factors.

Continuous Positive Airway Pressure plus Mandibular Advancement Therapy (PAPMAT): study protocol for an adaptive randomised crossover trial comparing the benefits and costs of combining two established treatments for obstructive sleep apnoea

BACKGROUND

Obstructive sleep apnoea (OSA) involves repeated breathing pauses during sleep due to upper airway obstruction. It causes excessive daytime sleepiness and has other health impacts. Continuous positive airway pressure (CPAP) therapy is effective first line treatment for moderate to severe OSA. Unfortunately, many patients have difficulty tolerating CPAP and pressure intolerance is probably an important contributing factor. Mandibular advancement devices (MAD) are an alternative to CPAP. They are worn in the mouth during sleep to reduce airway obstruction. There is some evidence that, when used in combination with CPAP, MADs improve airway anatomy enough to reduce the CPAP pressure required to treat OSA and that this combination therapy could improve CPAP adherence.

METHODS

Consecutive patients starting on CPAP for moderate to severe OSA will be recruited at a regional NHS sleep service. Patients with high CPAP pressure requirements after initial titration, who satisfy all entry criteria and consent to participate, will undertake a 2-arm randomised crossover trial. The arms will be (i) standalone CPAP and (ii) CPAP + MAD therapy. Each arm will last 12 weeks, including 2 weeks acclimatisation. CPAP machines will be auto-titrating and with facility for data download, so the impact of MAD on CPAP pressure requirements and CPAP adherence can be easily measured. The primary outcome will be CPAP adherence. Secondary outcomes will include measures of OSA severity, patient-reported outcome measures including subjective daytime sleepiness, quality of life, and treatment preference at the trial exit and health service use. Cost-effectiveness analyses will be undertaken.

DISCUSSION

If the intervention is shown to be effective and cost-effective in improving adherence in this standard CPAP-eligible OSA patient population it would be relatively straightforward to introduce into existing OSA treatment pathways, within the wider NHS and more widely. Both MAD and CPAP are already used by sleep services so their combination would require only minor adjustments to existing clinical pathways. It would be straightforward to disseminate the results of the study through regional, national, and international respiratory meetings. The health economics analysis would provide cost-effectiveness data to inform service planning and clinical guidelines through policy briefing papers, including those by NICE and SIGN.

TRIAL REGISTRATION

PAPMAT was registered with ISRCTN prior to recruitment beginning (ISRCTN Registry 2021): https://www.isrctn.com/ISRCTN33966032 . Registered on 17th November 2021.

Examining changes in knowledge and practice in nurse practitioners after an online educational module on obstructive sleep apnea

AIMS

The purpose of this study is to investigate primary care nurse practitioner (NP) knowledge and knowledge retention on obstructive sleep apnea (OSA) screening after an educational in-service.

BACKGROUND

The prevalence of OSA is high and continues to rise amid the obesity epidemic. Approximately 75-90 % of individuals with moderate to severe OSA remain undiagnosed. Continuing education of OSA risk factors among primary care providers may increase screening rates, leading to early diagnosis and treatment.

METHODS

An educational module was presented to NPs (n = 30) during a mandatory NP in-service at two sets of outpatient clinics. Knowledge was assessed with a pre-test and post-test survey consisting of 23 items. A 25-item follow-up test was administered five weeks after to assess knowledge retention.

RESULTS

An increase in total knowledge scores was demonstrated between the pre-test and post-test with a decrease in knowledge observed at follow-up. Follow-up test total mean scores remained above pre-test levels, indicating potential long-term learning.

CONCLUSIONS

While learning was demonstrated, NPs acknowledged continued barriers to screening for OSA such as time and having no OSA screening tool available in the electronic medical record (EMR).

Association Between Positive Airway Pressure Adherence and Health Care Costs Among Individuals With OSA

BACKGROUND

The impact of positive airway pressure (PAP) therapy for OSA on health care costs is uncertain.

RESEARCH QUESTION

Are 3-year health care costs associated with PAP adherence in participants from the Tele-OSA clinical trial?

STUDY DESIGN AND METHODS

Participants with OSA and prescribed PAP in the Tele-OSA study were stratified into three PAP adherence groups based on usage patterns over 3 years: (1) high (consistently ≥ 4 h/night), (2) moderate (2-3.9 h/night or inconsistently ≥ 4 h/night), and (3) low (< 2 h/night). Using data from 3 months of the Tele-OSA trial and 33 months of posttrial follow up, average health care costs (2020 US dollars) in 6-month intervals were derived from electronic health records and analyzed using multivariable generalized linear models.

RESULTS

Of 543 participants, 25% were categorized as having high adherence, 22% were categorized as having moderate adherence, and 52% were categorized as having low adherence to PAP therapy. Average PAP use mean ± SD was 6.5 ± 1.0 h, 3.7 ± 1.2 h, and 0.5 ± 0.5 h for the high, moderate, and low adherence groups, respectively. The high adherence group had the lowest average covariate-adjusted 6-month health care costs ± SE ($3,207 ± $251) compared with the moderate ($3,638 ± $363) and low ($4,040 ± $304) adherence groups. Significant cost differences were observed between the high and low adherence groups ($832; 95% CI, $127 to $1,538); differences between moderate and low adherence were nonsignificant ($401; 95% CI, -$441 to $1,243).

INTERPRETATION

In participants with OSA, better PAP adherence was associated with significantly lower health care costs over 3 years. Findings support the importance of strategies to enhance long-term PAP adherence.

Nasal Blockage and Academic Performance Among Medical College Students in the Kingdom of Saudi Arabia

Objectives The most frequent otolaryngological complaint is nasal obstruction. We aimed to determine if there is a relationship between nasal blockage and academic performance among medical college students in Saudi Arabia. Methods This cross-sectional survey carried out from August to December 2022, included 860 medical students determining the risk of obstructive sleep apnea (OSA) on the participants using the Berlin Sleep Questionnaire Risk Probability, then comparing it to their socio-demographic characteristics, while the Chi-square test was used for the comparison of categorical variables. Result The average age of the participants in our study was 21.52 years; 60% were females and 40% were males. The risk of obstructive sleep apnea was found to be two times higher in females than in males (95% CI: 1.195- 3.345; p-value 0.008). The hypertensive participants had a 27-fold increased risk of OSA compared to non-hypertensives. Grade Point Average (GPA) and snoring had a statistically significant relationship, however, a fifth of the participants reported snoring (79.8% reported not snoring). We also found that 14.8% of the participants with snoring had a GPA between 2-4.49 compared to 44.6% of participants without snoring. Conclusion Female students had a two-fold higher chance of developing OSA than males. While a GPA of 4.5 and above was more often associated with participants without snoring, the number of individuals with a GPA of 2-4.49 was greater among participants with snoring. To aid in the prevention of illness complications and the management of risk factors, additional efforts should be made to increase disease knowledge among students, primary healthcare practitioners, and specialty doctors.

Antero-Posterior Mandibular Excursion in Obstructive Sleep Apnea Patients Treated with Mandibular Advancement Device: A Retrospective Cohort Study

Since obstructive sleep apnea (OSA) management with a mandibular advancement device (MAD) is likely to be life-long, potential changes in mandibular movements during therapy should be investigated. The purpose of this study was to use a method that has already been shown to be reliable in order to determine whether the range of antero-posterior mandibular excursion, the procedure upon which MAD titration is based, varies between baseline (T0) and at least 1 year of treatment (T1). The distance between maximal voluntary protrusion and maximal voluntary retrusion determined using the millimetric scale of the George Gauge was retrospectively collected from the medical records of 59 OSA patients treated with the MAD and compared between T0 and T1. A regression analysis was performed to evaluate the influence of treatment time, MAD therapeutic advancement and the patient's initial characteristics in excursion range variation. A statistically significant increase of 0.80 ± 1.52 mm (mean ± standard deviation, p < 0.001) was found for antero-posterior mandibular excursion. The longer the treatment time (p = 0.044) and the smaller the patient's mandibular excursion at T0 (p = 0.002), the greater the increase was. These findings could be explained by a muscle-tendon unit adaptation to the forward mandibular repositioning induced by the MAD. During MAD therapy, patients can develop a wider range of antero-posterior mandibular excursion, especially those with a smaller initial excursion capacity.

