Obstructive sleep apnea syndrome: natural history, diagnosis, and emerging treatment options

The use of heart rate variability, oxygen saturation, and anthropometric data with machine learning to predict the presence and severity of obstructive sleep apnea

Introduction

Obstructive sleep apnea (OSA) is a prevalent sleep disorder with a high rate of undiagnosed patients, primarily due to the complexity of its diagnosis made by polysomnography (PSG). Considering the severe comorbidities associated with OSA, especially in the cardiovascular system, the development of early screening tools for this disease is imperative. Heart rate variability (HRV) is a simple and non-invasive approach used as a probe to evaluate cardiac autonomic modulation, with a variety of newly developed indices lacking studies with OSA patients.

Objectives

We aimed to evaluate numerous HRV indices, derived from linear but mainly nonlinear indices, combined or not with oxygen saturation indices, for detecting the presence and severity of OSA using machine learning models.

Methods

ECG waveforms were collected from 291 PSG recordings to calculate 34 HRV indices. Minimum oxygen saturation value during sleep (SatMin), the percentage of total sleep time the patient spent with oxygen saturation below 90% (T90), and patient anthropometric data were also considered as inputs to the models. The Apnea-Hypopnea Index (AHI) was used to categorize into severity classes of OSA (normal, mild, moderate, severe) to train multiclass or binary (normal-to-mild and moderate-to-severe) classification models, using the Random Forest (RF) algorithm. Since the OSA severity groups were unbalanced, we used the Synthetic Minority Over-sampling Technique (SMOTE) to oversample the minority classes.

Results

Multiclass models achieved a mean area under the ROC curve (AUROC) of 0.92 and 0.86 in classifying normal individuals and severe OSA patients, respectively, when using all attributes. When the groups were dichotomized into normal-to-mild OSA vs. moderate-to-severe OSA, an AUROC of 0.83 was obtained. As revealed by RF, the importance of features indicates that all feature modalities (HRV, SpO2, and anthropometric variables) contribute to the top 10 ranks.

Conclusion

The present study demonstrates the feasibility of using classification models to detect the presence and severity of OSA using these indices. Our findings have the potential to contribute to the development of rapid screening tools aimed at assisting individuals affected by this condition, to expedite diagnosis and initiate timely treatment.

Detection of sleep apnea using only inertial measurement unit signals from apple watch: a pilot-study with machine learning approach

PURPOSE

Despite increased awareness of sleep hygiene, over 80% of sleep apnea cases remain undiagnosed, underscoring the need for accessible screening methods. This study presents a method for detecting sleep apnea using data from the Apple Watch's inertial measurement unit (IMU).

METHODS

An algorithm was developed to extract seismocardiographic and respiratory signals from IMU data, analyzing features such as breathing and heart rate variability, respiratory dips, and body movements. In a cohort of 61 adults undergoing polysomnography, we analyzed 52,337 30-second epochs, with 12,373 (23.6%) identified as apnea/hypopnea episodes. Machine learning models using five classifiers (Logistic Regression, Random Forest, Gradient Boosting, k-Nearest Neighbors, and Multi-layer Perceptron) were trained on data from 41 subjects and validated on 20 subjects.

RESULTS

The Random Forest classifier performed best in per-epoch respiratory event detection, achieving an AUC of 0.827 and an F1 score of 0.572 in the training group, and an AUC of 0.831 and an F1 score of 0.602 in the test group. The model's per-subject predictions strongly correlated with the apnea-hypopnea index (AHI) from polysomnography (r = 0.93) and identified subjects with AHI ≥ 15 with 100% sensitivity and 90% specificity.

CONCLUSION

Utilizing the widespread availability of the Apple Watch and the low power requirements of the IMU, this approach has the potential to significantly improve sleep apnea screening accessibility.

A Survey of Physicians' Knowledge and Practices Towards Oral Appliance Therapy for Obstructive Sleep Apnea Treatment

BACKGROUND

Oral appliance therapy (OAT) is an effective treatment alternative for obstructive sleep apnea (OSA). Understanding physicians' knowledge and practices regarding OAT is crucial for improving OSA treatment, particularly in Southeast Asia, where there is limited research on this topic.

OBJECTIVES

This study sought to survey physicians' knowledge and practices regarding OAT for OSA treatment.

METHODS

A descriptive cross-sectional survey was conducted among Thai physicians attending the annual Sleep Society of Thailand meeting. The questionnaire included questions on demographics (six items), educational background (four items), OAT knowledge (two items), indications (three items), effectiveness (seven items), referral practices (five items), treatment planning (eight items), and the importance of OAT education (one item). Descriptive and comparative analyses were performed using SPSS to assess differences in knowledge and referral practices across various demographics.

RESULTS

This study achieved a response rate of 51.7% (30/58), with the respondents averaging 37.8 ± 6.0 years in age and 13.7 ± 6.7 years in practice. Although over 66.7% of the respondents recognized OAT's effectiveness and understood its indications, only 36.7% regularly prescribed OAT, and 57.7% referred patients to specific dentists. Knowledge and referral practices differed significantly based on years of practice and postgraduate training in sleep medicine. Physicians with 11-20 years of practice demonstrated higher pediatric OAT knowledge scores compared to those with less experience. Those with postgraduate training achieved higher adult OAT knowledge scores and had greater referral experience.

CONCLUSIONS

Despite the general awareness and good knowledge of OAT among physicians, clinical use and referral rates remain low. To bridge the gap between knowledge and practice, it is recommended that postgraduate training in dental sleep medicine is promoted and further research is conducted to identify barriers to the adoption of OAT.

Utilizing a Wireless Radar Framework in Combination With Deep Learning Approaches to Evaluate Obstructive Sleep Apnea Severity in Home-Setting Environments

Objective

Common examinations for diagnosing obstructive sleep apnea (OSA) are polysomnography (PSG) and home sleep apnea testing (HSAT). However, both PSG and HSAT require that sensors be attached to a subject, which may disturb their sleep and affect the results. Hence, in this study, we aimed to verify a wireless radar framework combined with deep learning techniques to screen for the risk of OSA in home-based environments.

Methods

This study prospectively collected home-based sleep parameters from 80 participants over 147 nights using both HSAT and a 24-GHz wireless radar framework. The proposed framework, using hybrid models (ie, deep neural decision trees), identified respiratory events by analyzing continuous-wave signals indicative of breathing patterns. Analyses were performed to examine correlations and agreement of the apnea-hypopnea index (AHI) with results obtained through HSAT and the radar-based respiratory disturbance index based on the time in bed from HSAT (bRDITIB). Additionally, Youden's index was used to establish cutoff thresholds for the bRDITIB, followed by multiclass classification and outcome comparisons.

Results

A strong correlation (ρ = 0.87) and high agreement (93.88% within the 95% confidence interval; 138/147) between the AHI and bRDITIB were identified. The moderate-to-severe OSA model achieved 83.67% accuracy (with a bRDITIB cutoff of 21.19 events/h), and the severe OSA model demonstrated 93.21% accuracy (with a bRDITIB cutoff of 28.14 events/h). The average accuracy of multiclass classification using these thresholds was 78.23%.

