High hypopnea/apnea ratio (HAR) in extreme obesity

Non-sleep related outcomes of maxillomandibular advancement, a systematic review

Maxillomandibular advancement has been shown to be an effective treatment for obstructive sleep apnea; however, the literature focuses mainly on sleep-related parameters such as apnea-hypopnea index, respiratory disturbance index and Epworth sleepiness scale. Other factors that may be important to patients, such as esthetics, patient satisfaction, nasality, swallowing problems and so forth have been reported in the literature but have not been systematically studied. Together with an information specialist, an extensive search in Medline, Embase and Scopus yielded 1592 unique articles. Titles and abstracts were screened by two blinded reviewers. In total, 75 articles were deemed eligible for full-text screening and 38 articles were included for qualitative synthesis. The most common categories of non-sleep related outcomes found were surgical accuracy, facial esthetics, functional outcomes, quality of life, patient satisfaction, and emotional health. All categories were reported using heterogenous methods, such that meta-analysis could not be performed. There was lack of consistent methods to assess these outcomes. This work is the first to systematically review non-sleep related outcomes of maxillomandibular advancement. Despite growing interest in evaluating surgical outcomes through patient subjective experiences, this review points to the need of standardized, validated methods to report these outcomes.

Deep learning of sleep apnea-hypopnea events for accurate classification of obstructive sleep apnea and determination of clinical severity

BACKGROUND

/Objective: Automatic apnea/hypopnea events classification, crucial for clinical applications, often faces challenges, particularly in hypopnea detection. This study aimed to evaluate the efficiency of a combined approach using nasal respiration flow (RF), peripheral oxygen saturation (SpO2), and ECG signals during polysomnography (PSG) for improved sleep apnea/hypopnea detection and obstructive sleep apnea (OSA) severity screening.

METHODS

An Xception network was trained using main features from RF, SpO2, and ECG signals obtained during PSG. In addition, we incorporated demographic data for enhanced performance. The detection of apnea/hypopnea events was based on RF and SpO2 feature sets, while the screening and severity categorization of OSA utilized predicted apnea/hypopnea events in conjunction with demographic data.

RESULTS

Using RF and SpO2 feature sets, our model achieved an accuracy of 94 % in detecting apnea/hypopnea events. For OSA screening, an exceptional accuracy of 99 % and an AUC of 0.99 were achieved. OSA severity categorization yielded an accuracy of 93 % and an AUC of 0.91, with no misclassification between normal and mild OSA versus moderate and severe OSA. However, classification errors predominantly arose in cases with hypopnea-prevalent participants.

CONCLUSIONS

The proposed method offers a robust automatic detection system for apnea/hypopnea events, requiring fewer sensors than traditional PSG, and demonstrates exceptional performance. Additionally, the classification algorithms for OSA screening and severity categorization exhibit significant discriminatory capacity.

Profile of sleep disturbances in patients with recurrent depressive disorder or bipolar affective disorder in a tertiary sleep disorders service

Bidirectional relationship between sleep disturbances and affective disorders is increasingly recognised, but its underlying mechanisms are far from clear, and there is a scarcity of studies that report on sleep disturbances in recurrent depressive disorder (RDD) and bipolar affective disorder (BPAD). To address this, we conducted a retrospective study of polysomnographic and clinical records of patients presenting to a tertiary sleep disorders clinic with affective disorders. Sixty-three BPAD patients (32 female; mean age ± S.D.: 41.8 ± 12.4 years) and 126 age- and gender-matched RDD patients (62 female; 41.5 ± 12.8) were studied. Whilst no significant differences were observed in sleep macrostructure parameters between BPAD and RDD patients, major differences were observed in comorbid sleep and physical disorders, both of which were higher in BPAD patients. Two most prevalent sleep disorders, namely obstructive sleep apnoea (OSA) (BPAD 50.8.0% vs RDD 29.3%, P = 0.006) and insomnia (BPAD 34.9% vs RDD 15.0%, P = 0.005) were found to be strongly linked with BPAD. In summary, in our tertiary sleep clinic cohort, no overt differences in the sleep macrostructure between BPAD and RDD patients were demonstrated. However, OSA and insomnia, two most prevalent sleep disorders, were found significantly more prevalent in patients with BPAD, by comparison to RDD patients. Also, BPAD patients presented with significantly more severe OSA, and with higher overall physical co-morbidity. Thus, our findings suggest an unmet/hidden need for earlier diagnosis of those with BPAD.