PATIENT-REPORTED OUTCOMES WHILE MANAGING OBSTRUCTIVE SLEEP APNEA WITH ORAL APPLIANCES: A SCOPING REVIEW

OBJECTIVE

This scoping review aims to describe dental treatment-related patient-reported outcomes (dPROs) while using oral appliances (OAs) to manage obstructive sleep apnea (OSA) in children and adults.

METHODS

Available literature that assessed dPROs in children and adults with OSA managed through OAs. Any clinical studies were included without restrictions of year or country. The results were analyzed and reported using narrative text and tables accompanying a descriptive summary.

RESULTS

The searches identified 1718 citations, and of these, forty-five studies were finally included. A total of 3498 adults were included in all 42 primary studies included in this review, in which all the studies presented adults as participants. The dPROs assessed were quality of life (QoL), reported side effects after OA usage, patient satisfaction, and experience with treatment, and subjective perception of occlusal changes after treatment.

CONCLUSION

This scoping review suggests that dPROs are mostly investigated as a secondary outcome from major studies exploring the effects of OAs on OSA severity, and often, dPROs are not well discussed or displayed on their report. As no risk of bias or certainty level assessment was completed, findings need to be carefully considered. Although in general terms management with OAs among adults with OSA does not seem to be uncomfortable or causing major problems to their lives, some mild discomfort and endured occlusal disturbances was reported in some studies. QoL seems to improve but consistent agreement was elusive. Data does not include experiences among those that dropped OA use. No data seems to exist about dPROs in children.

Sex differences in polysomnographic findings in patients with obstructive sleep apnea

BACKGROUND AND PURPOSE

Sex differences in the clinical findings and the polysomnographic presentation of patients with obstructive sleep apnea (OSA) are compelling current research issues. For example, patients suffering from obstructive sleep apnea are predominantly male. While women are older than men and tend to have a higher body mass index, men typically present with a more severe form of obstructive sleep apnea. Using polysomnography, we investigated a German cohort, subdivided per severity levels of obstructive sleep apnea (apnea-hypopnea index: ≥5 to < 15/h (mild), ≥15 to < 30/h (moderate), and ≥30/h (severe)) to provide a detailed analysis of breathing and sleep parameters, accounting for body position effects and severity of illness. A deeper understanding of sex differences may allow targeted diagnosis and treatment adjustment.

PATIENTS AND METHODS

This retrospective study included a cohort of 1242 German patients (940 male, 302 female) who underwent overnight polysomnography at the private sleep laboratory "Intersom Köln", Center for Sleep Medicine and Sleep Research. In 1125 subjects (878 male, 247 female), obstructive sleep apnea was diagnosed. All patients were examined between January 01, 2018 and December 31, 2020, comparing anthropometric, sleep morphological, and respiratory polysomnographic findings.

RESULTS

Female patients with obstructive sleep apnea were significantly older than male patients (60.9 ± 12.3 vs. 56.9 ± 12.5 years, P < .001), also among OSA subgroups per OSA severity. The body mass index was similar in male and female patients (29.6 ± 5.1 vs. 29.2 ± 7.3 kg/m², P > .05), including the three subgroups. Men were more likely to have severe obstructive sleep apnea (46.9%) than women (35.2%). Women exhibited a higher proportion of slow-wave sleep than men (129.4 ± 52.8 vs. 104.2 ± 53.2 min; P < .001). The apnea-hypopnea index of total sleep time was significantly greater in male than female patients (32.9 ± 21.2 vs. 27.2 ± 20.2 per hour; P < .001). Female patients had a higher apnea-hypopnea index during rapid-eye-movement (REM) sleep (34.0 ± 23.8 vs. 31.8 ± 22.3 per hour; P = .171). A statistically significant difference in the apnea-hypopnea index during REM sleep between sexes was found when the obstructive sleep apnea severity was considered. Women had a lower apnea-hypopnea index in non-rapid eye-movement (NREM) sleep than men (25.7 ± 21.1 vs. 32.7 ± 22.3 per hour; P < .001). The oxygen desaturation index (29.9 ± 20.3 vs. 22.4 ± 19.4%; P < .001) and an oxygen desaturation below 90% (9.4 ± 14.0 vs. 6.8 ± 11.7%; P = .003) was greater in men than in women. In severe obstructive sleep apnea, the oxygen desaturation index was similar between the sexes (45.0 ± 17.8 vs. 41.1 ± 20.9%; P = .077). Male patients showed a higher supine apnea-hypopnea-index than female patients. (45.7 ± 26.7 vs 36.1 ± 22.7 per hour; P < .001).

CONCLUSION

The present noninvasive, retrospective registry study is the first to examine sex differences in OSA in such a large German population in terms of respiratory and sleep parameters, taking into account the effects of body position and severity of the disease. We could confirm and extend observations from previous studies. Female patients were significantly older than the male patients. The apnea-hypopnea index was higher in male than in female patients. Women showed a higher apnea-hypopnea index in REM sleep and a lower one in NREM sleep. Men were desaturated more often and were more affected by supine-dependent obstructive sleep apnea than women. Contrary to the literature, there were no significant differences in body mass index (BMI) between the sexes. With increasing age and BMI, the gender differences become less significant.

Potential Diagnostic and Monitoring Biomarkers of Obstructive Sleep Apnea-Umbrella Review of Meta-Analyses

Obstructive sleep apnea (OSA) is a prevalent, underdiagnosed disease that imposes a significant impact on the health and wellbeing of patients and a financial burden on individuals, their families, and society. Development of new methods of testing other than an overnight sleep study, such as measurement of serum or plasma biomarkers, may provide an easier diagnostic process to identify patients with OSA and allow earlier initiation of treatment, which might prevent serious comorbidities. We conducted a systematic review and quality assessment of available meta-analyses regarding potential diagnostic and monitoring biomarkers of obstructive sleep apnea. A total of 14 sets of candidate biomarkers displayed differences in levels or concentrations in OSA patients compared to non-OSA controls, and decreased after OSA treatment: CRP, IL-6, TNF-α, Il-8, HCY, ICAM-1, VCAM-1, VEGF, TC, LDLc, HDLc, TG, leptin, MDA, ALT, AST, IGF-1, adiponectin, and cortisol. This review summarizes the evidence for OSA-associated potential biomarkers and demonstrates that the quality of available studies, as measured by AMSTAR2, is often low and associated with a high risk of bias.

Factors influencing patient delay in individuals with obstructive sleep apnoea: a study based on an integrated model

BACKGROUND

Obstructive sleep apnoea (OSA) is the most common sleep-related breathing disorder, yet it remains undiagnosed in a large proportion of adults.

OBJECTIVE

This study aims to investigate the status of patient delay and provider delay in OSA patients and examine related factors affecting patient delay in OSA individuals in China.

METHODS

A cross-sectional design was conducted on a sample of 309 OSA patients (aged from 18 to 76, median age of 47 years, 84.8% male) in Northeast China. Participants were required to complete the sociodemographic questionnaire, the symptom characteristics questionnaire, the help-seeking attitude scale (HSAS), the social support rating scale and the chronic disease self-efficacy scales (CDSES) to test the hypothesis. Binary logistic regression analysis was conducted to explore factors that account for the patient delay.

