Association Between Non-erosive Reflux Disease and High Risk of Obstructive Sleep Apnea in Korean Population

Obstructive Sleep Apnea and Acute Lower Respiratory Tract Infections: A Narrative Literature Review

Both obstructive sleep apnea (OSA) and acute lower respiratory tract infections (LRTIs) are important global health issues. The pathophysiological links between OSA and LRTIs include altered immune responses due to chronic intermittent hypoxia and sleep fragmentation, increased aspiration risk, and a high burden of comorbidities. In this narrative review, we evaluated the current evidence on the association between OSA and the incidence and outcomes of acute LRTIs in adults, specifically community-acquired pneumonia and viral pneumonia caused by influenza and severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Studies have demonstrated that OSA patients are more likely to develop bacterial pneumonia and exhibit a higher risk of invasive pneumococcal disease. The risk intensifies with the severity of OSA, influencing hospitalization rates and the need for intensive care. OSA is also associated with an increased risk of contracting influenza and suffering more severe disease, potentially necessitating hospitalization. Similarly, OSA contributes to increased COVID-19 disease severity, reflected by higher rates of hospitalization, longer hospital stays, and a higher incidence of acute respiratory failure. The effect of OSA on mortality rates from these infections is, however, somewhat ambiguous. Finally, we explored antibiotic therapy for OSA patients with LRTIs, addressing care settings, empirical regimens, risks, and pharmacokinetic considerations. Given the substantial burden of OSA and its significant interplay with acute LRTIs, enhanced screening, targeted vaccinations, and optimized management strategies for OSA patients should be prioritized.

Association of self-reported and objective sleep disturbance with the spectrum of gastroesophageal reflux disease

STUDY OBJECTIVES

The relationship between obstructive sleep apnea (OSA) and gastroesophageal reflux disease (GERD) is complex. We aimed to determine the association of self-reported and objective sleep parameters with diverse manifestations of the GERD spectrum.

METHODS

We prospectively recruited 561 individuals who underwent an electrocardiogram-based cardiopulmonary coupling for OSA screening during a health check-up. All participants received the Reflux Disease Questionnaire and an upper endoscopy to determine the presence of troublesome reflux symptoms and erosive esophagitis (EE). Sleep quality was evaluated by the Pittsburgh Sleep Quality Index and sleep dysfunction was defined as a Pittsburgh Sleep Quality Index score > 5. OSA was defined as a cardiopulmonary coupling-derived apnea-hypopnea index exceeding 15 events/h. Comparisons were made between participants on the GERD spectrum with respect to their various self-reported and objective sleep parameters.

RESULTS

Among the 277 patients with GERD (49.4%), 198 (35.3%) had EE. Patients with GERD had higher PSQI scores (6.99 ± 3.97 vs 6.07 ± 3.73, P = .005) and a higher prevalence of sleep dysfunction (60.6% vs 49.6%, P = .009). Patients with EE had a higher prevalence of OSA (42.9% vs 33.9%, P = .034). Along the GERD spectrum, symptomatic patients with EE had the highest PSQI scores and prevalence of sleep dysfunction (70.7%), while asymptomatic patients with EE had the highest prevalence of OSA (44%).

CONCLUSIONS

Our findings indicate a high prevalence of sleep dysfunction among individuals with GERD. Furthermore, patients on the GERD spectrum are prone to experiencing a range of self-reported and objective sleep disturbances.

CITATION

Hu K-Y, Tseng P-H, Hsu W-C, et al. Association of self-reported and objective sleep disturbance with the spectrum of gastroesophageal reflux disease. J Clin Sleep Med. 2024;20(6):911-920.

Relationship between obstructive sleep apnoea syndrome and gastrointestinal diseases: a systematic review and Meta-analysis

Studies exploring the association between obstructive sleep apnoea syndrome (OSA) and gastrointestinal diseases (GID) are important for enhancing clinical outcomes. This study aimed to systematically assess the association between these two diseases. Adhering to PRISMA guidelines, a comprehensive literature search was conducted across databases including PubMed, Web of Science, Willey Library, Cochrane Library and Scopus. This search focused on English literature published up to January 2024. Literature screening, quality assessment (using the NOS scale) and data extraction were performed by two independent researchers. Statistical analyses were performed using the meta-package of the R.4.2.2 software. An initial screening of 2178 papers was conducted and 11 studies were included. Meta-analysis results showed a significant association between OSA and GID (p < 0.01). Subgroup analyses further indicated a stronger association between OSA and GID in Asian populations compared to Europe and the United States. In addition, both benign and malignant GID were significantly associated with OSA, with a pronounced association for malignant GID than for benign GID. The results of publication bias analysis revealed no significant bias (Begg's test p = 0.45, Egger's test p = 0.60). This study uncovers a notable association between OSA and GID, especially in Asian populations, suggesting that clinicians should consider the potential connection between these two diseases during diagnosis and treatment. However, due to the heterogeneity and limitations of the study, these conclusions need to be further validated through more comprehensive research.

