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Sunwoo BY, Malhotra A. Mechanical Interactions Between the Upper Airway and the Lungs that Affect the Propensity to Obstructive Sleep Apnea in Health and Chronic Lung Disease. Sleep Med Clin 2024; 19:211-218. [PMID: 38692746 DOI: 10.1016/j.jsmc.2024.02.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/03/2024]
Abstract
Obstructive sleep apnea (OSA) is a common disorder characterized by repetitive narrowing and collapse of the upper airways during sleep. It is caused by multiple anatomic and nonanatomic factors but end-expiratory lung volume (EELV) is an important factor as increased EELV can stabilize the upper airway via caudal traction forces. EELV is impacted by changes in sleep stages, body position, weight, and chronic lung diseases, and this article reviews the mechanical interactions between the lungs and upper airway that affect the propensity to OSA. In doing so, it highlights the need for additional research in this area.
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Affiliation(s)
- Bernie Y Sunwoo
- Department of Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, University of California San Diego, San Diego, CA, USA.
| | - Atul Malhotra
- Department of Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, University of California San Diego, San Diego, CA, USA
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Trieu M, Weihe EK, Sunwoo BY. Bilioptysis Caused by Bronchobiliary Fistula. Am J Respir Crit Care Med 2023; 208:896-897. [PMID: 37339503 DOI: 10.1164/rccm.202303-0370im] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2023] [Accepted: 06/20/2023] [Indexed: 06/22/2023] Open
Affiliation(s)
- Megan Trieu
- Division of Pulmonary, Critical Care, Sleep Medicine, and Physiology, Department of Medicine, and
| | - Elizabeth K Weihe
- Department of Radiology, University of California, San Diego, La Jolla, California
| | - Bernie Y Sunwoo
- Division of Pulmonary, Critical Care, Sleep Medicine, and Physiology, Department of Medicine, and
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Beagle AJ, Sunwoo BY, Olin RL, Schwartz BS, Block BL. It's All in the Timing. N Engl J Med 2023; 389:940-947. [PMID: 37672698 DOI: 10.1056/nejmcps2307176] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/08/2023]
Affiliation(s)
- Alexander J Beagle
- From the Department of Medicine (A.J.B.), Divisions of Hematology and Oncology (R.L.O.), Infectious Diseases (B.S.S.), and Pulmonary, Critical Care, Allergy, and Sleep Medicine (B.L.B.), University of California, San Francisco, San Francisco, and the Department of Medicine, Division of Pulmonary, Critical Care, and Sleep Medicine, University of California, San Diego, La Jolla (B.Y.S.)
| | - Bernie Y Sunwoo
- From the Department of Medicine (A.J.B.), Divisions of Hematology and Oncology (R.L.O.), Infectious Diseases (B.S.S.), and Pulmonary, Critical Care, Allergy, and Sleep Medicine (B.L.B.), University of California, San Francisco, San Francisco, and the Department of Medicine, Division of Pulmonary, Critical Care, and Sleep Medicine, University of California, San Diego, La Jolla (B.Y.S.)
| | - Rebecca L Olin
- From the Department of Medicine (A.J.B.), Divisions of Hematology and Oncology (R.L.O.), Infectious Diseases (B.S.S.), and Pulmonary, Critical Care, Allergy, and Sleep Medicine (B.L.B.), University of California, San Francisco, San Francisco, and the Department of Medicine, Division of Pulmonary, Critical Care, and Sleep Medicine, University of California, San Diego, La Jolla (B.Y.S.)
| | - Brian S Schwartz
- From the Department of Medicine (A.J.B.), Divisions of Hematology and Oncology (R.L.O.), Infectious Diseases (B.S.S.), and Pulmonary, Critical Care, Allergy, and Sleep Medicine (B.L.B.), University of California, San Francisco, San Francisco, and the Department of Medicine, Division of Pulmonary, Critical Care, and Sleep Medicine, University of California, San Diego, La Jolla (B.Y.S.)
| | - Brian L Block
- From the Department of Medicine (A.J.B.), Divisions of Hematology and Oncology (R.L.O.), Infectious Diseases (B.S.S.), and Pulmonary, Critical Care, Allergy, and Sleep Medicine (B.L.B.), University of California, San Francisco, San Francisco, and the Department of Medicine, Division of Pulmonary, Critical Care, and Sleep Medicine, University of California, San Diego, La Jolla (B.Y.S.)