Outcome of nasal measurements in patients with OSA - Mounting evidence of a nasal endotype

BACKGROUND

Increased nasal resistance as measured by 4-phase rhinomanometry is associated with a paucity of apneas relative to hypopneas in obstructive sleep apnea (OSA) patients. The ratio of hypopneas to apneas for a given apnea hypopnea index (AHI) may influence treatment choice. This study aimed to investigate if OSA patients with an elevated hypopnea apnea ratio are associated with differences in acoustic rhinometry measurements.

METHODS

One hundred and thirty-nine (n = 139) OSA patients (AHI >5) were enrolled in this prospective case-control study (all male). OSA Diagnosis was established through a type three sleep study. Both acoustic rhinometry and 4-phase rhinomanometry were performed on all patients at baseline and after decongestion. Possible associations between apnea-hypopnea index, oxygen desaturation index, nadir oxygen saturation, apnea index, hypopnea index, hypopnea to apnea ratio and body mass index and were analysed using multiple logistic and linear regression models.

RESULTS

The acoustic rhinometry measurements minimal cross-sectional area, total volume and minimal cross-sectional areas are significantly smaller in patients with increased nasal resistance as measured by 4-phase rhinomanometry (P < 0.01). No consistent statistically significant associations were found between the acoustic rhinometry variables, and the respiratory variables analysed in the sleep studies. OSA patients with an elevated hypopnea apnea ratio are more than 4 times more likely to present with increased nasal resistance measured by 4-phase rhinomanometry (OR = 4.4, 95% CI [1.5-13.2], P < 0.01).

CONCLUSIONS

Acoustic rhinometry is significantly associated with 4-phase rhinomanometry. However, acoustic rhinometry measurements are not associated with the respiratory indices routinely measured in OSA in a clinical setting. 4-phase rhinomanometry is a more suitable method for detecting clinically relevant nasal obstruction in obstructive sleep apnea patients.

Obstructive Sleep Apnea Resolution in Hypopnea-Predominant versus Apnea-Predominant Patients after Maxillomandibular Advancement

This retrospective cohort study aimed: (1) to analyze the influence of apnea-predominant versus hypopnea-predominant obstructive sleep apnea (OSA) on surgical outcome after maxillomandibular advancement (MMA); and (2) to evaluate whether MMA alters the presence of apnea-predominant to hypopnea-predominant OSA more than vice versa. In total 96 consecutive moderate to severe OSA patients, who underwent MMA between 2010 and 2021, were included. The baseline apnea−hypopnea index, apnea index, and oxygen desaturation index were significantly higher in apnea-predominant group, while the hypopnea index was significantly higher in hypopnea-predominant group (p < 0.001). No significant difference was found between apnea-predominant group and hypopnea-predominant group in the degree of advancement of A-point, B-point, and pogonion. Surgical success and cure were significantly higher in the hypopnea-predominant group compared to the apnea-predominant group, 57.4% versus 82.1% (p = 0.021) and 13.2% versus 55.5% (p = 0.012), respectively. Of the 68 (70.8%) apnea-predominant patients, 37 (54.4%) shifted to hypopnea-predominant after MMA. Of the 28 (29.2%) hypopnea-predominant patients, 7 (25%) shifted to apnea-predominant postoperatively. These findings suggest that preoperative hypopnea-predominant OSA patients might be more suitable candidates for MMA compared to preoperative apnea-predominant OSA patients. Additionally, MMA proved to alter the presence of apnea-predominant to hypopnea-predominant OSA to a larger extend than vice versa.