Assessment of cephalometric parameters and correlation with the severity of the obstructive sleep apnea syndrome

BACKGROUND

In individuals diagnosed with obstructive sleep apnea syndrome (OSAS), variations in craniofacial structure have been inconsistently documented, showing differing degrees of alteration between obese and nonobese patients. In addition, sleep disturbance has also been shown to induce disequilibrium in this population of patients. This pilot observational study aimed to assess craniofacial values in obese and nonobese subpopulations of patients with OSAS and their correlation and association with the severity of OSAS. We also assessed whether OSAS patients are characterized by an impaired equilibrium in relation to and associated with the severity of OSAS.

METHODS

We included all consecutive adult patients with OSAS. Through cephalometry, we assessed the upper (UPa-UPp) and lower (LPa-LPp) pharynx diameters, superior anterior facial height (Sor-ANS), anterior facial height (ANS-Me), anterior vertical dimension (Sor-Me), posterior facial height (S-Go) and craniovertebral angle (CVA). Furthermore, we analyzed postural equilibrium through a stabilometric examination.

RESULTS

Forty consecutive OSAS patients (45% female with a mean age of 56 ± 8.2 years) were included. The subgroup of nonobese patients had a reduced UPa-UPp (p = 0.02). Cephalometric measurements were correlated with the severity of OSAS in nonobese patients, whereas only Sor-ANS was correlated with the severity of OSAS in the obese subpopulation. In the overall population, altered craniofacial values are associated with severe OSAS. Although there are differences in equilibrium between obese and nonobese OSAS patients, the stabilometric measurements were not correlated or associated with OSAS severity.

CONCLUSION

Altered craniofacial values and compromised equilibrium in OSAS patients are linked to OSAS severity. Therefore, the management of OSAS should be tailored not only to weight management but also to craniofacial and postural rehabilitation to enhance patient outcomes.

Association between obstructive sleep apnea and gastroesophageal reflux disease: A systematic review and meta-analysis

BACKGROUND AND AIM

We aim to conduct a systematic review and determine the association between obstructive sleep apnea (OSA) and gastroesophageal reflux disease (GERD).

METHODS

Literature search for eligible studies was performed across major databases. The main endpoint was to assess the association between GERD and OSA. Subgroup analyses were performed to determine this strength of the association stratified by the diagnostic tools used for OSA (nocturnal polysomnogram or Berlin questionnaire) and GERD (validated reflux questionnaire or esophagogastroduodenoscopy). We also compared sleep efficiency, apnea hypopnea index, oxygen desaturation index, and Epworth Sleepiness Scale in OSA patients with or without GERD. Results were pooled together using Reviewer Manager 5.4.

RESULTS

Six studies involving 2950 patients with either GERD or OSA were included in the pooled analysis. Our findings suggest that there was a statistically significant unidirectional association between GERD and OSA (odds ratio [OR] = 1.53, P = 0.0001). Subgroup analyses redemonstrated an OSA-GERD association irrespective of the tools used for diagnosing either GERD or OSA (P = 0.24 and P = 0.82, respectively). Sensitivity analyses demonstrated the same association after controlling for gender (OR = 1.63), BMI (OR = 1.81), smoking (OR = 1.45), and alcohol consumption (OR = 1.79). In patients with OSA, there were no statistically significant differences between patients with or without GERD in terms of apnea hypopnea index (P = 0.30), sleep efficiency (P = 0.67), oxygen desaturation index (P = 0.39), and Epworth Sleepiness Scale (P = 0.07).

CONCLUSION

There exists an association between OSA and GERD that is independent of the modalities used for screening or diagnosing both disorders. However, the presence of GERD did not affect the severity of OSA.

The Influence of Gastroesophageal Reflux Disease on Daytime Sleepiness and Depressive Symptom in Patients With Obstructive Sleep Apnea

Background/Aims

As there is insufficient evidence for a relationship between gastroesophageal reflux disease (GERD) and obstructive sleep apnea (OSA), we investigated whether OSA diagnosed by polysomnography (PSG) is related to GERD.