Conclusion

The proposed framework, with its cutoff thresholds, has the potential to be applied in home settings as a surrogate for HSAT, offering acceptable accuracy in screening for OSA without the interference of attached sensors. However, further optimization and verification of the radar-based total sleep time function are necessary for independent application.

Predictors of Decision to Pursue Sleep Surgery

Objective

To identify predictors of patient decision to pursue sleep apnea surgery following initial consultation with a sleep surgeon.

Study Design

Retrospective cohort analysis.

Setting

Outpatient tertiary care academic center.

Methods

A retrospective review of patients with obstructive sleep apnea (OSA) diagnosis, BMI < 35 kg/m², and prior positive airway pressure (PAP) trial who were evaluated at a sleep surgery clinic. Patients who completed drug-induced sleep endoscopy (DISE) and/or surgery were compared to those who did not within at least 4 months of consultation. Surveys on OSA-related symptoms and decisional conflict were completed prior to the consultation for PAP alternatives.

Results

Among 437 patients, 321 did not undergo DISE/surgery, whereas 116 completed DISE/surgery within an average of 16.8 months of consultation. Patients who underwent DISE/surgery had a significantly higher Epworth sleepiness scale score (10.1 ± 4.9 vs 8.5 ± 5.1, P = .006) and insomnia severity index (15.6 ± 5.5 vs 14.3 ± 5.8, P = .037) as well as significantly lower decisional conflict scale (DCS) scores (27.9 ± 21.8 vs 38.2 ± 24.9, P < .001). Multivariate analysis revealed that lower preconsultation DCS score (OR = 0.97, 95% CI [0.97, 0.99], P < .001) and lower BMI (OR = 0.91, 95% CI [0.85, 0.99], P = .019) were independently significant predictors of pursuing DISE/surgery.

Conclusion

Decisional conflict prior to consultation is significantly associated with completion of DISE/surgery. Those with higher decisional conflict are less likely to proceed with DISE/surgery after consultation on PAP alternatives. Effective interventions that improve patient understanding of OSA and enhance support in decision-making are needed.

Analysis of Possible Predictors of Moderate and Severe Obstructive Sleep Apnea in Obese Patients

Objectives: To determine if there are clinical or anatomical differences between patients with grade II-IV obesity without obstructive sleep apnea (OSA) or mild OSA and patients with moderate or severe OSA and to assess whether any of these factors are predictive of moderate/severe OSA. Methods: Observational case-control study with consecutive sampling including patients between 18 and 65 years of age with grade II-IV obesity who were candidates for bariatric surgery. An anamnesis regarding OSA symptoms, a physical examination of the upper airway and a cardiorespiratory polygraphy were performed. Results: A total of 124 patients were included in the study, of whom 61.3% did not have OSA or had mild OSA and 38.7% had moderate or severe OSA. Age over 48 years was the only independent factor associated with moderate or severe OSA. Other factors showed a relation with moderate/severe OSA after multivariate analysis: male sex, STOP-BANG questionnaire ≥ 3, weight ≥ 105 kg, thick neck, neck circumference ≥ 41.25 cm, flaccid palate, Mallampati III-IV index, Friedman tongue position III-IV and retropalatal narrowing. Conclusions: The only independent predictive factor related to moderate or severe OSA in patients with morbid obesity was age over 48 years, therefore a sleep study remains essential for its diagnosis.

Supplementary Information

The online version contains supplementary material available at 10.1007/s12070-024-04908-0.

[Analysis of Snoring in Patients with Obstructive Sleep Apnea (OSA) by Polysomnography and LEOSound]

INTRODUCTION

Snoring was monitored in patients with obstructive sleep apnea (OSA) using the LEOSound-Monitor and simultaneously polysomnographic (PSG) recording. In obstructive apneas snoring is normally apparent after apnea termination and the beginning of ventilation. We wanted to know how often obstructive apneas are terminated by ventilation in combination with snoring.

METHODS AND INTENTION

In 40 patients with OSA (AHI > 15/h) simultaneous polysomnographic recordings were performed amongst long-term respiratory sound monitoring using the LEOSound monitor. Patients' average age was 57±11 years. Average weight was 100±19 kg by a mean body mass index (BMI) of 33±7 kg/m². 12 out of 40 recordings had to be rejected for further analysis because of artifacts. Snoring recorded by polysomnography was compared with snoring monitored by LEOSound.

RESULTS

3778 obstructive apnea episodes were monitored. LEOSound identified snoring in 1921 (51,0%), polysomnography in 2229 (58,8%) obstructive apneas. Only in one patient there was a higher difference in snoring episodes between PSG and LEOSound.

DISCUSSION

In nearly 60% of obstructive apnea events we found snoring during apnea-terminating hyperpnoea. LEOSound is a good diagnostic tool to monitor snoring. It is necessary to clarify why only 60% of all obstructive events/hyperpnoea develop snoring. From a pathophysiological point of view opening of collapsed upper airway should lead in a very high percentage to turbulences in airstream and committed snoring.

A Scoping Review of Sleep Apnea: Where Do We Stand?

Obstructive sleep apnea (OSA), a condition in which there is a recurrent collapse of the upper airway while sleeping, is a widespread disease affecting 5% to 10% people worldwide. Despite several advances in the treatment modalities for OSA, morbidity and mortality remain a concern. Common symptoms include loud snoring, gasping for air during sleep, morning headache, insomnia, hypersomnia, attention deficits, and irritability. Obese individuals, male gender, older age (65+), family history, smoking, and alcohol consumption are well recognized risk factors of OSA. This condition holds the ability to increase inflammatory cytokines, cause metabolic dysfunction, and increase the sympathetic output, all of which exacerbate OSA due to their effect on the cardiovascular system. In this review, we discuss its brief history, risk factors, complications, treatment modalities, and the role of clinicians in curbing its risk.

The Link between Obstructive Sleep Apnea Syndrome and Cephalometric Assessment of Upper Airways and Hyoid Bone Position

Background and Objectives: To determine whether there are changes in the cephalometric characteristics of the upper airways and hyoid bone, in patients diagnosed with obstructive sleep apnea syndrome (OSAS) compared to a healthy control group. Material and Methods: This retrospective case−control study included 24 patients diagnosed with OSAS (apnea−hypopnea index (AHI) > 5 obtained after polysomnography) and 24 healthy subjects as a control group that completed the STOP-Bang questionnaire to determine whether they had OSAS. Lateral cephalometric examinations were recommended for all these patients. The software used for the cephalogram interpretation was CS 3D Imaging and CS Airway imaging from Carestream Dental. Results: The subjects with OSAS had a smaller superior posterior airway space (SPAS), with an average of 10.32 mm compared to a 12.20 mm mean in the control group (p = 0.03). Patients with OSAS, had a lowered middle airway space (MAS) with a mean of 7.96 mm in the OSAS group and a 10.96 mm mean in the control group (p = 0.00). All the measurements made for the hyoid bone, such as—H-MnP, H-C3, and H-B—showed increased values (means of 26.31 mm, 39.08 mm, 60.05 mm, respectively), for the OSAS group (p = 0.00). Conclusions: Patients suffering from OSAS had reduced dimensions of the SPAS and MAS values. The hyoid bone had a more inferior position in the study group (with increased values for H-MnP, H-C3, and H-B) compared to the control group.