Disparities in oxygen saturation and hypoxic burden levels in obstructive sleep apnea patient's response to oral appliance treatment

Background

Oxygen saturation indices show a strong correlation with long‐term health outcomes. Nonetheless, evidence on the relationship between reduction in respiratory events and increase in oxygenation levels following oral appliance (OA) treatment is scarce.

Objectives

To verify the relationship between reduction in the apnoea‐hypopnoea index (AHI) and oxygen saturation levels following OA treatment, we have conducted an evaluation of polysomnography (PSG) and clinical parameters associated with the improvement of oxygen desaturation.

Methods

OSA patients (n = 48) who received an OA and had pre‐ and post‐treatment PSG were classified into three responder groups according to the change in AHI and min O₂ post‐treatment: responder_AHIonly (decrease in AHI of ≥50% but increase in min O₂ level of <4% or decrease); responder_MinO2only (increase in min O₂ level of ≥4% but decrease in AHI <50% or increase) and responder_Congruous (decrease in AHI of ≥50% and increase in min O₂ level of ≥4%). Various demographic and PSG variables were statistically compared among groups.

Results

There were 26 (54.17%) responder_AHIonly, 9 (18.75%) responder_MinO2only and 13 (27.08%) responder_Congruous. Pre‐treatment min O₂ was significantly lower in responder_MinO2only. A higher pre‐treatment min O₂ showed a significant correlation with a smaller amount of change in mean O₂ (r = −.486) and min O₂ (r = −.764) with treatment. Pre‐treatment min O₂ showed the strongest ability to predict those who would show a ≥4% min O₂ increase following treatment.

Conclusion

Certain patients do not show sufficient decrease in hypoxaemia in spite of the improvement in AHI. Pre‐treatment min O₂ should be considered in OA treatment planning regarding its close relation to improvements in oxygenation levels with treatment.

[Comparative Study of Clinical Manifestations and Sleep Structure in Children with Obstructive Sleep Apnea-hypopnea Syndrome with Different BMI]

OBJECTIVE

To compare and analyze the clinical manifestations and sleep structure of children with obstructive sleep apnea-hypopneasyndrome (OSAHS) with different body mass index (BMI).

METHODS

452 children who were diagnosed with OSAHS between December 2016 and February 2021 by the Department of Respiratory Medicine, Children's Hospital of Soochow University were included in the study. All of them did polysomnography (PSG). They were divided, according to their BMI, into the normal BMI group, the overweight group, and the obesity group. Their clinical data and PSG results were collected.

RESULTS

287 boys (63.5%) and 165 girls (36.5%) were enrolled, with their age ranging between 3 and 15, and the median age being 5.5 (4.5, 7.0). Their BMI ranged between 12.09 kg/m 2 and 38.48 kg/m 2, with the median being 16.29 kg/m 2. 275 cases (60.8%) had normal BMI, 76 cases (16.8%) were overweight, and 101 cases (22.3%) were obese. There was no significant difference in the distribution of clinical manifestations and severity of OSAHS among the three groups. The duration and proportion of rapid eye movement (REM) stage sleep in the obese group was lower than that of the overweight and the normal BMI groups ( P<0.05). The lowest oxyhemoglobin saturation (LSaO 2) of children in the overweight group was lower than that of the normal BMI group ( P=0.050). The oxygen desaturation index (ODI) of the obese group was higher than that of the normal BMI and the overweight groups ( P<0.05).

CONCLUSION

Obesity worsens the degree of hypoxia in children with OSAHS and affects their sleep structure.

Clinical, polysomnographic, and cephalometric features of obstructive sleep apnea with AHI over 100

PURPOSE

Obstructive sleep apnea (OSA) is induced by a sleep-related collapse of the upper airway in association with multiple factors. The severity of OSA is determined by the apnea-hypopnea index (AHI). Although obesity and sex differences are common factors in OSA, the level of the AHI varies to the same degree according to the age and sex and degree of obesity. However, only a few studies have evaluated AHI over 100/h, those reports did not describe why they set the AHI cutoff at 100/h. The purpose of this study was to elucidate the pathogenesis of "very" severe OSA, defined as having an AHI > 100/h.