Methods

A total of 402 subjects was evaluated. Overnight PSG was performed and a few questionnaires on GERD, anxiety, depression, and daytime sleepiness were administered. An apnea-hypopnea index < 5 was the classification criterion for subjects without OSA. Subjects with heartburn or acid regurgitation at least once a week were classified as having GERD.

Results

Among the 402 subjects, 318 had OSA and 84 did not. The prevalence of GERD was 12.9% among patients with OSA and 10.7% among those without (P = 0.590). The prevalence of GERD did not correlate with OSA severity (P = 0.474). Patients with OSA with GERD had higher Stanford Sleepiness Scale (P = 0.004), Epworth Sleepiness Scale (P = 0.001), and depression (P < 0.001) scores than patients with OSA without GERD. Subjects with nocturnal gastroesophageal reflux symptoms had a higher body mass index, waist-to-height ratio, and waist circumference-to-height index than those without symptoms. Multiple logistic regression showed that higher Epworth Sleepiness Scale and depression scores were independent factors associated with GERD in patients with OSA.

Conclusions

The prevalence of GERD in patients with OSA was 12.9%. The prevalence of GERD did not correlate with OSA severity. Daytime sleepiness and depression seem to be associated with GERD in patients with OSA, while nocturnal reflux symptoms seem to be related to obesity in OSA.

Craniofacial morphology in patients with obstructive sleep apnea: cephalometric evaluation

Introduction

Obstructive sleep apnea is characterized by a reduced airflow through the upper airways during sleep. Two forms of obstructive sleep apnea are described: the central form and the obstructive form. The obstructive form is related to many factors, such as the craniofacial morphology.

Objective

To evaluate the correlation between the morphology of the cranial base, of the mandible and the maxilla, and obstructive sleep apnea severity.

Methods

Eighty-four patients, mean age of 50.4 years old; 73 males and 11 females with obstructive sleep apnea were enrolled in the present study. Patients with high body mass index and comorbidities were excluded. Lateral cephalograms and polysomnography were collected for each patient to evaluate the correlation between craniofacial morphology and obstructive sleep apnea severity. A Spearman’s rho correlation test between cephalometric measurements and obstructive sleep apnea indexes was computed. Statistical significance was set at p < 0.05.

Results

Patients with a severe obstructive sleep apnea presented a reduction of sagittal growth of both effective mandibular length and cranio-basal length. The mandibular length was the only variable with a statistical correlation with apnea-hypopnea index. Vertical dimension showed a weak correlation with the severity of obstructive sleep apnea. No correlation with maxillary sagittal dimension was shown.

Conclusion

Obstructive sleep apnea severity may be correlated to mandibular and cranial base growth. Facial vertical dimension had no correlation with obstructive sleep apnea severity.

Ankylosing Spondylitis Is Associated With Risk of New-Onset Obstructive Sleep Apnea: A Nationwide Population-Based Cohort Study

Objectives: Investigating the risk of obstructive sleep apnea(OSA) among ankylosing spondylitis (AS) patients based on administrative healthcare databases.

Methods: We conducted a nationwide cohort study by using the Taiwan National Health Insurance Research Database with 1997–2013 claim records. The AS cohort included 2,210 patients who were newly diagnosed between 2003 and 2013. Randomly selected non-AS controls were matched at a 1:4 ratio. The endpoint was set as OSA occurrence or the end of 2013. Cumulative incidences, hazard ratios (HRs) and 95% confidence intervals (CIs) were calculated after adjusting for age, gender, comorbidities, and co-medication. Multivariate analyses were performed using the Cox proportional hazards model. Due to the violation of the proportionality assumption, landmark analysis was conducted to explore the risk of OSA during specific follow-up periods.

Results: The adjusted HR (aHR) of OSA in the AS group was 2.826 (95% C.I. = 1.727–4.625) compared to the control group. On landmark analysis, aHR was 7.919 (95% C.I. = 3.169–19.792) for the AS group 0–24 months from the index date and decreased to 1.816 (95% C.I. = 0.944–3.494) at ≥ 24 months from the index date. The increased risks of OSA in the AS group compared to the control group were found for both males and females (aHRs were 4.533 and 2.672). On age-stratified analysis, a significant risk only for the 40–59 age group with aHR of 3.913 (95% C.I. = 1.890–8.102).

Conclusions: A higher risk of developing OSA was found among newly diagnosed AS cohort during the maximum 11-year follow-up period, especially within 2 years after newly diagnosed AS and in the 40–59 age group.