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Sunwoo BY, Kaufmann CN, Murez A, Lee E, Gilbertson D, Bosompra NO, DeYoung P, Malhotra A. The language of sleepiness in obstructive sleep apnea beyond the Epworth. Sleep Breath 2023; 27:1057-1065. [PMID: 36098927 PMCID: PMC9469060 DOI: 10.1007/s11325-022-02703-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Revised: 08/06/2022] [Accepted: 08/26/2022] [Indexed: 02/01/2023]
Abstract
PURPOSE Obstructive sleep apnea (OSA) is underdiagnosed, partially from variable clinical presentations. Emphasis is often placed on Epworth Sleepiness Scale (ESS), a subjective measure of sleepiness, but variable in OSA. We hypothesized that daytime complaints measured with Language of Sleepiness Questionnaire (LOS) in OSA are not being captured by ESS. METHODS Adults referred to a tertiary sleep clinic undergoing sleep studies completed ESS and LOS questionnaires (20 items with various patient-reported descriptors). LOS was examined in patients who had or did not have OSA without sleepiness based on ESS < 10. Cluster analysis was performed to assess whether or not groups of individuals differed based on classification with or without OSA and with or without ESS-based sleepiness. RESULTS Approximately half the study population (n = 185 completed) had OSA. ESS score (mean ± SD) was 9.0 ± 5.4. There was no significant difference in ESS between patients with and without OSA (9.0 ± 5.1 vs 9.1 ± 5.7, p = 0.969). In patients with OSA, females, older patients and white patients were significantly less likely to have an ESS ≥ 10 when compared to patients with an ESS < 10. In patients with an ESS < 10, there were no significant differences in descriptors of sleepiness between patients with and without OSA with the most common descriptors selected being "I lack energy," "I wake up sleepy," "I keep waking up," and "I don't sleep enough." CONCLUSIONS The ESS failed to discriminate patients with OSA from those without OSA. Despite an ESS < 10, both daytime and sleep complaints using the LOS questionnaire were present in patients with OSA. Asymptomatic OSA may be less common than previously reported.
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Affiliation(s)
- Bernie Y Sunwoo
- Division of Pulmonary, Critical Care and Sleep Medicine, University of California San Diego, San Diego, CA, 92121, USA.
| | - Christopher N Kaufmann
- Division of Epidemiology and Data Science in Gerontology, Department of Aging and Geriatric Research, University of Florida College of Medicine, Gainesville, USA
| | - Andrea Murez
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Ellen Lee
- Division of Psychiatry, University of California San Diego, San Diego, USA
| | - Dillon Gilbertson
- Division of Pulmonary, Critical Care and Sleep Medicine, University of California San Diego, San Diego, CA, 92121, USA
| | - Naa-Oye Bosompra
- Division of Pulmonary, Critical Care and Sleep Medicine, University of California San Diego, San Diego, CA, 92121, USA
| | - Pamela DeYoung
- Division of Pulmonary, Critical Care and Sleep Medicine, University of California San Diego, San Diego, CA, 92121, USA
| | - Atul Malhotra
- Division of Pulmonary, Critical Care and Sleep Medicine, University of California San Diego, San Diego, CA, 92121, USA
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Mokhlesi B, Won CH, Make BJ, Selim BJ, Sunwoo BY. Optimal Noninvasive Medicare Access Promotion: Patients with Hypoventilation Syndromes A Technical Expert Panel Report from the American College of Chest Physicians, the American Association for Respiratory Care, the American Academy of Sleep Medicine, and the American Thoracic Society. Chest 2021; 160:e377-e387. [PMID: 34339686 DOI: 10.1016/j.chest.2021.06.083] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2021] [Revised: 05/27/2021] [Accepted: 06/17/2021] [Indexed: 10/20/2022] Open
Abstract
The existing coverage criteria for home noninvasive ventilation (NIV) do not recognize the diversity of hypoventilation syndromes and advances in technologies. This document summarizes the work of the Hypoventilation Syndromes Technical Expert Panel working group. The most pressing current coverage barriers identified were: 1) overreliance on arterial blood gases (particularly during sleep); 2) need to perform testing on prescribed oxygen; 3) requiring a sleep study to rule out obstructive sleep apnea as the cause of sustained hypoxemia; 4) need for spirometry; 5) need to demonstrate BPAP without a backup rate failure to qualify for BPAP S/T; and 6) qualifying hospitalized patients for home NIV therapy at the time of discharge. Critical evidence support for changes to current policies include randomized clinical trial evidence and clinical practice guidelines. In order to decrease morbidity-mortality by achieving timely access to NIV for patients with hypoventilation, particularly those with obesity hypoventilation syndrome, we make the following key suggestions: 1) Given the significant technological advances, we advise acceptance of surrogate noninvasive end tidal and transcutaneous PCO2 and venous blood gases in lieu of arterial blood gases,; 2) Not requiring PCO2 measures while on prescribed oxygen; 3) Not requiring a sleep study to avoid delays in care in patients being discharged from the hospital; 4) Remove spirometry as a requirement; 5) Not requiring BPAP without a backup rate failure to approve BPAP S/T. The overarching goal of the Technical Expert Panel is to establish pathways that improve clinicians' management capability to provide Medicare beneficiaries access to appropriate home NIV therapy. Adoption of these proposed suggestions would result in the right device, at the right time, for the right type of patients with hypoventilation syndromes.