METHODS

AHI > 100/h was set as very severe OSA (VS-OSA) in this study. As controls, moderate to severe OSA patients, matched with VS-OSA for age, sex, and body mass index (BMI), were enrolled. The findings of polysomnography and cephalography between VS-OSA and controls were compared.

RESULTS

Eleven patients in the VS-OSA group (mean AHI 110.2/h) and 22 patients in the control group (mean AHI 41.6/h) were compared (mean age 50.2 vs 50.6, male:female 5:6 vs 10:12, mean BMI 35.4 kg/m2 vs 34.5 kg/m2). There were no significant differences in the clinical characteristics. In the polysomnographic parameters, the VS-OSA group showed apnea predominance, the mean percutaneous oxygen saturation (SO2) was significantly lower in all sleep stages, and the minimum SO2 was significantly lower (49.0% vs 77.5%, p = 0.002). A similar apnea duration and rather shorter hypopnea duration were shown. The time of apnea-to-arousal was significantly earlier (- 0.1 s vs 0.9 s, p = 0.003). Lung-to-finger circulation time showed no differences. The cephalometric findings showed no significant differences.

CONCLUSIONS

VS-OSA patients were more likely to have apnea predominance, desaturation when sleeping despite a similar apnea duration, and rather shorter hypopnea duration, and arousals were evoked significantly earlier.

Use of polysomnography and home sleep apnea tests for the longitudinal management of obstructive sleep apnea in adults: an American Academy of Sleep Medicine clinical guidance statement

INTRODUCTION

Obstructive sleep apnea is an important and common disorder with associated health risks. Assuring successful longitudinal management is vital to patient health and sleep-related quality of life. This paper provides guidance from the American Academy of Sleep Medicine (AASM) regarding the use of polysomnography (PSG) and home sleep apnea tests (HSATs) after a diagnosis of obstructive sleep apnea has been established and, in most cases, treatment implemented.

METHODS

The AASM commissioned a task force of five sleep medicine experts. A literature search was conducted to identify studies that included adult patients with OSA who underwent follow-up PSG or an HSAT. The task force developed clinical guidance statements based on a review of these studies and expert opinion. The AASM Board of Directors approved the final clinical guidance statements.

CLINICAL GUIDANCE STATEMENTS

The AASM supports the following clinical guidance statements on indications for follow-up PSG and HSAT in adult patients with OSA. 1. Follow-up PSG or HSAT is not recommended for routine reassessment of asymptomatic patients with obstructive sleep apnea on PAP therapy, however, follow-up PSG or HSAT can be used to reassess patients with recurrent or persistent symptoms, despite good PAP adherence. 2. Follow-up PSG or HSAT is recommended to assess response to treatment with non-PAP interventions. 3. Follow-up PSG or HSAT may be used if clinically significant weight gain or loss has occurred since diagnosis of OSA or initiation of its treatment. 4. Follow-up PSG may be used for reassessment of sleep-related hypoxemia and/or sleep-related hypoventilation following initiation of treatment for OSA. 5. Follow-up PSG or HSAT may be used in patients being treated for OSA who develop or have a change in cardiovascular disease. 6. Follow-up PSG may be used in patients with unexplained PAP device-generated data. The ultimate judgment regarding propriety of any specific care must be made by the clinician, in light of the individual circumstances presented by the patient, available diagnostic tools, accessible treatment options and resources.