Recent Advances in Bioutilization of Marine Macroalgae Carbohydrates: Degradation, Metabolism, and Fermentation

Marine macroalgae are considered renewable natural resources due to their high carbohydrate content, which gives better utilization value in biorefineries and higher value conversion than first- and second-generation biomass. However, due to the diverse composition, complex structure, and rare metabolic pathways of macroalgae polysaccharides, their bioavailability needs to be improved. In recent years, enzymes and pathways related to the degradation and metabolism of macroalgae polysaccharides have been continuously developed, and new microbial fermentation platforms have emerged. Aiming at the bioutilization and transformation of macroalgae resources, this review describes the latest research results from the direction of green degradation, biorefining, and metabolic pathway design, including summarizing the the latest biorefining technology and the fermentation platform design of agarose, alginate, and other polysaccharides. This information will provide new research directions and solutions for the biotransformation and utilization of marine macroalgae.

Correlation between heart rate variability and polysomnography-derived scores of obstructive sleep apnea

Obstructive sleep apnea (OSA) is one of the most common sleep disorders and affects nearly a billion people worldwide. Furthermore, it is estimated that many patients with OSA are underdiagnosed, which contributes to the development of comorbidities, such as cardiac autonomic imbalance, leading to high cardiac risk. Heart rate variability (HRV) is a non-invasive, widely used approach to evaluating neural control of the heart. This study evaluates the relationship between HRV indices and the presence and severity of OSA. We hypothesize that HRV, especially the nonlinear methods, can serve as an easy-to-collect marker for OSA early risk stratification. Polysomnography (PSG) exams of 157 patients were classified into four groups: OSA-free (N = 26), OSA-mild (N = 39), OSA-moderate (N = 37), and OSA-severe (N = 55). The electrocardiogram was extracted from the PSG recordings, and a 15-min beat-by-beat series of RR intervals were generated every hour during the first 6 h of sleep. Linear and nonlinear HRV approaches were employed to calculate 32 indices of HRV. Specifically, time- and frequency-domain, symbolic analysis, entropy measures, heart rate fragmentation, acceleration and deceleration capacities, asymmetry measures, and fractal analysis. Results with indices of sympathovagal balance provided support to reinforce previous knowledge that patients with OSA have sympathetic overactivity. Nonlinear indices showed that HRV dynamics of patients with OSA display a loss of physiologic complexity that could contribute to their higher risk of development of cardiovascular disease. Moreover, many HRV indices were found to be linked with clinical scores of PSG. Therefore, a complete set of HRV indices, especially the ones obtained by the nonlinear approaches, can bring valuable information about the presence and severity of OSA, suggesting that HRV can be helpful for in a quick diagnosis of OSA, and supporting early interventions that could potentially reduce the development of comorbidities.

Prevalence of and risk factors for obstructive sleep apnea in children with sickle cell: a multicentric cross sectional study

The prevalence of obstructive sleep apnea syndrome (OSAS) is elevated in some high-risk populations. Children with sickle cell disease (SCD) are known to have many comorbidities, including OSAS. The objectives of this study were to assess the prevalence of and risk factors for OSAS among children with SCD in two major tertiary health care facilities in Jeddah, Saudi Arabia. This multicenter cross-sectional study took place in two major tertiary health care facilities-King Abdulaziz University Hospital and King Khalid National Guard Hospital, Jeddah, Saudi Arabia. Children with SCD who were admitted between January 2010 and December 2017 were enrolled. The Pediatric Sleep Questionnaire (PSQ) was used to screen for OSAS. Data were collected from 150 children with SCD aged between 2 and 18 years. Eighty-five percent of the children had sickle cell anemia (SCA) with HbSS, and the rest had sickle beta-thalassemia (HbS/ß-thalassemia). Based on the PSQ, 33 of the 150 (22%) children had OSAS (score ≥ 7). The average score on the PSQ was 3.8/22 (± 3.8). A history of adenotonsillar hypertrophy was found to be a significant risk factor in bivariate and multivariate analyses [aOR 5.5; 95% CI 1.84-16.35 (P < 0.001)]. The odds of having OSAS were ninefold higher in children who had periodic limb movements than in those who did not after adjustment [95% CI 1.75-48.03 (P < 0.001)]. OSAS is a highly prevalent disease among children with SCD. Many factors were associated with OSAS in the bivariate analysis, including nationality, education level, a history of adenotonsillar hypertrophy, and a history of periodic limb movements.

Novel proteins associated with chronic intermittent hypoxia and obstructive sleep apnea: From rat model to clinical evidence

OBJECTIVE

To screen for obstructive sleep apnea (OSA) biomarkers, isobaric tags for relative and absolute quantitation (iTRAQ)-labeled quantitative proteomics assay was used to identify differentially expressed proteins (DEPs) during chronic intermittent hypoxia (CIH).

METHOD

The iTRAQ technique was applied to compare DEPs in the serum of a CIH rat model and control group. Biological analysis of DEPs was performed using Gene Ontology and Kyoto Encyclopedia to explore related biological functions and signaling pathways. Enzyme-linked immunosorbent assay (ELISA) was performed to validate their expression in sera from patients with OSA and CIH rats.

RESULTS

Twenty-three DEPs (fold change ≥1.2 or ≤0.833, p<0.05) were identified, and two DEPs (unique peptides>3 and higher coverage) were further verified by ELISA in the CIH rat model and OSA subject: apolipoprotein A-IV (APOA4, p<0.05) and Tubulin alpha-1A chain (TUBA1A, p<0.05). Both groups showed significant differences in the expression levels of DEPs between the CIH and control groups and the severe OSA and non-OSA groups. APOA4 was found to be upregulated and TUBA1A downregulated in both the sera from OSA patients and CIH rats, on comparing proteomics results with clinical results. There were two pathways that involved three DEPs, the mitogen-activated protein kinase (MAPK) signaling pathway (p<0.05) and cytokine-cytokine receptor interaction (p<0.05).

CONCLUSION

APOA4 and TUBA1A may be potential novel biomarkers for CIH and OSA, and may play an important role in the development of OSA complications.

Prevalence, Risk Factors, and Comorbidities of Obstructive Sleep Apnea Risk Among a Working Population in Kuwait: A Cross-Sectional Study

Background: Obstructive sleep apnea (OSA) affects a considerable proportion of adults globally and is associated with elevated morbidity and mortality. Given the lack of epidemiologic data on the burden of OSA in Kuwait, this study sought to estimate its prevalence, associated risk factors, and comorbid conditions among a working population in Kuwait. Methods: This was a cross-sectional study of a sample of working adults (n = 651) from public institutions in Kuwait. High/low risk for OSA was ascertained according to the Berlin Questionnaire criteria. Participants self-reported their coexisting health conditions. Associations were assessed using Poisson regression with robust variance estimation; adjusted prevalence ratios (aPRs) and 95% confidence intervals (CIs) were estimated. Results: Overall, 20.0% (130/651) of participants were classified as being at high risk for OSA, with more male than female subjects being at high risk (24.0% [56/233] vs. 17.7% [74/418], P = 0.053), though this difference did not gain statistical significance. Moreover, a high risk for OSA was more common among older and obese subjects. Factors associated with increased prevalence of a high risk for OSA included current smoking status (aPR = 1.58, 95% CI: 1.02-2.06), longer hours spent watching television (1.76, 1.10-2.81), and lower self-perceived physical health (2.11, 1.15-3.87). However, decreasing trends in the prevalence of high risk for OSA were observed with frequent engagement in vigorous physical activity and longer nightly sleep duration. Compared to those at a low risk for OSA, the subjects at high risk for OSA were more likely to have insomnia disorder (2.83, 1.81-4.41), diabetes (1.94, 1.15-3.27), hypertension (3.00, 1.75-5.16), and depression (4.47, 1.80-11.08). Conclusion: This study estimated that 1/5 of working adults in Kuwait were at high risk for OSA, and the prevalence varied according to personal characteristics and lifestyle factors. Also, a high risk for OSA classification was associated with multiple comorbid health conditions.