RESULTS

The median patient delay among OAS patients in this study was 22 months, the median provider delay was one month, and the median total delay was 26 months. As shown by multivariate analysis results, patients who have snored for over 6 years (OR = 3.377, 95%CI: 1.175-9.702) were more likely to experience prolonged patient delays. Per capita monthly family income above 3000 RMB (OR = 0.172, 95%CI: 0.052-0.571), taking up residence in cities or towns (OR = 0.484, 95%CI: 0.248-0.946), higher self-recognition of the disease (OR = 0.793, 95%CI: 0.647-0.972), higher objective support (OR = 0.825, 95%CI: 0.739-0.921) and stronger self-efficacy (OR = 0.674, 95%CI: 0.525-0.867) were significantly associated with shorter patient delays.

CONCLUSION

Patient delay is common in Chinese OSA patients. The upstream factors affecting the patient delay in individuals with OSA include income, place of residence, and objective support; midstream factors include self-recognition of the disease and self-efficacy; downstream factors include years of snoring.KEY MESSAGESDespite being a high-prevalence disease, many obstructive sleep apnoea (OSA) patients are not clearly diagnosed and treated.The factors affecting the delay in seeking medical treatment in individuals with OSA included income, place of residence, objective support, self-recognition of the disease, self-efficacy and years of snoring.Investigations into OSA patients' care-seeking behaviours can better reflect the secondary prevention of OSA, and it is crucial to pay attention to the delayed phase of patients.

Selection of OSA-specific pronunciations and assessment of disease severity assisted by machine learning

STUDY OBJECTIVES

To screen all of the obstructive sleep apnea (OSA)-characteristic pronunciations, explore the pronunciations which provide a better OSA classification effect than those used previously, and further clarify the correlation between speech signals and OSA.

METHODS

A total of 158 adult male Mandarin native speakers who completed polysomnography at the Sleep Medicine Center of Beijing Tongren Hospital from November 15, 2019, to January 19, 2020, were enrolled in this study. All Chinese syllables were collected from each participant in the sitting position. The syllables, vowels, consonants, and tones were screened to identify the pronunciations that were most effective for OSA classification.

RESULTS

The linear prediction coefficients of Chinese syllables were extracted as features and mathematically modeled using a decision tree model to dichotomize participants with apnea-hypopnea index thresholds of 10 and 30 events/h, and the leave-one-out method was used to verify the classification performance of Chinese syllables for OSA. Chinese syllables such as [leng] and [jue], consonant pronunciations such as [zh] and [f], and vowel pronunciations such as [ing] and [ai] were the most suitable pronunciations for classification of OSA. An OSA classification model consisting of several syllable combinations was constructed, with areas under curve of 0.83 (threshold of apnea-hypopnea index = 10) and 0.87 (threshold of apnea-hypopnea index = 30), respectively.

CONCLUSIONS

This study is the first comprehensive screening of OSA-characteristic pronunciations and can act as a guideline for the construction of OSA speech corpora in other languages.

CITATION

Ding Y, Sun Y, Li Y, et al. Selection of OSA-specific pronunciations and assessment of disease severity assisted by machine learning. J Clin Sleep Med. 2022;18(11):2663-2672.

Co-exposure to multiple air pollutants and sleep disordered breathing in patients with or without obstructive sleep apnea: A cross-sectional study

BACKGROUND

Air pollution may be a contributing risk factor for obstructive sleep apnea (OSA). However, the health effects of co-exposure to multiple air pollutants on OSA patients remain unclear.

OBJECTIVES

To assess the joint effect of multi-pollutant on sleep disordered breathing (SDB) parameters in patients with or without OSA and identify the dominant pollutants.

METHODS

A total of 2524 outpatients from April 2020 to May 2021 were recruited in this cross-sectional study. Ambient air pollutant data were obtained from the nearest central monitoring stations to participants' residential address. SDB parameters were measured by the ApneaLink devices, including apnea-hypopnea index (AHI), hypopnea index (HI), oxygen desaturation index (ODI), average oxygen saturation (SpO₂), percentage sleep time with <90% saturation (T90), and desaturation. Bayesian kernel machine regression (BKMR) was applied to evaluate the effects of multiple pollutants.

RESULTS

Significant associations were observed between air pollutants and SDB parameters (including increases in AHI, HI, ODI, and desaturation) among patients with OSA. Co-exposure to air pollutants was positively correlated with AHI, HI, and ODI. PM₁₀ and O₃ dominated the effects of pollutant mixtures on OSA, with the highest posterior inclusion probability (PIP) values of 0.592 and 0.640, respectively. Stratified analysis showed that, compared to male patients with OSA, stronger effects on the SDB parameters were observed in female patients. Stronger associations were also found in the warm season than those in the cold season.

CONCLUSION

Co-exposure to air pollutants was associated with SDB parameters among patients with OSA, PM₁₀ and O₃ might play the dominant roles.

Study protocol of a randomized controlled trial of motivational interviewing-based intervention to improve adherence to continuous positive airway pressure in patients with obstructive sleep apnea syndrome: The MotivAir study

Objective

This study aims to evaluate the effectiveness of the MotivAir program-a phone-based intervention based on Motivational Interviewing (MI) principles and techniques-in enhancing adherence to Continuous Positive Airway Pressure (CPAP) therapy among patients with Obstructive Sleep Apnea Syndrome (OSAS).

Methods

A multicenter randomized controlled trial (RCT) design with random allocation at the level of the individual will be conducted to compare the impact of the experimental program (usual care plus MI) with a control group receiving usual care only in improving selected clinical and psychological parameters in the patients. A minimum sample of 80 participants (40 patients per group) will be recruited in each center according to the inclusion criteria. After the initial screening, participants will be randomly assigned to either the experimental group or the control condition. The program will last 180 days and will be delivered by a trained nurse. The impact of the MotivAir program on selected primary (adherence to CPAP in terms of average hours of usage per night and the Apnea-Hypopnea Index, AHI) and secondary (motivation, perceived competence, quality of life, sleepiness) outcomes will be measured at baseline, and after 1-, 3-, and 6-month from CPAP initiation.

Discussion

Participants are expected to show an increased level of adherence to CPAP and to acquire the skills and self-confidence necessary to deal with the psychological consequences of their chronic condition.

Correlation of Dyslipidemia and Inflammation With Obstructive Sleep Apnea Severity

Introduction: Obstructive sleep apnea (OSA) is a serious condition linked with various metabolic disorders and associated with increased all-cause and cardiovascular mortality. Although the potential mechanisms of pathophysiological processes related to OSA are relatively well known, the data regarding the correlation between obstructive sleep apnea, dyslipidemia, and systemic inflammation are still inconclusive.

Methods: The study was conducted as a retrospective cohort study including 328 patients with newly diagnosed obstructive sleep apnea during the period between April 2018, and May 2020, in University Clinical Hospital Center “Bezanijska kosa”, Belgrade, Serbia. Polysomnography was performed in all patients according to the protocol. Numerous demographic, antropometric, laboratory, and clinical data were correlated to Apnea-Hypopnea Index (AHI) as a dependent variable, with a particular review on the relation between lipid abnormalities, inflammatory parameters, and obstructive sleep apnea severity. Multivariate logistic regression model was used to assess predictors of severe OSA (AHI ≥30 per hour).

Results: A total of 328 patients were included in the study. The mean age of the patients was 54.0 ± 12.5 years and more than two-thirds were male (68.8%). The majority of the patients had an AHI of at least 30 events per hour. Patients with severe OSA were more frequently male, obese, hypertensive and hyperlipidemic, and had increased neck circumference (both male and female patients). One hundred and thirty-two patients had metabolic syndrome. Patients with severe OSA more frequently had metabolic syndrome and significantly higher levels of glucose, creatinine, uric acid, AST, ALT, CK, microalbumine/creatinine ratio, triglyceride, total cholesterol, HDL, total cholеsterol to HDL‐C ratio, CRP, and ESR. In the multivariate linear regression model with AHI (≥30 per hour) as a dependent variable, of demographic and clinical data, triglycerides ≥1.7 mmol/L and CRP >5 mg/L were significantly associated with AHI≥30 per hour.