Changes in headache characteristics with oral appliance treatment for obstructive sleep apnea

Changes in headache characteristics in obstructive sleep apnea (OSA) patients following oral appliance treatment was investigated for the first time. Thirteen OSA patients with headaches treated with a mandibular advancement device were investigated. Level I polysomnography and Migraine Disability Assessment Questionnaire were completed before and after treatment. Various headache characteristics and concomitant conditions were analyzed. The patient was considered a headache responder when ≥ 30% reduction in headache frequency following treatment. Differences in headache and polysomnographic parameters were compared between headache responder groups. Eight patients (62%) were headache responders. Eleven patients (85%) before and 7 (54%) after treatment reported morning headaches. Significantly more patients had bilateral headache in the responder group before treatment (P = 0.035). The severest headache intensity (P = 0.018) at baseline showed a significant decrease in the headache responder group after treatment. The time spent in N2 (r = - 0.663, P = 0.014), REM sleep (r = 0.704, P = 0.007) and mean oxygen saturation (r = 0.566, P = 0.044) showed a significant correlation with post-treatment average headache intensity. Pre-treatment lower PLM index (r = - 0.632, P = 0.027) and higher mean oxygen saturation levels (r = 0.592, P = 0.043) were significantly correlated with higher post-treatment severest headache intensity. Treatment with an oral appliance is beneficial for many OSA patients with headaches. It should be considered as an alternative treatment in headache patients with mild to moderate OSA.

Severe paediatric obesity and sleep: A mutual interactive relationship!

Childhood severe obesity is a serious, urgent and complex global health problem with long-term co-morbidities. Obstructive sleep-disordered breathing is more common in obese children and adolescents. Increased body mass index is associated with an increase in apnea-hypopnea index. Obstructive sleep apnea leads to a decrease in rapid eye movement sleep, and obese children have been noted to have a decrease in rapid eye movement sleep, leading to weight gain. Short sleep duration and poor sleep quality are associated with childhood obesity and cardiometabolic risks. Public health strategies for obesity prevention should focus more on sleep. Targeting childhood obesity is important in the prevention and management of obstructive sleep-disordered breathing.

Impact of nasal resistance on the distribution of apneas and hypopneas in obstructive sleep apnea

BACKGROUND

This study aims to investigate how increased nasal resistance affects respiratory variables in obstructive sleep apnea (OSA). In this setting, to assess how nasal resistance, as measured by 4-phase rhinomanometry, affects the distribution of hypopneas and apneas when measured with routine Sleep Polygraphy (PG).

METHODS

PG recordings were analysed and 4-phase rhinomanometry was conducted. Crude differences between groups were compared using Mann-Whitney Wilkoxon test. Odds for higher nasal resistance were modelled using logistic regression. All tests were two-sided. P < 0.05 was considered statistically significant.

RESULTS

In sum, 126 OSA patients referred to our center examined with PG were included. OSA Patients with a higher ratio of hypopneas relative to apneas are more than three times more likely (OR = 3.72, 95%CI [1.30-10.66], p = 0.015) to have increased nasal resistance as measured by 4-phase rhinomanometry, compared to those who have a lower ratio of hypopneas relative to apneas, regardless of OSA severity. The median Hypopnea to Apnea Ratio (HAR) in the low nasal resistance group was 0.8 compared to 2.6 in the high nasal resistance group (p = 0.000). The median apnea index in the low nasal resistance group was 13.6, in the high nasal group it was 5.2 (p = 0.001).

CONCLUSIONS

Our investigation shows that OSA patients presenting with increased nasal resistance demonstrate significant differences in the distribution of hypopneas and apneas. OSA patients with increased nasal resistance exhibit a significantly lower apnea index and a higher hypopnea to apnea ratio compared to OSA patients presenting with low nasal resistance. Thus, analysis of the HAR in sleep studies is a useful tool to identify patients who may potentially have nasal obstruction as part of their respiratory pathophysiology. We therefore recommend that OSA patients with a predominance of hypopneas relative to apneas should undergo further nasal measurements.

Polysomnographic phenotype as a risk factor for cardiovascular diseases in patients with obstructive sleep apnea syndrome: a retrospective cohort study

Background

Obstructive sleep apnea syndrome (OSAS) is associated with the development of cardiovascular diseases caused by hypoxemia during sleeping. We classified OSAS phenotypes based on polysomnographic findings and aimed to evaluate that the unique phenotypes would be differentially associated with risk of cardiovascular disease.