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Sunwoo BY, Schmickl CN, Malhotra A. Contemporary Concise Review 2019: Sleep and ventilation. Respirology 2020; 25:552-558. [PMID: 32048407 PMCID: PMC7162714 DOI: 10.1111/resp.13781] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2020] [Accepted: 01/29/2020] [Indexed: 12/30/2022]
Affiliation(s)
- Bernie Y Sunwoo
- Division of Pulmonary, Critical Care and Sleep Medicine, University of California, San Diego (UCSD), La Jolla, CA, USA
| | - Christopher N Schmickl
- Division of Pulmonary, Critical Care and Sleep Medicine, University of California, San Diego (UCSD), La Jolla, CA, USA
| | - Atul Malhotra
- Division of Pulmonary, Critical Care and Sleep Medicine, University of California, San Diego (UCSD), La Jolla, CA, USA
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Sunwoo BY, Light M, Malhotra A. Strategies to augment adherence in the management of sleep-disordered breathing. Respirology 2019; 25:363-371. [PMID: 31270925 DOI: 10.1111/resp.13589] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2018] [Revised: 02/05/2019] [Accepted: 05/02/2019] [Indexed: 01/05/2023]
Abstract
Continuous positive airway pressure (CPAP) is highly effective in treating sleep-disordered breathing (SDB). However, unlike surgical interventions, this treatment modality relies heavily on patient acceptance and adherence. The current definition of adherence is largely arbitrary and is mainly used by third-party payers to determine CPAP reimbursement but CPAP adherence remains sub-optimal. Strategies to augment adherence, especially early in the course of a CPAP trial, are needed in the management of SDB. An understanding of the basis for observed differences in CPAP and oral appliance (OA) use is necessary in developing these strategies, but to date no single factor has been consistently identified. Consequently, a multidimensional approach using educational, behavioural, technological and potentially pharmacological strategies to target (i) disease characteristics, (ii) patient characteristics including psychosocial factors, (iii) treatment protocols and (iv) technological devices and side effects that may influence adherence, is likely required to augment the complex behaviour of CPAP and OA use. In the near future, we envision a personalized medicine approach to determine the risk of non-adherence and set individualized adherence goals aimed at treating specific symptoms (e.g. excessive daytime sleepiness) and reducing the risk of patient-specific SDB consequences (e.g. atherosclerosis). Resources for interventions to improve adherence such as educational programmes and telemedicine encounters could then be more efficiently allocated.
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Affiliation(s)
- Bernie Y Sunwoo
- Department of Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, University of California, San Diego, CA, USA
| | - Matthew Light
- Department of Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, University of California, San Diego, CA, USA
| | - Atul Malhotra
- Department of Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, University of California, San Diego, CA, USA
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Affiliation(s)
- Bernie Y Sunwoo
- Division of Pulmonary, Critical Care and Sleep Medicine, University of California San Diego, San Diego, CA, USA
| | - Robert L Owens
- Division of Pulmonary, Critical Care and Sleep Medicine, University of California San Diego, San Diego, CA, USA
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Sunwoo BY, Mokhlesi B. Obesity Hypoventilation Syndrome: Will Early Detection and Effective Therapy Improve Long-Term Outcomes? J Clin Sleep Med 2018; 14:1455-1457. [PMID: 30176983 DOI: 10.5664/jcsm.7310] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2018] [Accepted: 08/13/2018] [Indexed: 12/28/2022]
Affiliation(s)
- Bernie Y Sunwoo
- Department of Medicine, Division of Pulmonary and Critical Care, University of California San Diego, San Diego, California
| | - Babak Mokhlesi
- Department of Medicine, Section of Pulmonary and Critical Care, Sleep Disorders Center, The University of Chicago Pritzker School of Medicine, Chicago, Illinois
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Benn BS, Lehman Z, Kidd SA, Miaskowski C, Sunwoo BY, Ho M, Sun S, Ramstein J, Gelfand JM, Koth LL. Sleep disturbance and symptom burden in sarcoidosis. Respir Med 2018; 144S:S35-S40. [PMID: 29628134 DOI: 10.1016/j.rmed.2018.03.021] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2017] [Revised: 02/11/2018] [Accepted: 03/19/2018] [Indexed: 12/19/2022]
Abstract
INTRODUCTION Sarcoidosis is a systemic inflammatory disease associated with myriad symptoms, including fatigue. It can affect physiological processes like sleep, leading to poor sleep quality and excessive daytime sleepiness. We hypothesized that sarcoidosis patients would report more severe sleep disturbance than healthy controls and that relationships would be found with sleep disturbance and the severity of other symptoms. METHODS We enrolled 84 sarcoidosis patients and 30 healthy controls and recorded demographic and clinical characteristics. Self-report measures were used to assess sleep disturbance, psychosocial symptoms, and quality of life at enrollment and longitudinally. Relationships between different self-report outcomes were analyzed using correlation statistics. RESULTS Using the General Sleep Disturbance Scale, 54% of sarcoidosis patients reported frequent and occasional sleep disturbance compared to only 17% of healthy controls (p < 0.0001). This significant increase in sleep disturbance found in sarcoidosis patients strongly correlated with multiple psychosocial symptoms, including fatigue, depression, and cognitive dysfunction, and negatively impacted quality of life (p < 0.01). Traditional measures of sarcoidosis disease severity or activity were not associated with sleep disturbance. Sleep disturbance scores remained stable at follow-up (mean time between first and last administration of questionnaire was 17.3 months) in 56 of the sarcoidosis patients. CONCLUSIONS Sarcoidosis patients experienced significant sleep disturbance that correlated with higher levels of fatigue, depression, and cognitive dysfunction, and poorer quality of life. These associations were present regardless of disease severity or activity and result in decrements in quality of life and mental health.