Conclusion: The present study on 328 patients with newly diagnosed obstructive sleep apnea revealed significant relation of lipid abnormalities, inflammatory markers, and other clinically important data with obstructive sleep apnea severity. These results can lead to a better understanding of the underlying pathophysiological processes and open the door to a new world of potentially useful therapeutic modalities.

Continuous positive airway pressure and adverse cardiovascular events in obstructive sleep apnea: are participants of randomized trials representative of sleep clinic patients?

STUDY OBJECTIVES

Randomized controlled trials (RCTs) have shown no reduction in adverse cardiovascular (CV) events in patients randomized to continuous positive airway pressure (CPAP) therapy for obstructive sleep apnea (OSA). This study examined whether randomized study populations were representative of OSA patients attending a sleep clinic.

METHODS

Sleep clinic patients were 3,965 consecutive adults diagnosed with OSA by in-laboratory polysomnography from 2006 to 2010 at a tertiary hospital sleep clinic. Characteristics of these patients were compared with participants of five recent RCTs examining the effect of CPAP on adverse CV events in OSA. The percentage of patients with severe (apnea-hypopnea index, [AHI] ≥ 30 events/h) or any OSA (AHI ≥ 5 events/h) who met the eligibility criteria of each RCT was determined, and those criteria that excluded the most patients identified.

RESULTS

Compared to RCT participants, sleep clinic OSA patients were younger, sleepier, more likely to be female and less likely to have established CV disease. The percentage of patients with severe or any OSA who met the RCT eligibility criteria ranged from 1.2% to 20.9% and 0.8% to 21.9%, respectively. The eligibility criteria that excluded most patients were preexisting CV disease, symptoms of excessive sleepiness, nocturnal hypoxemia and co-morbidities.

CONCLUSIONS

A minority of sleep clinic patients diagnosed with OSA meet the eligibility criteria of RCTs of CPAP on adverse CV events in OSA. OSA populations in these RCTs differ considerably from typical sleep clinic OSA patients. This suggests that the findings of such OSA treatment-related RCTs are not generalizable to sleep clinic OSA patients.Randomized Intervention with Continuous Positive Airway Pressure in CAD and OSA (RICCADSA) trial, https://clinicaltrials.gov/ct2/show/NCT00519597, ClinicalTrials.gov number, NCT00519597.Usefulness of Nasal Continuous Positive Airway Pressure (CPAP) Treatment in Patients with a First Ever Stroke and Sleep Apnea Syndrome, https://clinicaltrials.gov/ct2/show/NCT00202501, ClinicalTrials.gov number, NCT00202501.Effect of Continuous Positive Airway Pressure (CPAP) on Hypertension and Cardiovascular Morbidity-Mortality in Patients with Sleep Apnea and no Daytime Sleepiness, https://clinicaltrials.gov/ct2/show/NCT00127348, ClinicalTrials.gov number, NCT00127348.Continuous Positive Airway Pressure (CPAP) in Patients with Acute Coronary Syndrome and Obstructive Sleep Apnea (OSA) (ISAACC), https://clinicaltrials.gov/ct2/show/NCT01335087, ClinicalTrials.gov number, NCT01335087.

Effect of an Interdisciplinary Weight Loss and Lifestyle Intervention on Obstructive Sleep Apnea Severity: The INTERAPNEA Randomized Clinical Trial

Importance

Obesity is the leading cause of obstructive sleep apnea (OSA); however, the effects of weight loss and lifestyle interventions on OSA and comorbidities remain uncertain.

Objective

To evaluate the effect of an interdisciplinary weight loss and lifestyle intervention on OSA and comorbidities among adults with moderate to severe OSA and overweight or obesity.

Design, Setting, and Participants

The Interdisciplinary Weight Loss and Lifestyle Intervention for OSA (INTERAPNEA) study was a parallel-group open-label randomized clinical trial conducted at a hospital-based referral center in Granada, Spain, from April 1, 2019, to October 23, 2020. The study enrolled 89 Spanish men aged 18 to 65 years with moderate to severe OSA and a body mass index (calculated as weight in kilograms divided by height in meters squared) of 25 or greater who were receiving continuous positive airway pressure (CPAP) therapy. The sole inclusion of men was based on the higher incidence and prevalence of OSA in this population, the differences in OSA phenotypes between men and women, and the known effectiveness of weight loss interventions among men vs women.

Interventions

Participants were randomized to receive usual care (CPAP therapy) or an 8-week weight loss and lifestyle intervention involving nutritional behavior change, aerobic exercise, sleep hygiene, and alcohol and tobacco cessation combined with usual care.

Main Outcomes and Measures

The primary end point was the change in the apnea-hypopnea index (AHI) from baseline to the intervention end point (8 weeks) and 6 months after intervention. Secondary end points comprised changes in other OSA sleep-related outcomes, body weight and composition, cardiometabolic risk, and health-related quality of life.

Results

Among 89 men (mean [SD] age, 54.1 [8.0] years; all of Spanish ethnicity; mean [SD] AHI, 41.3 [22.2] events/h), 49 were randomized to the control group and 40 were randomized to the intervention group. The intervention group had a greater decrease in AHI (51% reduction; change, -21.2 events/h; 95% CI, -25.4 to -16.9 events/h) than the control group (change, 2.5 events/h; 95% CI, -2.0 to 6.9 events/h) at the intervention end point, with a mean between-group difference of -23.6 events/h (95% CI, -28.7 to -18.5 events/h). At 6 months after intervention, the reduction in AHI was 57% in the intervention group, with a mean between-group difference of -23.8 events/h (95% CI, -28.3 to -19.3 events/h). In the intervention group, 18 of 40 participants (45.0%) no longer required CPAP therapy at the intervention end point, and 6 of 40 participants (15.0%) attained complete OSA remission. At 6 months after intervention, 21 of 34 participants (61.8%) no longer required CPAP therapy, and complete remission of OSA was attained by 10 of 34 participants (29.4%). In the intervention vs control group, greater improvements in body weight (change, -7.1 kg [95% CI, -8.6 to -5.5 kg] vs -0.3 kg [95% CI, -1.9 to 1.4 kg]) and composition (eg, change in fat mass, -2.9 kg [95% CI, -4.5 to -1.3 kg] vs 1.4 kg [95% CI, -0.3 to 3.1 kg]), cardiometabolic risk (eg, change in blood pressure, -6.5 mm Hg [95% CI, -10.3 to -2.6 mm Hg] vs 2.2 mm Hg [95% CI, -2.1 to 6.6 mm Hg]), and health-related quality of life (eg, change in Sleep Apnea Quality of Life Index, 0.8 points [95% CI, 0.5-1.1 points] vs 0.1 points [95% CI, -0.3 to 0.4 points]) were also found at the intervention end point.

Conclusions and Relevance

In this study, an interdisciplinary weight loss and lifestyle intervention involving Spanish men with moderate to severe OSA and had overweight or obesity and were receiving CPAP therapy resulted in clinically meaningful and sustainable improvements in OSA severity and comorbidities as well as health-related quality of life. This approach may therefore be considered as a central strategy to address the substantial impact of this increasingly common sleep-disordered breathing condition.

Trial Registration

ClinicalTrials.gov Identifier: NCT03851653.

Characterization of fecal metabolome changes in patients with obstructive sleep apnea

STUDY OBJECTIVES

Obstructive sleep apnea (OSA) is a clinical syndrome characterized by recurrent episodes of apnea or hypopnea of the upper airway, leading to increased negative intrathoracic pressure, sleep fragmentation, intermittent hypoxia during sleep, and increased risk for morbidity and mortality of affected patients. The gut microbiome plays a key role in OSA pathogenesis, and fecal metabolic profiling reflects the gut microbial functional readout and mediates host-microbiome interactions.