A 3D-printed microfluidic platform for simulating the effects of CPAP on the nasal epithelium

Obstructive sleep apnoea (OSA) is a chronic disorder that involves a decrease or complete cessation of airflow during sleep. It occurs when the muscles supporting the soft tissues in the throat relax during sleep, causing narrowing or closure of the upper airway. Sleep apnoea is a serious medical condition with an increased risk of cardiovascular complications and impaired quality of life. Continuous positive airway pressure (CPAP) is the most effective treatment for moderate to severe cases of OSA and is effective in mild sleep apnoea. However, CPAP therapy is associated with the development of several nasal side effects and is inconvenient for the user, leading to low compliance rates. The effects of CPAP treatment on the upper respiratory system, as well as the pathogenesis of side effects, are incompletely understood and not adequately researched. To better understand the effects of CPAP treatment on the upper respiratory system, we developed an in vitro 3D-printed microfluidic platform. A nasal epithelial cell line, RPMI 2650, was then exposed to certain conditions to mimic the in-vivo environment. To create these conditions, the microfluidic device was utilized to expose nasal epithelial cells grown and differentiated at the air-liquid interface. The airflow was similar to what is experienced with CPAP, with pressure ranging between 0-20 cm of H20. Cells exposed to pressure showed decreased barrier integrity, change in cellular shape, and increased cell death (lactate dehydrogenase release into media) compared to unstressed cells. Stressed cells also showed increased secretions of inflammatory markers IL-6 and IL-8 and had increased production of ATP. Our results suggest that stress induced by airflow leads to structural, metabolic, and inflammatory changes in the nasal epithelium, which may be responsible for developing nasal side-effects following CPAP treatment.

Positive airway pressure therapy for obstructive sleep apnea in patients with Osteogenesis imperfecta: a prospective pilot study

BACKGROUND

Obstructive sleep apnea (OSA) is prevalent in individuals with Osteogenesis imperfecta (OI). To date, no study has investigated treatment of OSA in adult individuals with OI using positive airway pressure (PAP). This observational pilot study examined the adherence of adults with OI to treatment of OSA with PAP therapy, and the evolution of self-experienced sleepiness and depression symptoms before and after treatment.

METHODS

We included 20 patients, with a mean age of 51 years, who represented varying severity of OI and displayed an apnea and hypopnea index ≥ 5 /sleeping hour as recorded by an overnight polysomnography. PAP therapy was proposed to all patients. Epworth Sleepiness Scale (ESS) questionnaire to evaluate daytime sleepiness, and a validated self-rating depression questionnaire to identify possible depression, were completed prior to PAP therapy and repeated after a minimum of one year. The datasets supporting the conclusions of this article are included within the article.

RESULTS

From the 20 patients, 15 initiated PAP therapy, and two patients later interrupted it. The mean PAP follow-up period was 1230 days. At baseline, an abnormally high ESS score was reported by 29% of the respondents, and an abnormally high number of symptoms suggesting depression by 29%. Follow-up questionnaires were completed by 60% of the patients, of whom 83% were adherent to PAP treatment. ESS score and depression symptoms did not decrease significantly with PAP therapy.

CONCLUSIONS

Patients with OI accepted well PAP therapy and remained compliant. Sleepiness and depression persisted unaltered despite good PAP adherence. These unexpectedly poor improvements in symptoms by PAP therapy may be due to subjective depression symptoms and the complexity of factors underlying persisting sleepiness in OI. Further research is needed to confirm this novel finding.

Co-existing obstructive sleep apnea among patients with chronic obstructive pulmonary disease

Background and Objectives:

Chronic obstructive pulmonary disease (COPD) is a common airway disease that is frequently associated with comorbidities. In this study, we assessed the co-existence of obstructive sleep apnea (OSA) among patients with stable COPD.

Methodology:

This cross-sectional study included patients with stable COPD who were screened with Epworth's Sleepiness Scale (ESS). Those with ESS score of >10 were subjected to in-lab polysomnography (PSG). PSG was manually analyzed and reported. Patients with apnea–hypopnea index of >5/h were diagnosed as OSA.

Results:

This study included 301 patients (78.1% male, 76.4% smokers, age 59.6 ± 10 years) with stable COPD. ESS score of >10 was observed in 47 (15.6%) patients. Among patients with ESS score of >10, OSA was observed in 34 (72.3%) patients. The overall prevalence of OSA among patients with COPD was 10.9%. Patients with co-existing OSA were older and had thicker neck and higher body mass index (BMI) as compared to COPD alone. In addition, patients with associated OSA had worse health-related quality of life (QOL) as shown by higher St. George's Respiratory Questionnaire score (42.42 ± 7.22 vs. 25.22 ± 8.66; P < 0.001).

Conclusions:

Co-existing OSA is common among patients with COPD and has a significant adverse effect on the QOL. Among COPD patients, older age, thick neck, and high BMI may predict co-existing OSA and require PSG for the confirmation.

Are oropharyngeal exercises effective in Obstructive Sleep Apnea Syndrome?

OBJECTIVE

This study has been conducted to examine the effects of posture, cervical region and oropharyngeal exercises in patients with Obstructive Sleep Apnea Syndrome (OSAS).

METHOD

Thirty patients with OSAS have been randomly divided into two groups. The first group received supervised exercise program including oropharyngeal, posture and cervical region exercises for 12 weeks. The patients in the control group have been informed about the posture but the exercise was not recommended. Epworth Sleepiness Scale (ESS), Pittsburgh Sleep Quality Index (PSQI), Beck Depression Inventory (BDI), Short Form 36 (SF-36), International Physical Activity Questionnaire-Short Form (IPAQ-SF) and 6 Minute Walk Test (6MWT) have been used in the evaluation of individuals participating in the study. Evaluations have been made at the beginning of the treatment and at the end of the 12-week exercise program.

RESULTS

Statistically significant improvements have been observed in the exercise group in PSQI total value, ESS score, SF-36 General Health Subscale and 6MWT (p< 0.05). Statistical significance could not be reached for other parameters.

CONCLUSIONS

Sleep quality, general health, and functional capacity have been found to improve in OSAS patients with oropharyngeal exercises.