Methods

This retrospective and observational study assessed adult patients who underwent polysomnography at the Wonju Severance Christian Hospital from November 2008 to February 2018. The OSAS phenotypes were classified as apnea-predominant, hypopnea-predominant, and respiratory effort-related arousal (RERA)-predominant based on the polysomnography results. The polysomnographic data were collected and analysed, and clinical features such as medical history and comorbidities were assessed by a review of the electronic medical records.

Results

A total of 860 adult patients were classified as apnea-predominant (n=220), hypopnea-predominant (n=119), or RERA-predominant (n=275). The hypopnea-predominant group had significantly higher rates of hyperlipidaemia (P<0.001), heart failure (15.5%, P<0.001), and coronary artery disease (20.9%, P=0.005) than the other groups. After classifying the patients according to severity of the hypopnea index, logistic regression analyses adjusted for age, sex, and smoking history revealed that the hypopnea index increased the risk for coronary artery disease and heart failure.

Conclusions

The hypopnea-predominant group would be a specific phenotype that has a differential association with the risks for coronary artery disease and heart failure.

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 role of upper airway morphology in apnea versus hypopnea predominant obstructive sleep apnea patients: an exploratory study

OBJECTIVE

The objective of this study was to investigate the association between upper airway morphology and apnea vs hypopnea predominance in patients with obstructive sleep apnea (OSA) syndrome.

METHODS

A retrospective study on consecutively CT scans obtained from 54 OSA patients and 53 non-snoring controls. CT scans were measured to evaluate upper airway and surrounding structures' morphologic characteristics. OSA patients (matched for age, gender and body mass index) compared as two groups; apneic group: apnea ratio >50% and hypopneic group: hypopnea ratio >50%. Morphologic characteristics were analyzed using Kruskal-Wallis test and Pearson's correlation test.

RESULTS

Apneic group (17 patients) showed 76.56% apnea rate and hypopneic group (37 patients) showed 78.46% hypopnea rate. Minimal lateral and anteroposterior dimensions of velopharynx in the apneic group (0.86 ± 0.73 and 0.21 ± 0.13 cm, respectively) was statistically lesser from that of the hypopneic group (1.2 ± 0.42 and 0.54 ± 0.22 cm, respectively). Minimum cross-sectional area of the velopharynx was also lesser in apneic group (0.21 ± 0.16 cm²) than that in hypopneic group (0.65 ± 0.38 cm²). Almost all upper airway parameters in both apneic and hypopneic groups were tended to be smaller than in controls.

CONCLUSION

Decrease in airway volume does not signify the type of respiratory event, but significant narrowing of velopharynx in both dimensions; thus having the narrowest value below a certain level causes more apnea. Advances in knowledge: We did not find a similar study when we did a literature search, showing the relationship of apnea vs hypopnea predominance and upper airway parameters in CT in patients with OSA.

Association between subjective actual sleep duration, subjective sleep need, age, body mass index, and gender in a large sample of young adults

BACKGROUND

Poor sleep is a major health concern, and there is evidence that young adults are at increased risk of suffering from poor sleep. There is also evidence that sleep duration can vary as a function of gender and body mass index (BMI). We sought to replicate these findings in a large sample of young adults, and also tested the hypothesis that a smaller gap between subjective sleep duration and subjective sleep need is associated with a greater feeling of being restored.

METHODS

A total of 2,929 university students (mean age 23.24±3.13 years, 69.1% female) took part in an Internet-based survey. They answered questions related to demographics and subjective sleep patterns.

RESULTS

We found no gender differences in subjective sleep duration, subjective sleep need, BMI, age, or feeling of being restored. Nonlinear associations were observed between subjective sleep duration, BMI, and feeling of being restored. Moreover, a larger discrepancy between subjective actual sleep duration and subjective sleep need was associated with a lower feeling of being restored.

CONCLUSION

The present pattern of results from a large sample of young adults suggests that males and females do not differ with respect to subjective sleep duration, BMI, or feeling of being restored. Moreover, nonlinear correlations seemed to provide a more accurate reflection of the relationship between subjective sleep and demographic variables.