METHODS

Herein, we conducted a cohort study to explore fecal metabolic signatures distinguishing OSA (44 patients) from healthy controls (22 healthy controls) by untargeted gas chromatography-time-of-flight mass spectroscopy.

RESULTS

Significant metabolic signatures were detected in stool samples of patients with OSA: 246 metabolites of 24 ontology classes were identified, and 48 metabolites of 6 ontology classes were shifted. An enrichment of arachidonic acid, docosahexaenoic acid, and 11Z-eicosenoic acid and reduction in stearic acid, 5-hydroxyindoleacetic acid, gluconic acid, and α-hyodeoxycholic acid were observed in stool samples from patients with OSA. Fecal variance resulted in alterations in potential metabolic activities and was thereby strongly associated with host phenotypes, such as pulse blood oxygen saturation and apnea-hypopnea index. The prediction model based on feces metabolomics was established to distinguish OSA from healthy controls with high accuracy.

CONCLUSIONS

This study revealed the metabolomic signatures of patients with OSA in feces, and the findings provide evidence of an association between metabolome and OSA.

CITATION

Dong Y, Wang P, Lin J, et al. Characterization of fecal metabolome changes in patients with obstructive sleep apnea. J Clin Sleep Med. 2022;18(2):575-586.

A Model for Sleep Apnea Management in Underserved Patient Populations

INTRODUCTION

Obstructive sleep apnea (OSA) is a common condition in the United States that is strongly linked to metabolic disease, cardiovascular disease, and increased mortality. Uninsured populations experience sleep health disparities, including delayed recognition, diagnosis, and treatment of OSA due to barriers accessing and affording care. Partnerships between primary care clinics and sleep medicine specialists for sleep apnea management have the potential to increase screening, testing, and treatment among underserved populations. Here, we present an integrated and cost-effective model that is easier to navigate for patients while maintaining high quality care.

METHODS

We designed and implemented a specialty sleep clinic at Shade Tree Clinic, Vanderbilt's student-run, free primary care clinic. Patients with signs and symptoms of OSA were identified at primary care appointments and screened using the STOP-BANG questionnaire. Clinic visits took place over telehealth with a medical student and sleep specialist. Patients were diagnosed using a home sleep test, and if indicated, were prescribed and given a CPAP device for treatment. CPAP adherence was monitored using a cloud-based remote monitoring system.

RESULTS

From December 2020 through August 2021, we hosted 6 telehealth Sleep Clinics, seeing a total of 28 patients across these visits. We have received a total of 37 referrals and have coordinated sleep evaluations and diagnostic testing for 18 of these patients so far. Prior to initiation of the sleep clinic, there were 17 patients on our primary care panel at Shade Tree with a diagnosis of OSA. These patients were using donated equipment and many had been lost to follow-up or had broken parts. We were able to replace 10 of these patient's CPAP devices and plan to replace the remaining seven.

CONCLUSIONS

We have created a model of integrated specialty care that is efficient and cost-effective. This paradigm can be replicated for the many specialties that are typically overlooked and undertreated when working with uninsured patients. As awareness of this sleep medicine program becomes more widespread at Shade Tree Clinic, we anticipate reaching more primary care patients with signs and symptoms of sleep apnea through student education, cost-effective diagnostics, and partnership with sleep specialists.

Proof of principle study: diagnostic accuracy of a novel algorithm for the estimation of sleep stages and disease severity in patients with sleep-disordered breathing based on actigraphy and respiratory inductance plethysmography

PURPOSE

In this proof of principle study, we evaluated the diagnostic accuracy of the novel Nox BodySleepTM 1.0 algorithm (Nox Medical, Iceland) for the estimation of disease severity and sleep stages based on features extracted from actigraphy and respiratory inductance plethysmography (RIP) belts. Validation was performed against in-lab polysomnography (PSG) in patients with sleep-disordered breathing (SDB).

METHODS

Patients received PSG according to AASM. Sleep stages were manually scored using the AASM criteria and the recording was evaluated by the novel algorithm. The results were analyzed by descriptive statistics methods (IBM SPSS Statistics 25.0).

RESULTS

We found a strong Pearson correlation (r=0.91) with a bias of 0.2/h for AHI estimation as well as a good correlation (r=0.81) and an overestimation of 14 min for total sleep time (TST). Sleep efficiency (SE) was also valued with a good Pearson correlation (r=0.73) and an overestimation of 2.1%. Wake epochs were estimated with a sensitivity of 0.65 and a specificity of 0.59 while REM and non-REM (NREM) phases were evaluated a sensitivity of 0.72 and 0.74, respectively. Specificity was 0.74 for NREM and 0.68 for REM. Additionally, a Cohen's kappa of 0.62 was found for this 3-class classification problem.

CONCLUSION

The algorithm shows a moderate diagnostic accuracy for the estimation of sleep. In addition, the algorithm determines the AHI with good agreement with the manual scoring and it shows good diagnostic accuracy in estimating wake-sleep transition. The presented algorithm seems to be an appropriate tool to increase the diagnostic accuracy of portable monitoring. The validated diagnostic algorithm promises a more appropriate and cost-effective method if integrated in out-of-center (OOC) testing of patients with suspicion for SDB.

Characteristics of Patients with Obstructive Sleep Apnea at High Risk for Cardiovascular Disease

Background and Objectives: To evaluate the influence of obstructive sleep apnea (OSA)-related symptoms on prevalent cardiovascular disease (CVD) in a large clinical population of patients. Materials and Methods: A total of 2127 patients (mean age 55 years, 24% women) underwent diagnostic polysomnography and were evaluated using the Epworth sleepiness scale (ESS), the Athens Insomnia Scale (AIS), and the Beck Depression Inventory (BDI). We investigated the predictive value of OSA-associated symptoms for prevalent cardiovascular disease, after adjustment for relevant confounding factors including age, obesity, and co-morbidities. Results: Patients with OSA and CVD were older and had a higher Body Mass Index (BMI); the percentage of obese patients was also higher (83% vs. 70%, p < 0001). They also had greater neck, waist, and hip circumferences and a higher waist-to-hip ratio. Excessive daytime sleepiness (ESS ≥ 10) [odds ratio (95% CI) 1.112 (0.708–1.748), p = 0.64], insomnia symptoms (AIS ≥ 6) [odds ratio (95% CI) 0.748 (0.473–1.184), p = 0.21], frequent awakenings [odds ratio (95% CI) 1.599 (1.019–2.508), p = 0.06], and nocturia [odds ratio (95% CI) 1.359 (0.919–2.009), p = 0.124] were not associated with CVD after adjustment for the previous confounders. On the other hand, depressive symptoms (BDI ≥ 10) independently predicted prevalent CVD [odds ratio (95% CI) 1.476 (1.154–1.887), p = 0.002]. Further analysis in subgroups stratified by age, BMI, and gender demonstrated that depressive symptoms predicted prevalent CVD but only in the subgroup of younger (age group < 60 years), obese (BMI group ≥ 30), and male (OR = 1.959, 95% CI = 1.209–3.175, p = 0.006) OSA patients. Conclusions: OSA patients with CVD were more likely to complain of less typical OSA symptoms and depressive symptoms compared to patients without CVD in this large clinical patient cohort, supportingthecomplexity and heterogeneityof OSA.