[Analysis of Snoring in Patients with Obstructive Sleep Apnea (OSA) by Polysomnography and LEOSound]

INTRODUCTION

 Snoring was monitored in patients with obstructive sleep apnea (OSA) using the LEOSound-Monitor and simultaneously polysomnographic (PSG) recording. In obstructive apneas snoring is normally apparent after apnea termination and the beginning of ventilation. We wanted to know how often obstructive apneas are terminated by ventilation in combination with snoring.

METHODS AND INTENTION

 In 40 patients with OSA (AHI > 15/h) simultaneous polysomnographic recordings were performed amongst long-term respiratory sound monitoring using the LEOSound monitor. Patients' average age was 57 ± 11 years. Average weight was 100 ± 19 kg by a mean body  mass  index (BMI) of 33 ± 7 kg/m². 12 out of 40 recordings had to be rejected for further analysis because of artifacts. Snoring recorded by polysomnography was compared with snoring monitored by LEOSound.

RESULTS

 3778 obstructive apnea episodes were monitored. LEOSound identified snoring in 1921 (51,0 %), polysomnography in 2229 (58,8 %) obstructive apneas. Only in one patient there was a higher difference in snoring episodes between PSG and LEOSound.

DISCUSSION

 In nearly 60 % of obstructive apnea events we found snoring during apnea-terminating hyperpnoea. LEOSound is a good diagnostic tool to monitor snoring. It is necessary to clarify why only 60 % of all obstructive events/hyperpnoea develop snoring. From a pathophysiological point of view opening of collapsed upper airway should lead in a very high percentage to turbulences in airstream and committed snoring.

Cognitive impairment in obstructive sleep apnea syndrome: a descriptive review

PURPOSE

Obstructive sleep apnea syndrome is a clinical sleep disorder defined by total or partial airflow restraint during sleep that results in fragmented sleep and hypoxemia, impacting negatively with cognitive functioning. This review was conducted on studies investigating structural brain alteration and cognitive impairment in obstructive sleep apnea syndrome.

METHOD

We searched on PubMed databases and screening references of included studies and review articles for additional citations. From initial 190 publications, only 17 met search criteria and described the cognitive impairment in obstructive sleep apnea syndrome.

RESULTS

Findings showed that patients with this syndrome had worse performance than healthy controls in attention, memory, and executive functions, showing specific neuroanathomical features. Cognitive impairment is also related to the severity of pathology. Treatment could improve certain cognitive aspects.

CONCLUSIONS

Cognitive deficits seem to be mainly attributable to decreased daytime vigilance and nocturnal hypoxemia.

Prevalence of risk for sleep apnea among hospitalized patients who survived a medical emergency team activation

STUDY OBJECTIVES

Sleep-disordered breathing (SDB) is a common disorder that causes people to stop breathing in their sleep, and obstructive sleep apnea (OSA) is the most common form of SDB in the general population. Because OSA is often undiagnosed and undermanaged, it has been associated with adverse events and morbidity in hospitalized patients. The purpose of the study was to evaluate prevalence of OSA risk in a population of patients who survived a medical emergency team (MET) activation during hospitalization.

METHODS

This prospective study was conducted at a hospital in the Midwest in 2014. Patients who survived a MET activation and consented to participate were administered the STOP-Bang questionnaire and asked other health and lifestyle questions. Review of the medical record was conducted to ascertain patient characteristics, comorbidities, and medications. Differences were assessed using Kruskal-Wallis one-way analysis of variance and the chi-square test.

RESULTS

Of 148 study patients, median age was 68 years (interquartile range: 55-78) and 15% were morbidly obese (body mass index ≥ 40 kg/m²). Fifty percent of patients (n = 74) were found to be at high risk for OSA, yet only 38% (n = 28) of those patients received a previous diagnosis of OSA. Variables available in the medical record were highly correlated with the overall STOP-Bang score (r =. 75, P < .001).

CONCLUSIONS

Half of patients who survived a MET activation during hospitalization screened at high risk for OSA. Standardized screening for risk of sleep apnea, as well as a truncated risk score generated by variables in the medical record, could guide clinical decision making in this at-risk population.

Genetic influences on the onset of obstructive sleep apnoea and daytime sleepiness: a twin study

Background

Obstructive sleep apnoea (OSA) is one of the major sources of the excessive daily sleepiness, cognitive dysfunction, and it increases cardiovascular morbidity and mortality. Previous studies suggested a possible genetic influence, based on questionnaires but no objective genetic study was conducted to understand the exact variance underpinned by genetic factors.

Methods

Seventy-one Hungarian twin pairs involved from the Hungarian Twin Registry (48 monozygotic, MZ and 23 dizygotic, DZ pairs, mean age 51 ± 15 years) underwent overnight polysomnography (Somnoscreen Plus Tele PSG, Somnomedics GMBH, Germany). Apnoea hypopnea index (AHI), respiratory disturbance index (RDI) and oxygen desaturation index (ODI) were registered. Daytime sleepiness was measured with the Epworth Sleepiness Scale (ESS). Bivariate heritability analysis was applied.

Results

The prevalence of OSA was 41% in our study population. The heritability of the AHI, ODI and RDI ranged between 69% and 83%, while the OSA, defined by an AHI ≥5/h, was itself 73% heritable. The unshared environmental component explained the rest of the variance between 17% and 31%. Daytime sleepiness was mostly determined by the environment, and the variance was influenced in 34% by the additive genetic factors. These associations were present after additional adjustment for body mass index.

Conclusion

OSA and the indices of OSA severity are heritable, while daytime sleepiness is mostly influenced by environmental factors. Further studies should elucidate whether close relatives of patients with OSA may benefit from early family risk based screening.

Role of Obesity in Otorhinolaryngologic Diseases

PURPOSE OF REVIEW

Obesity is a major public health problem associated with various diseases. Improving obesity control and achieving greater patient satisfaction are critical unmet needs. Various otorhinolaryngologic diseases can have negative effects on quality of life or actual health status depending on their type. Over the past decade, the relationship between obesity and otorhinolaryngologic conditions has been investigated. The purpose of this review was to discuss the relationship between obesity and otorhinolaryngological diseases.

RECENT FINDINGS

This is a narrative review on the current state of incidence, effects, and associated mechanisms between obesity and otorhinolaryngologic diseases. In various otologic diseases, otitis media (OM) and hearing loss (HL) are associated with obesity. In rhinologic parts, chronic rhinosinusitis (CRS) and obstructive sleep apnea (OSA) were significantly associated with obesity. Most of these diseases are reported to have higher susceptibility and severity as body mass index (BMI) increases. However, the incidence of head and neck cancer (HNC) was inversely associated with obesity, especially central adiposity. The relevance of obesity in laryngopharyngeal reflux disease (LPR) and allergic rhinitis (AR) has yet to be clarified, and this remains controversial. This review provides a comprehensive overview of the current state of incidence, effects, and associated mechanisms between obesity and otorhinolaryngologic diseases. Various otorhinolaryngological diseases are related to obesity. As obesity can be a negative risk factor in these otorhinolaryngologic diseases, early diagnosis and treatment of these diseases in obese patients will be critical.