The Association between Health Conditions in World Trade Center Responders and Sleep-Related Quality of Life and Sleep Complaints

Background: World Trade Center (WTC) dust-exposed subjects have multiple comorbidities that affect sleep. These include obstructive sleep apnea (OSA), chronic rhinosinusitis (CRS), gastroesophageal-reflux disorder (GERD) and post-traumatic stress disorder (PTSD). We examined the impact of these conditions to sleep-related outcomes. Methods: Demographics, co-morbidities and symptoms were obtained from 626 WTC (109F/517M), 33⁻87years, BMI = 29.96 ± 5.53 kg/m²) subjects. OSA diagnosis was from a 2-night home sleep test (ARES^TM). Subjective sleep quality, sleep-related quality of life (QOL, Functional Outcomes of Sleep Questionnaire), excessive daytime sleepiness (Epworth Sleepiness Scale), sleep duration and sleep onset and maintenance complaints were assessed. Results: Poor sleep quality and complaints were reported by 19⁻70% of subjects and average sleep duration was 6.4 h. 74.8% of subjects had OSA. OSA diagnosis/severity was not associated with any sleep-related outcomes. Sleep duration was lower in subjects with all conditions (p < 0.05) except OSA. CRS was a significant risk factor for poor sleep-related QOL, sleepiness, sleep quality and insomnia; PTSD for poor sleep-related QOL and insomnia; GERD for poor sleep quality. These associations remained significant after adjustment for, age, BMI, gender, sleep duration and other comorbidities. Conclusions: Sleep complaints are common and related to several health conditions seen in WTC responders. Initial interventions in symptomatic patients with both OSA and comorbid conditions may need to be directed at sleep duration, insomnia or the comorbid condition itself, in combination with intervention for OSA.

The relationship between obstructive sleep apnea hypopnea syndrome and gastroesophageal reflux disease: a meta-analysis

BACKGROUND

Obstructive sleep apnea hypopnea syndrome (OSAHS) means apnea and hypopnea caused by partial or complete obstruction of upper airway collapse during sleep. Gastroesophageal reflux disease (GERD) is believed to be associated with various manifestations in the otorhinolaryngology and has been found to be an additional risk factor for OSAHS.

AIM

A meta-analysis was performed to identify the association between obstructive sleep apnea hypopnea syndrome and gastroesophageal reflux disease.

METHODS

To identify eligible original articles, we searched a series of computerized databases, including Medline via PubMed, EMBASE, Web of Science, and CNKI with a systematic searching strategy. The characteristics of each article and pooled odds ratios (ORs) with corresponding confidence intervals (CIs) were calculated and subgroup analysis was performed to analyze the source of heterogeneity.

RESULTS

A total of 2699 patients from seven articles were included in the meta-analysis. We identified a significant relationship between obstructive sleep apnea syndrome and gastroesophageal reflux disease, with a pooled OR of 1.75 (95% CI 1.18-2.59, P < 0.05). The pooled data was calculated under the random-effects model as a significant moderate heterogeneity was found among the meta-analysis.

CONCLUSIONS

The meta-analysis showed that there was a significant correlation between obstructive sleep apnea hypopnea syndrome and gastroesophageal reflux disease.

Sex and Gender Differences in Gastroesophageal Reflux Disease

It is important to understand sex and gender-related differences in gastroesophageal reflux disease (GERD) because gender-related biologic factors might lead to better prevention and therapy. Non-erosive reflux disease (NERD) affects more women than men. GERD symptoms are more frequent in patients with NERD than in those with reflux esophagitis. However, men suffer pathologic diseases such as reflux esophagitis, Barrett’s esophagus (BE), and esophageal adenocarcinoma (EAC) more frequently than women. The prevalence of reflux esophagitis is significantly increased with age in women, especially after their 50s. The mean age of EAC incidence in women is higher than in men, suggesting a role of estrogen in delaying the onset of BE and EAC. In a chronic rat reflux esophagitis model, nitric oxide was found to be an aggravating factor of esophageal injury in a male-predominant way. In addition, the expression of esophageal occludin, a tight junction protein that plays an important role in the esophageal defense mechanism, was up-regulated in women. This explains the male predominance of reflux esophagitis and delayed incidence of BE or EAC in women. Moreover, the symptoms such as heartburn, regurgitation, and extra-esophageal symptoms have been more frequently reported by women than by men, suggesting that sex and gender play a role in symptom perception. Differential sensitivity with augmented symptoms in women might have diagnostic and therapeutic influence. Furthermore, recent studies have suggested that hormone replacement therapy has a protective effect against esophageal cancer. However, an anti-inflammatory role of estrogen remains compelling, which means further study is necessary in this area.