Interleukin-8 concentrations in obstructive sleep apnea syndrome: a systematic review and meta-analysis

Interleukin (IL)-8 has been shown to play an important role in obstructive sleep apnea syndrome (OSAS). However, its role in OSAS development is still controversial. This meta-analysis was to explore the correlation between interleukin (IL)-8 concentration and OSAS. Database (from the inception to July 2021) searches on PubMed, Web of Science, Medline, EMBASE, and Cochrane Library were conducted for studies analyzing the correlation between IL-8 concentration and OSAS, regardless of the language of publication. Standardized mean difference (SMD) and 95% confidence intervals (CI) were used to analyze any prospective association between IL-8 concentration and OSAS. A total of 25 eligible studies, including 2301 participants and 1123 controls, were included in this meta-analysis. The included studies evaluating the association between serum IL-8 concentration and OSAS indicated that adults and children with OSAS had elevated serum concentrations of IL-8 compared with controls (SMD = 0.997, 95% CI = 0.437–1.517, P < 0.001; SMD = 0.431, 95% CI = 0.104–0.759, P = 0.01). Categorization of the study population into subgroups according to body mass index, apnea–hypopnea index (AHI), ethnicity, and sample size also showed that individuals with OSAS had elevated serum concentrations of IL-8 compared with controls. Additionally, the results demonstrated that the higher the AHI, higher was the IL-8 concentration. Similar results were observed in the literature on the association between plasma IL-8 concentration and OSAS. This meta-analysis verified that compared with controls, children and adults with OSAS have significantly elevated IL-8 concentrations.

New Paths in Respiratory Sleep Medicine: Consumer Devices, e-Health, and Digital Health Measurements

Sleep health and tracking sleep with contemporary wearables have become more popular. Sleep disorders, in particular, sleep-disordered breathing, have a higher prevalence than estimated previously. Many patients with apnea and hypopnea events suffer whereas others do not report complaints or show cardiovascular consequences. Assessment with wearables may support efforts to distinguish which type of apnea is related to aging and which to cardiovascular comorbidities. Innovative methods offer smart solutions for problems that are insufficiently addressed. Telemedical concepts help bring patients to sleep medicine expertise at an early stage. To use these methods clinically, they must be certified as medical devices.

Electroencephalographic Activity and Cognitive Function in Middle-Aged Patients with Obstructive Sleep Apnea Before and After Continuous Positive Airway Pressure Treatment

PURPOSE

To investigate the effect of continuous positive airway pressure (CPAP) on sleep electroencephalogram (EEG) activity in patients with obstructive sleep apnea (OSA) and to examine the correlation between quantitative EEG changes and cognitive function.

PATIENTS AND METHODS

A total of 69 men and 11 women were collected with an average age of 39.61 ± 7.67 years old from among middle-aged patients who had first visits with snoring as their main complaint. All of them completed sleep questionnaires, neurocognitive tests and night polysomnography (PSG). The patients in the OSA group also completed the second night of PSG monitoring under CPAP after pressure titration. A power spectrum analysis of EEG was used, and the correlation between the frequency powers of EEG and the scores of the Epworth Sleepiness Scale (ESS), Pittsburgh Sleep Quality Index (PSQI), Mini-Mental State Examination (MMSE), and the Montreal Cognitive Assessment (MoCA) were further analyzed.

RESULTS

Compared with the control group, the delta/alpha power ratio (DAR) and the (delta + theta)/(alpha + beta) power ratio (the slowing ratio, TSR) of the OSA group before CPAP were higher (P < 0.05). The DAR and TSR of the OSA patients decreased significantly after CPAP. ESS scores were correlated with parameters such as respiratory-related microarousal index (RRMAI), apnea hypopnea index (AHI), and the average absolute power of delta, DAR and TSR (P < 0.05). The PSQI, MMSE and MoCA scores were not correlated with the average absolute power of each frequency band, DAR or TSR (P > 0.05).

CONCLUSION

Patients with OSA have greater slow frequency EEG activity during sleep than the control group. CPAP treatment reversed the slow frequency EEG activity in patients with OSA.

A Pharyngoplasty with a Dorsal Palatal Flap Expansion: The Evaluation of a Modified Surgical Treatment Method for Obstructive Sleep Apnea Syndrome-A Preliminary Report

Surgical techniques for obstructive sleep apnea syndrome (OSAS) constantly evolve. This study aims to assess the effectiveness and safety of a new surgical approach for an OSAS pharyngoplasty with a dorsal palatal flap expansion (PDPFEx). A total of 21 participants (mean age 49.9; mean BMI 32.5) underwent a type III sleep study, an endoscopy of the upper airways, a filled medical history, a visual analog scale for snoring loudness, an Epworth Sleepiness Scale, and a Short Form Health Survey-36 questionnaire. A follow-up re-evaluation was performed 11 ± 4.9 months post-operatively. The study group (4 with moderate, 17 with severe OSAS) showed an improvement in all measured sleep study characteristics (p < 0.05), apnea-hypopnea index (pre-median 45.7 to 29.3 post-operatively, p = 0.009, r = 0.394), oxygen desaturation index (pre-median 47.7 and 23.3 post-operatively, p = 0.0005, r = 0.812), mean oxygen saturation (median 92% pre-operatively and median 94% post-operatively, p = 0.0002, r = 0.812), lowest oxygen saturation (p = 0.0001, r = 0.540) and time of sleep spent with blood oxygen saturation less than 90% (p = 0.0001, r = 0.485). The most commonly reported complications were throat dryness (11 patients) and minor difficulties in swallowing (5 patients transient, 3 patients constant). We conclude that a PDPFEx is a promising new surgical method; however, further controlled studies are needed to demonstrate its safety and efficacy for OSAS treatment in adults.

Diagnostic accuracy of screening questionnaires for obstructive sleep apnoea in adults in different clinical cohorts: a systematic review and meta-analysis

PURPOSE

The majority of individuals with clinically significant obstructive sleep apnoea (OSA) are undiagnosed and untreated. A simple screening tool may support risk stratification, identification, and appropriate management of at-risk patients. Therefore, this systematic review and meta-analysis evaluated and compared the accuracy and clinical utility of existing screening questionnaires for identifying OSA in different clinical cohorts.

METHODS

We conducted a systematic review and meta-analysis of observational studies assessing the diagnostic value of OSA screening questionnaires. We identified prospective studies, validated against polysomnography, and published to December 2020 from online databases. To pool the results, we used random effects bivariate binomial meta-analysis.

RESULTS

We included 38 studies across three clinical cohorts in the meta-analysis. In the sleep clinic cohort, the Berlin questionnaire's pooled sensitivity for apnoea-hypopnoea index (AHI) ≥ 5, ≥ 15, and ≥ 30 was 85%, 84%, and 89%, and pooled specificity was 43%, 30%, and 33%, respectively. The STOP questionnaire's pooled sensitivity for AHI ≥ 5, ≥ 15, and ≥ 30 was 90%, 90%, and 95%, and pooled specificity was 31%, 29%, and 21%. The pooled sensitivity of the STOP-Bang questionnaire for AHI ≥ 5, ≥ 15, and ≥ 30 was 92%, 95%, and 96%, and pooled specificity was 35%, 27%, and 28%. In the surgical cohort (AHI ≥ 15), the Berlin and STOP-Bang questionnaires' pooled sensitivity were 76% and 90% and pooled specificity 47% and 27%.

CONCLUSION

Among the identified questionnaires, the STOP-Bang questionnaire had the highest sensitivity to detect OSA but lacked specificity. Subgroup analysis considering other at-risk populations was not possible. Our observations are limited by the low certainty level in available data.

Chronic apnea during REM sleep increases arterial pressure and sympathetic modulation in rats

STUDY OBJECTIVES

Obstructive sleep apnea can induce hypertension. Apneas in REM may be particularly problematic: they are independently associated with hypertension. We examined the role of sleep stage and awakening on acute cardiovascular responses to apnea. In addition, we measured cardiovascular and sympathetic changes induced by chronic sleep apnea in REM sleep.

METHODS

We used rats with tracheal balloons and electroencephalogram and electromyogram electrodes to induce obstructive apnea during wakefulness and sleep. We measured the electrocardiogram and arterial pressure by telemetry and breathing effort with a thoracic balloon.