The Prevalence of Sleep Apnea in Iran: a Systematic Review and Meta-Analysis

BACKGROUND

Sleep apnea is a common sleep disorder which is associated with cardiovascular diseases, diabetes and stroke. Different studies conducted in Iran have reported different prevalence for sleep apnea. The aim of the present study was to determine the prevalence of sleep apnea in Iran.

MATERIALS AND METHODS

In this study, 42 studies that have been published in Farsi and English languages were selected with no time limit up to the March of 2018. Article search was conducted using "prevalence", "frequency", "sleep apnea" and "obstructive sleep apnea" keywords in Scientific Information Database (SID), MagIran, Google Scholar, Science Direct, PubMed and Scopus databases. Data were analyzed using meta-analysis and random effect model methods. Heterogeneity between the studies was evaluated using I2 test. Data were analyzed using Stata software version 11.2.

RESULTS

The total prevalence of metabolic syndrome was 44% (95% CI: 35% to 53%). The highest prevalence of sleep apnea distinguished by the disease belonged to patients with sleep disorders (74%, 95% CI: 66%-82%), diabetes mellitus (61%; 95% CI: 46%-76%) and cardiovascular disease (55%; 95% CI: 47%-63%).

CONCLUSION

Given high prevalence of sleep apnea in Iran, identifying people at risk and providing instructional materials for controlling and treating sleep apnea is necessary.

Impairment of vascular strain in patients with obstructive sleep apnea

Background

Obstructive sleep apnea (OSA) is an independent risk factor for the development of cardiovascular diseases. Aim of this present study was to evaluate and extend recent research on the influence of obstructive sleep apnea on vascular strain.

Methods

A total number of 98 patients were integrated in the study. Patients were grouped according to the Apnea-Hypopnea-Index (AHI) in patients with mild-to-moderate OSA (5/h ≤ AHI < 30/h), severe OSA (AHI ≥ 30/h) and controls (AHI < 5/h). Groups were matched in age, body-mass-index and cardiovascular risks. Vascular strain of common carotid arteries was assessed by ultrasound speckle-tracking. A minor group of 30 patients and controls further underwent assessment of vascular strain of brachial and femoral arteries. Additionally, all patients underwent blood testing to reveal potential influences of inflammatory markers on arterial stiffness. In additional analysis we examined the effect of statin therapy on vascular strain.

Results

Patients with OSA showed significantly reduced values of vascular strain of common carotid arteries. Radial and circumferential strains were significantly lower in both patients with mild-to-moderate (p = .05) and patients with severe OSA (p = .001) compared to control. Vascular strain parameters of brachial and femoral arteries showed no consistent results. There were no significant correlations of inflammatory markers with vascular strain parameters. No significant differences in vascular strain were detected between statin and non-statin groups.

Conclusion

Patients with OSA show significantly reduced vascular strain assessed by ultrasound-based speckle-tracking. Vascular stiffness increases with the severity of the disease. Target vessels to assess vascular strain in patients with OSA are common carotid arteries, whereas other sites of the arterial tree are not reliable. No significant impact of current statin therapy on vascular strain was found. Further studies are needed to evaluate potential benefit of statins in secondary prevention of atherosclerosis in OSA.

Surgical treatment of a Pattern I Obstructive Sleep Apnea Syndrome individual - clinical case report

Obstructive Sleep Apnea Syndrome (OSA) is a multifactorial disease that highly alters a persons quality of life. It is characterized by the repeated interruption of breathing during sleep, due to an obstruction or the collapse of the upper airways. Since it is a multifactorial etiological disorder, it requires a thorough diagnosis and treatment with an interdisciplinary team, which comprises several professionals such as a surgical dentist, phonoaudiologist, otorhinolaryngologist, sleep doctor, neurologist and physiotherapist. The diagnosis and the degree of severity of the syndrome is determined through a polysomnography examination. After that, the best form of treatment is devised depending on the gravity of the case. In cases of moderate to severe apnea, invasive treatment through surgical procedures such as maxillomandibular advancement remains the preferred option as it increases the posterior air space, reducing and/or eliminating the obstruction. Thus, improving the patients respiratory function and, consequently, his quality of life as it is shown in the clinical case at hand. In which the male patient, facial pattern type I, 41 years of age, diagnosed with moderate OSA (Apnea-Hypopnea Index - AHI of 23.19), decided to have a surgical treatment instead of a conservative one, resulting in the cure of apnea (AHI of 0.3).

Prevalence and risk factors of moderate to severe obstructive sleep apnea syndrome in major depression: a observational and retrospective study on 703 subjects

Background

Several studies have investigated the prevalence and risk factors of depression in subjects with obstructive sleep apnea syndrome. However, few studies have investigated the prevalence and risk factors for obstructive sleep apnea syndrome in major depression. The aim of this study was to examine the prevalence and risk factors of moderate to severe obstructive sleep apnea syndrome in a large sample of individuals with major depression.

Methods

Data from 703 individuals with major depression recruited from the research database of the sleep laboratory of the Erasme Hospital were analysed. An apnea-hypopnea index of ≥15 events per hour was used as cut-off score for moderate to severe obstructive sleep apnea syndrome. Logistic regression analyses were conducted to examine clinical and demographic risk factors of moderate to severe obstructive sleep apnea syndrome in major depression.

Results

The prevalence of moderate to severe obstructive sleep apnea syndrome in major depression is 13.94%. Multivariate logistic regression analysis revealed that male gender, snoring, excessive daytime sleepiness, lower insomnia complaint, presence of metabolic syndrome, age ≥ 50 years, BMI >30 kg/m², ferritin >300 μg/L, CRP >7 mg/L and duration of sleep ≥8 h were significant risk factors of moderate to severe obstructive sleep apnea syndrome in major depression.

Conclusion

Moderate to severe obstructive sleep apnea syndrome is a common pathology in major depression. The identification of these different risk factors advances a new perspective for more effective screening of moderate to severe obstructive sleep apnea syndrome in major depression.

Allergic and Non-Allergic Rhinitis Are Common in Obstructive Sleep Apnea but Not Associated With Disease Severity

STUDY OBJECTIVES

Several studies have suggested that rhinitis contributes to the pathogenesis of obstructive sleep apnea (OSA). We aimed to investigate the prevalence and influence of allergic rhinitis (AR) and non-allergic rhinitis (NAR) on severity of OSA.

METHODS

Two hundred forty patients with OSA confirmed by standardized polysomnography were assessed for presence of AR and NAR, using validated questionnaires and skin prick tests. Data comparison was carried out by using chi-square test, analysis of variance, and least significant difference test. Associations between severity of OSA and rhinitis, age, sex, and body mass index were assessed with ordinal logistic regression analysis.

RESULTS

The prevalence of AR and NAR among patients with OSA was 27.1% and 28.7%, respectively, with no significant differences in the severity of rhinitis. Ordinal logistic regression analysis showed AR and NAR were not the risk factors for severity of OSA. There were significant differences of polysomnography parameters in sleep efficiency (79.7 ± 2.0 versus 85.2 ± 1.4 between AR and NAR; 79.7 ± 2.0 versus 87.2 ± 1.4 between AR and no-rhinitis) and arousal index (36.8 ± 4.1 versus 24.7 ± 3.5 between AR and no-rhinitis). Patients with NAR had lower average arterial oxygen saturation (91.9 ± 0.6 versus 94.0 ± 0.6) and minimal arterial oxygen saturation (70.6 ± 1.7 versus 77.3 ± 1.8), compared with subjects categorized as no-rhinitis.