RESULTS

Apneas induced during wakefulness caused a pressor response, intense bradycardia, and breathing effort. On termination of apnea, arterial pressure, heart rate, and breathing effort returned to basal levels within 10 s. Responses to apnea were strongly blunted when apneas were made in sleep. Post-apnea changes were also blunted when rats did not awake from apnea. Chronic sleep apnea (15 days of apnea during REM sleep, 8 h/day, 13.8 ± 2 apneas/h, average duration 12 ± 0.7 s) reduced sleep time, increased awake arterial pressure from 111 ± 6 to 118 ± 5 mmHg (p < 0.05) and increased a marker for sympathetic activity. Chronic apnea failed to change spontaneous baroreceptor sensitivity.

CONCLUSION

Our results suggest that sleep blunts the diving-like response induced by apnea and that acute post-apnea changes depend on awakening. In addition, our data confirm that 2 weeks of apnea during REM causes sleep disruption and increases blood pressure and sympathetic activity.

Effects of the mandibular advancement device on daytime sleepiness, quality of life and polysomnographic profile of public transport drivers with obstructive sleep apnea syndrome

OBJECTIVE

To evaluate the effects of the mandibular advancement device (MAD) on daytime sleepiness, quality of life (QoL) and polysomnographic profile of intercity transport drivers with obstructive sleep apnea syndrome (OSAS).

MATERIAL AND METHODS

A quasi-experimental study evaluating intercity transport drivers from March to September 2019. The apnea-hypopnea index (AHI) was evaluated by type III polysomnography, which defined the severity of the disease. OSAS: mild (5 to 15), moderate (15 to 29), or severe (= 30). Sleepiness was assessed using the Epworth sleepiness scale, consisting of 8 questions about the likelihood of drowsiness in daily situations. QoL was assessed using the SF-36 questionnaire, which provides the score in eight domains: functional capacity, physical aspects, pain, general health status, vitality, social aspects, emotional aspects, and mental health. Drivers with OSAS underwent intervention with application of personalized MAD for 8 to 12 weeks.

RESULTS

The total sample (n=23) (44.77±11.56 years) had a body mass index (BMI) of 30.64±4.66kg/m2, and an OSAS prevalence of 65.2% of drivers (n=15). There were losses of 4 drivers so that the final sample of drivers with OSAS for the intervention with the MAD was 11 individuals, with an average age of 45.54±9.41 years and BMI of 32.21±3.17kg/m². There was a decrease in AHI (28.51±15.66ev/h 012.11±6.70ev/h, p=0.002) and pain (60 (50-60)040 (40-50), p=0.015) after the intervention.

CONCLUSION

There was a reduction in AHI in intercity transport drivers after implementing the MAD procedure.

Effects of Weight Loss on Obstructive Sleep Apnea Severity. Ten-Year Results of the Sleep AHEAD Study

Rationale: Weight loss is recommended to treat obstructive sleep apnea (OSA).Objectives: To determine whether the initial benefit of intensive lifestyle intervention (ILI) for weight loss on OSA severity is maintained at 10 years.Methods: Ten-year follow-up polysomnograms of 134 of 264 adults in Sleep AHEAD (Action for Health in Diabetes) with overweight/obesity, type 2 diabetes mellitus, and OSA were randomized to ILI for weight loss or diabetes support and education (DSE).Measurements and Main Results: Change in apnea-hypopnea index (AHI) was measured. Mean ± SE weight losses of ILI participants of 10.7 ± 0.7, 7.4 ± 0.7, 5.1 ± 0.7, and 7.1 ± 0.8 kg at 1, 2, 4, and 10 years, respectively, were significantly greater than the 1-kg weight loss at 1, 2, and 4 years and 3.5 ± 0.8 kg weight loss at 10 years for the DSE group (P values ≤ 0.0001). AHI was lower with ILI than DSE by 9.7, 8.0, and 7.9 events/h at 1, 2, and 4 years, respectively (P values ≤ 0.0004), and 4.0 events/h at 10 years (P = 0.109). Change in AHI over time was related to amount of weight loss, baseline AHI, visit year (P values < 0.0001), and intervention independent of weight change (P = 0.01). OSA remission at 10 years was more common with ILI (34.4%) than DSE (22.2%).Conclusions: Participants with OSA and type 2 diabetes mellitus receiving ILI for weight loss had reduced OSA severity at 10 years. No difference in OSA severity was present between ILI and DSE groups at 10 years. Improvement in OSA severity over the 10-year period with ILI was related to change in body weight, baseline AHI, and intervention independent of weight change.

Determining the prevalence of symptoms and risk of obstructive sleep apnoea among old Saudis

Objectives

This study aimed to determine the prevalence of symptoms and risk of obstructive sleep apnoea (OSA) and to identify the risk factors associated with OSA among old Saudis.

Methods

In this population-based survey, we administered the Saudi National Survey for Elderly Health to old Saudis between 2006 and 2007. Symptoms of OSA and its associated risk factors were determined using the Berlin questionnaire. A multivariable logistic regression analysis was used to determine key factors associated with the risk of OSA.

Results

Out of 2946 participants, 1544 (52.4%) were at high risk of OSA, with women having a higher risk than men (60.8% vs. 44.2%, respectively; p-value <0.001). Obesity was higher among women than men (40.5% vs. 24.8%, respectively; p-value <0.001). Almost 56% of the participants reported snoring as a risk factor, but there was no statistical difference between women and men (57.3% vs. 53.5%, respectively; p-value = 0.317). The factors identified as independent predictors of a high risk of OSA were the female gender (OR 1.732, 95% CI [1.375–2.182]), living in rural areas (OR 1.384, 95% CI [1.094–1.750]), severe cognitive impairment (OR 2.709, 95% CI [1.350–5.436]), depression (OR: 1.432 95%CI [1.147–1.789]), and antidepressants usage (OR 2.959, 95% CI [1.402–6.244]).

Conclusion

This study reported a 52.4% prevalence of a high risk of OSA. Women were more likely to be at high risk of OSA than men. In addition to the female gender, depression, antidepressant usage, severe cognitive impairment, and living in rural areas were main predictors of OSA.

Barbed Reposition Pharyngoplasty versus Expansion Sphincter Pharyngoplasty: A Meta-Analysis

OBJECTIVE

This study was to compare barbed reposition pharyngoplasty (BRP) and expansion sphincter pharyngoplasty (ESP) in the treatment of obstructive sleep apnea (OSA).

METHODS

Relevant 907 articles were searched from various databases until August 2020, including PubMed, MEDLINE, EMBASE, Cochrane Library, Web of Science and Scopus, and reference lists.

RESULTS

Four studies with a total of 208 participants were included. The mean reduction of apnea-hypopnea index (AHI) in the BRP group was 74.03% and the mean reduction of AHI in the ESP group was 60.17%. The mean success rate in the BRP group and the ESP group was 84.96% and 79.87%, respectively. The mean difference (MD) of the change in AHI between groups was not significantly different (MD = -1.24 event/hr, 95% CI [-11.86, 9.36], P = .82). There was no significant difference in postoperative AHI, postoperative Epworth Sleepiness Scale, pain, hospital stay, time to oral diet, and the change in oxygen desaturation index in both groups whereas the analgesic requirement was lower in the BRP group. Operative time was lower in the BRP group (MD = 21.72 minutes, 95% CI [18.85, 24.60], P < .0001).

CONCLUSION

The outcomes in both procedures are comparable in the improvement of OSA with palatal collapse. BRP is superior to ESP in term of surgical time. However, randomized clinical controlled trials with multicenter cooperation and long-term follow-up are essential to further demonstrate the efficacy of these procedures. Laryngoscope, 131:1420-1428, 2021.