CONCLUSIONS

This study suggests that despite a comparatively high prevalence in patients with OSA, the presence or severity of AR or NAR does not influence the severity of OSA; however, rhinitis may significantly disturb sleep in patients with OSA.

Prevalence and risk factors of moderate to severe obstructive sleep apnea syndrome in insomnia sufferers: a study on 1311 subjects

Background

Several studies have investigated the prevalence and risk factors of insomnia in subjects with obstructive sleep apnea syndrome. However, few studies have investigated the prevalence and risk factors for obstructive sleep apnea syndrome in insomnia sufferers. Thus, the aim of this study was to examine the prevalence and risk factors of moderate to severe obstructive sleep apnea syndrome in a large sample of insomnia sufferers.

Methods

Data from 1311 insomnia sufferers who were recruited from the research database of the sleep laboratory of the Erasme Hospital were analysed. An apnea-hypopnea index of ≥15 events per hour was used as the cut-off score for moderate to severe obstructive sleep apnea syndrome. Logistic regression analyses were conducted to examine clinical and demographic risk factors of moderate to severe obstructive sleep apnea syndrome in insomnia sufferers.

Results

The prevalence of moderate to severe obstructive sleep apnea syndrome in our sample of insomnia sufferers was 13.88%. Multivariate logistic regression analysis revealed that male gender, snoring, excessive daytime sleepiness, lower maintenance insomnia complaint, presence of metabolic syndrome, age ≥ 50 & <65 years, age ≥ 65 years, BMI ≥ 25 & <30 kg/m², BMI >30 kg/m², and CRP >7 mg/L were significant risk factors of moderate to severe obstructive sleep apnea syndrome in insomnia sufferers.

Conclusion

Moderate to severe obstructive sleep apnea syndrome is a common pathology in insomnia sufferers. The identification of these different risk factors advances a new perspective for more effective screening of moderate to severe obstructive sleep apnea syndrome in insomnia sufferers.

Association of sleep apnea and sleep duration with peripheral artery disease: The Multi-Ethnic Study of Atherosclerosis (MESA)

BACKGROUND AND AIMS

Numerous biological pathways linking sleep disturbances to atherosclerosis have been identified, such as insulin resistance, inflammation, hypertension, and endothelial dysfunction. Yet, the association of sleep apnea and sleep duration with peripheral artery disease (PAD) is not well characterized.

METHODS

We evaluated the cross-sectional association between objectively measured sleep and prevalent PAD in 1844 participants (mean age 68 years) who in 2010-2013 had in-home polysomnography, 7-day wrist actigraphy and ankle-brachial index (ABI) measurements. We also evaluated the relation between self-reported diagnosed sleep apnea and PAD incidence in 5365 participants followed from 2000 to 2012. PAD was defined as ABI < 0.90.

RESULTS

In cross-sectional analyses, severe sleep apnea [apnea-hypopnea index (AHI) ≥30 vs. AHI <5] was associated with greater prevalent PAD only among black participants [multivariate adjusted prevalence ratio (95% CI): 2.29 (1.07-4.89); p-interaction = 0.05]. Short and long sleep duration was also associated with a 2-fold higher prevalence of PAD as compared with those who slept 7 h/night, in the full sample. In longitudinal analyses, participants with self-reported diagnosed sleep apnea were at higher risk of incident PAD [multivariable adjusted hazard ratio (95% CI): 1.93 (1.05-3.53)], with no evidence of interaction by race/ethnicity.

CONCLUSIONS

These findings support a significant association between sleep apnea and prevalent and incident PAD, with evidence for stronger associations with objectively measured sleep apnea and cross sectional PAD in blacks. In addition, short and long sleep duration was associated with PAD. These results identify sleep disturbances as a potential risk factor for PAD.

Racial/Ethnic Differences in Sleep Disturbances: The Multi-Ethnic Study of Atherosclerosis (MESA)

OBJECTIVES

There is limited research on racial/ethnic variation in sleep disturbances. This study aimed to quantify the distributions of objectively measured sleep disordered breathing (SDB), short sleep duration, poor sleep quality, and self-reported sleep disturbances (e.g., insomnia) across racial/ethnic groups.

DESIGN

Cross-sectional study.

SETTING

Six US communities.

PARTICIPANTS

Racially/ethnically diverse men and women aged 54-93 y in the Multi-Ethnic Study of Atherosclerosis Sleep Cohort (n = 2,230).

INTERVENTIONS

N/A.

MEASUREMENTS AND RESULTS

Information from polysomnography-measured SDB, actigraphy-measured sleep duration and quality, and self-reported daytime sleepiness were obtained between 2010 and 2013. Overall, 15.0% of individuals had severe SDB (apnea-hypopnea index [AHI] ≥ 30); 30.9% short sleep duration (< 6 h); 6.5% poor sleep quality (sleep efficiency < 85%); and 13.9% had daytime sleepiness. Compared with Whites, Blacks had higher odds of sleep apnea syndrome (AHI ≥ 5 plus sleepiness) (sex-, age-, and study site-adjusted odds ratio [OR] = 1.78, 95% confidence interval [CI]: 1.20, 2.63), short sleep (OR = 4.95, 95% CI: 3.56, 6.90), poor sleep quality (OR = 1.57, 95% CI: 1.00, 2.48), and daytime sleepiness (OR = 1.89, 95% CI: 1.38, 2.60). Hispanics and Chinese had higher odds of SDB and short sleep than Whites. Among non-obese individuals, Chinese had the highest odds of SDB compared to Whites. Only 7.4% to 16.2% of individuals with an AHI ≥ 15 reported a prior diagnosis of sleep apnea.

CONCLUSIONS

Sleep disturbances are prevalent among middle-aged and older adults, and vary by race/ethnicity, sex, and obesity status. The high prevalence of sleep disturbances and undiagnosed sleep apnea among racial/ethnic minorities may contribute to health disparities.

Misclassification of OSA severity with automated scoring of home sleep recordings

BACKGROUND

The advent of home sleep testing has allowed for the development of an ambulatory care model for OSA that most health-care providers can easily deploy. Although automated algorithms that accompany home sleep monitors can identify and classify disordered breathing events, it is unclear whether manual scoring followed by expert review of home sleep recordings is of any value. Thus, this study examined the agreement between automated and manual scoring of home sleep recordings.

METHODS

Two type 3 monitors (ApneaLink Plus [ResMed] and Embletta [Embla Systems]) were examined in distinct study samples. Data from manual and automated scoring were available for 200 subjects. Two thresholds for oxygen desaturation (≥ 3% and ≥ 4%) were used to define disordered breathing events. Agreement between manual and automated scoring was examined using Pearson correlation coefficients and Bland-Altman analyses.