Diligent and disagreeable? The influence of personality on continuous positive airway pressure (CPAP) adherence for obstructive sleep apnea

CPAP is an effective treatment for obstructive sleep apnea (OSA), though low adherence rates limit its benefits. Previous research has linked personality to a range of health behaviours including CPAP adherence. In keeping with these findings it was hypothesised that CPAP adherence would be positively correlated with conscientiousness and negatively correlated with emotionality. The present study also tested for an interaction between conscientiousness and emotionality as well as investigating the relationship between personality facets and adherence.

Participants were 110 adults, diagnosed with OSA. After approximately one month's treatment, average nightly usage for the previous week was downloaded from the CPAP device. Participants also completed the HEXACO Personality Inventory – revised. Contrary to expectation, there was no significant relationship between CPAP adherence and conscientiousness or emotionality and no significant interaction. However, the diligence facet of conscientiousness showed a significant positive correlation with CPAP adherence (r = .23, p < .05). Unanticipated negative correlations were also found between CPAP adherence and agreeableness and two of its facets: gentleness (r = –.33, p < .01) and patience (r = –.22, p < .05).

The results provide support for an association between CPAP adherence and personality. It is recommended that future research focus on facet level measurement, in particular the personality facets associated with conscientiousness and agreeableness.

The effect of CPAP therapy on excessive daytime sleepiness and quality of life in subjects with obstructive sleep apnoea: an AB design study

BACKGROUND

Obstructive sleep apnoea (OSA) is a disorder characterized by apnoeas and hypopnoeas due to repetitive upper airway collapse during sleep. So far, there are no published data regarding quality of life (QoL) and adherence to CPAP among patients with OSA in India. This study aims to measure sleepiness and QoL of patients before and after effective CPAP use in patients with OSA.

METHOD

Newly diagnosed subjects with OSA were included, and socio-demographic risk factors and anthropomorphic measures were collected. Epworth sleepiness scale (ESS) and short sleep apnoea quality of life index (SAQLI) were administered before and after a minimum of 4 weeks of domiciliary CPAP use. While short SAQLI is a disease-specific questionnaire, ESS measures excessive daytime sleepiness.

RESULTS

In 92 subjects age range was 28-74 years, mean age 49.7 ± 11.3 years, and male:female ratio was 70:22. Mean BMI was 32.1 ± 6.4 kg/sq.m; mean neck circumference was 39.4 ± 3.4 cm; 56 subjects had Mallampati score of 3 or 4. One-month follow-up was completed by 34 subjects who reported a mean of 5.8 ± 1.1 hours/night usage of CPAP. Mean ESS score was 11.31 ± 5.6 at baseline vs 6.9 ± 3.3 after 1 month (p = 0.02), and baseline short SAQLI score was at 2.54 ± 1.26 vs 1.38 ± 0.87 after 1 month (p = 0.0001).

CONCLUSIONS

Subjects reported adequate compliance with CPAP at 1 month, and both ESS and short SAQLI showed a significant improvement in these patients. CPAP compliance improved both QoL and sleepiness in patients with OSA.

Findings of routine nocturnal polysomnography in children with Down syndrome: a retrospective cohort study

STUDY OBJECTIVE

Children with Down syndrome (DS) are at risk for sleep disorders including; obstructive sleep apnea (OSA). Although OSA is diagnosed by polysomnography (PSG), the practicality of PSG in DS is questionable. Further, OSA treatment efficacy in DS is largely unknown given the challenges of PSG. Our aims were to review (i) the feasibility of PSG, and (ii) the efficacy (improvement in obstructive apnea hypopnea index (OAHI)) of OSA treatment using follow-up PSG in DS.

METHODS

Retrospective review of patients aged <21 years with DS who underwent PSG from October 2016 to June 2019. Successful PSG was determined using total sleep time (TST). PSG following treatment with adenotonsillectomy (AT) or positive airway pressure (PAP) was evaluated and compared to pre-treatment.

RESULTS

Among 248 patients with DS, only 11(4.4%) had unsuccessful PSG (TST<1h). Of the 237 successful studies (age: 7.9 ± 0.3y), average TST and sleep efficiency was 5.6 ± 0.1h and 79.5 ± 1.3%. 41 had post-AT PSG and 11(27%) achieved OSA cure (OAHI<2) with all demonstrating improved SE (p = 0.01) and OAHI (p = 0.0003). Multivariate analysis revealed only age was predictive (p = 0.003) of residual OSA post-AT. Of 24 children who underwent PAP titration, 20(83%) tolerated titration with improved OAHI (p = 0.01), however, no significant improvements in SE were observed.

CONCLUSIONS

In a large cohort of DS children, PSG was well tolerated. Following AT or PAP therapy, post treatment PSG confirmed efficacy, although residual OSA was identified. PSG is thus both feasible and useful in identifying OSA, OSA treatment response and should guide in decision making in children with DS.

Symptom subtypes and cognitive function in a clinic-based OSA cohort: a multi-centre Canadian study

BACKGROUND

Distinct symptom subtypes are found in patients with OSA. The association between these subtypes and neurocognitive function is unclear.

OBJECTIVE

The purposes of this study were to assess whether OSA symptom subtypes are present in a cohort of Canadian patients with suspected OSA and evaluate the relationship between subtypes and neurocognitive function.

METHODS

Patients with suspected OSA who completed a symptom questionnaire and underwent testing for OSA were included. Symptom subtypes were identified using latent class analysis. Associations between subtypes and neurocognitive outcomes (Montreal Cognitive Assessment [MoCA], Rey Auditory Verbal Learning Test [RAVLT], Wechsler Adult Intelligence Scale [WAIS-IV], Digit-Symbol Coding subtest [DSC]) were assessed using analysis of covariance (ANCOVA), controlling for relevant covariates.

RESULTS

Four symptom subtypes were identified in patients with OSA (oxygen desaturation index ≥5 events/hour). Three were similar to prior studies, including the Excessively Sleepy (N=405), Disturbed Sleep (N=382) and Minimally Symptomatic (N=280), and one was a novel subtype in our sample defined as Excessively Sleepy with Disturbed Sleep (N=247). After covariate adjustment, statistically significant differences among subtypes (p=0.037) and among subtypes and patients without OSA (p=0.044) were observed in DSC scores; the Minimally Symptomatic subtype had evidence of higher DSC scores than all other groups, including non-OSA patients. No differences were seen in MoCA or RAVLT.

CONCLUSIONS

Results support the existence of previously identified OSA symptom subtypes of excessively sleepy, disturbed sleep and minimally symptomatic in a clinical sample from Canada. Subtypes were not consistently associated with neurocognitive function across multiple instruments.

[Recommendations on performing polygraphy or polysomnography in the fields of psychiatry and psychotherapy : Position paper of the working group on sleep medicine of the German Association for Psychiatry, Psychotherapy and Psychosomatics]

Difficulties in falling asleep and maintaining sleep, nonrestorative sleep and decreased daytime wakefulness represent very common but relatively unspecific health complaints. Around 100 specific sleep-related disorders will be classified in their own major chap. 7 (sleep wake disorders) for the first time in the upcoming 11th version of the International Classification of Diseases (ICD 11). With respect to the disciplines of psychiatry and psychotherapy there is a bidirectional relationship between mental health and sleep wake disorders. Sleep wake disorders can be an independent risk factor for the onset of a mental disorder and have a negative influence on the course of the disease. In addition, sleep wake disorders can also precede a mental disease as an early symptom and therefore be an important indication for early recognition. Many sleep wake disorders can be diagnosed based on the anamnesis and routine clinical investigations. In special cases, examination in a specialized sleep laboratory and treatment in a sleep medicine center following a staged care approach can be mandatory. Polysomnography represents the gold standard for the differential diagnostics; however, there is no legal foundation in the field of neuropsychiatric disorders for remuneration in the German healthcare system. This review summarizes the current guidelines with respect to the criteria for an investigation in a sleep laboratory from the perspective of the disciplines of psychiatry and psychotherapy. From this the requirements for guideline-conform diagnostics and treatment are derived.