RESULTS

Automated scoring consistently underscored disordered breathing events compared with manual scoring for both sleep monitors irrespective of whether a ≥ 3% or ≥ 4% oxygen desaturation threshold was used to define the apnea-hypopnea index (AHI). For the ApneaLink Plus monitor, Bland-Altman analyses revealed an average AHI difference between manual and automated scoring of 6.1 (95% CI, 4.9-7.3) and 4.6 (95% CI, 3.5-5.6) events/h for the ≥ 3% and ≥ 4% oxygen desaturation thresholds, respectively. Similarly for the Embletta monitor, the average difference between manual and automated scoring was 5.3 (95% CI, 3.2-7.3) and 8.4 (95% CI, 7.2-9.6) events/h, respectively.

CONCLUSIONS

Although agreement between automated and manual scoring of home sleep recordings varies based on the device used, modest agreement was observed between the two approaches. However, manual review of home sleep test recordings can decrease the misclassification of OSA severity, particularly for those with mild disease.

TRIAL REGISTRY

ClinicalTrials.gov; No.: NCT01503164; www.clinicaltrials.gov.

Quality measures for the care of adult patients with obstructive sleep apnea

ABSTRACT

Obstructive sleep apnea (OSA) is a prevalent disorder associated with a multitude of adverse outcomes when left untreated. There is significant heterogeneity in the evaluation and management of OSA resulting in variation in cost and outcomes. Thus, the goal for developing these measures was to have a way to evaluate the outcomes and reliability of the processes involved with the standard care approaches used in the diagnosis and management of OSA. The OSA quality care measures presented here focus on both outcomes and processes. The AASM commissioned the Adult OSA Quality Measures Workgroup to develop quality care measures aimed at optimizing care for adult patients with OSA. These quality care measures developed by the Adult OSA Quality Measures Workgroup are an extension of the original Centers for Medicare & Medicaid Services (CMS) approved Physician Quality Reporting System (PQRS) measures group for OSA. The measures are based on the available scientific evidence, focus on public safety, and strive to improve quality of life and cardiovascular outcomes for individual OSA patients. The three outcomes that were selected were as follows: (1) improve disease detection and categorization; (2) improve quality of life; and (3) reduce cardiovascular risk. After selecting these relevant outcomes, a total of ten process measures were chosen that could be applied and assessed for the purpose of accomplishing these outcomes. In the future, the measures described in this document may be reported through the PQRS in addition to, or as a replacement for, the current OSA measures group. The overall objective for the development of these measures is that implementation of these quality measures will result in improved patient outcomes, reduce the public health burden of OSA, and provide a measurable standard for evaluating and managing OSA.

Early effects of a hypocaloric, Mediterranean diet on laboratory parameters in obese individuals

Calorie restriction is a common strategy for weight loss in obese individuals. However, little is known about the impact of moderate hypocaloric diets on obesity-related laboratory parameters in a short-term period. Aim of this study was to evaluate the variation of laboratory biomarkers in obese individuals following a Mediterranean, hypocaloric (1400-1600 Kcal/die) diet. 23 obese, pharmacologically untreated patients were enrolled and subjected to the determination of anthropometric variables and blood collection at baseline, 1 and 4 months after diet initiation. After 4 months of calorie restriction, we observed a significant decrease in body weight and BMI (both P < 0.0001), insulin (P = 0.037), HOMA-IR (P = 0.026), leptin (P = 0.008), and LDH (P = 0.023) and an increase in EGF (P = 0.013). All these parameters, except LDH, varied significantly already at 1 month after diet initiation. Also, lower levels of insulin (P = 0.025), leptin (P = 0.023), and EGF (P = 0.035) were associated with a greater (>5%) weight loss. Collectively, our data support a precocious improvement of insulin and leptin sensitivity after a modest calorie restriction and weight reduction. Moreover, EGF and LDH may represent novel markers of obesity, which deserve further investigations.

Salivary markers of oxidative stress in patients with obstructive sleep apnea treated with continuous positive airway pressure

PURPOSE

Obstructive sleep apnea syndrome (OSAS) is characterized by elevated oxidative stress. Measurement of oxidative stress in saliva seems to be promising in long-term treatment monitoring of OSAS patients. In this study, our aim was to investigate whether short-term continuous positive airway pressure (CPAP) treatment would influence oxidative stress in saliva.

METHODS

Patients with diagnosed OSAS (16 women, 28 men) underwent polysomnography during the first night and CPAP treatment during the second night. Saliva samples were taken in the evening and morning on both days. Markers of oxidative stress and antioxidant status were analyzed in saliva.

RESULTS

Evening concentrations of the salivary thiobarbituric acid reacting substances (p < 0.001), advanced glycation end-products (p < 0.001), and advanced oxidation protein products (p < 0.01) were significantly lower than morning values during the diagnostic night. However, salivary concentrations of none of the oxidative stress markers were significantly influenced by the CPAP treatment. No changes in salivary antioxidant status after CPAP therapy were found.

CONCLUSION

Salivary markers of oxidative stress and antioxidant status do not change significantly after one night treatment with CPAP. On the contrary, after 1 month with CPAP therapy, reduced markers of oxidative stress were reported. Therefore, the future studies should be focused on finding the optimal sampling frequency to clarify the potential of saliva for the monitoring of OSAS treatment.

Oral pressure therapy for treatment of obstructive sleep apnea: clinical feasibility

PURPOSE

This feasibility study examined the initial-use safety and effectiveness of a new noninvasive oral pressure therapy (OPT) system developed to treat obstructive sleep apnea (OSA).

METHODS

The OPT system consists of a console that connects with flexible tubing to a premanufactured polymer mouthpiece. Through the mouthpiece, a pump in the console creates oral vacuum intended to move the soft palate anteriorly to decrease obstruction of the airway during sleep. The mouthpiece was produced in ten different sizes to accommodate a range of oral dimensions. Subjects with OSA in this single-center, single-night study underwent a polysomnography (PSG) study at baseline, followed by PSG during use of OPT.

RESULTS

Fifty-six men and 20 women, aged 50.8 ± 12.0 years (mean ± standard deviation [SD]), had OSA with apnea-hypopnea indices (AHI) greater than five events per hour at baseline. Body weight averaged 98.0 ± 18.2 kg (mean ± SD), body mass index ranged from 22.6 kg/m(2) to 57.9 kg/m(2) and averaged 32.5 ± 5.8 kg/m(2) (mean ± SD). OPT was generally well tolerated without any serious adverse events. Baseline AHI was 38.7 ± 27.5 events/hour (mean ± SD) and was reduced with treatment to 24.6 ± 25.7 events/hour (P < 0.001, Cohen's d 0.53). Treatment produced AHI less than or equal to ten events/hour in 38% of the subjects. Oxygen desaturation index was 30.1 ± 23.7 events/hour at baseline versus 15.8 ± 19.1 events/hour with treatment (P < 0.001, Cohen's d 0.66). The minimum oxygen saturation increased with treatment from 77.9 ± 8.3 to 82.2 ± 7.9 (P < 0.001, Cohen's d 0.53). Stage-N1 sleep shifts, total sleep-stage shifts, and awakenings were significantly reduced with treatment.

CONCLUSION

This single-center, single-night feasibility study demonstrates that OPT can improve OSA in certain subjects identifiable by PSG during systematic usage. In appropriately responsive patients, OPT shows potential as a clinically useful new alternative for treatment of OSA without the need for custom manufacture of an oral device component.