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Affiliation(s)
- Bryan S Benn
- University of California, San Francisco, Division of Pulmonary and Critical Care, 505 Parnassus Ave, San Francisco, CA 94143, USA
| | - Zoe Lehman
- University of California, San Francisco, Division of Pulmonary and Critical Care, 505 Parnassus Ave, San Francisco, CA 94143, USA
| | - Sharon A Kidd
- University of California, San Francisco, Division of Pulmonary and Critical Care, 505 Parnassus Ave, San Francisco, CA 94143, USA
| | - Christine Miaskowski
- University of California, San Francisco, Department of Physiological Nursing, 2 Koret Way, San Francisco, CA 94143, USA
| | - Bernie Y Sunwoo
- University of California, San Francisco, Division of Pulmonary and Critical Care, 505 Parnassus Ave, San Francisco, CA 94143, USA
| | - Melissa Ho
- University of California, San Francisco, Division of Pulmonary and Critical Care, 505 Parnassus Ave, San Francisco, CA 94143, USA
| | - Sara Sun
- University of California, San Francisco, Division of Pulmonary and Critical Care, 505 Parnassus Ave, San Francisco, CA 94143, USA
| | - Joris Ramstein
- University of California, San Francisco, Division of Pulmonary and Critical Care, 505 Parnassus Ave, San Francisco, CA 94143, USA
| | - Jeffrey M Gelfand
- University of California, San Francisco, Department of Neurology, Multiple Sclerosis and Neuroinflammation Center, 1500 Owens Street, San Francisco, CA 94158, USA
| | - Laura L Koth
- University of California, San Francisco, Division of Pulmonary and Critical Care, 505 Parnassus Ave, San Francisco, CA 94143, USA.
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Abstract
Streptococcus anginosus has long been recognized to cause invasive pyogenic infections. This holds true for thoracic infections where S. anginosus has a propensity for abscess and empyema formation. Early diagnosis is important given the significant morbidity and mortality associated with thoracic S. anginosus infections. Yet, distinguishing thoracic S. anginosus clinically is difficult. We present three cases of thoracic S. anginosus that demonstrated radiographic extension across tissue planes, including the interlobar fissure, diaphragm, and chest wall. Few infectious etiologies are known to cross tissue planes. Accordingly, we propose S. anginosus be considered among the differential diagnosis of potential infectious etiologies causing radiographic extension across tissue planes.
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Affiliation(s)
- Bernie Y Sunwoo
- Department of Medicine, Division of Pulmonary, Allergy, Critical Care Medicine, Division of Sleep Medicine, Perelman School of Medicine, The University of Pennsylvania, Philadelphia, PA.
| | - Wallace T Miller
- Department of Radiology, Perelman School of Medicine, The University of Pennsylvania, Philadelphia, PA
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Sunwoo BY, Mulholland M, Rosen IM, Wolfe LF. The changing landscape of adult home noninvasive ventilation technology, use, and reimbursement in the United States. Chest 2014; 145:1134-1140. [PMID: 24798837 DOI: 10.1378/chest.13-0802] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
There has been an exponential increase in the use of home noninvasive ventilation (NIV). Despite growing use, there is a paucity of evidence-based guidelines and practice standards in the United States to assist clinicians in the initiation and ongoing management of home NIV. Consequently, home NIV practices are being influenced by complicated local reimbursement policies and coding. This article aims to provide a practice management perspective for clinicians providing home NIV, including Local Coverage Determination reimbursement criteria for respiratory assist devices, Durable Medical Equipment coding, and Current Procedural Terminology coding to optimize clinical care and minimize lost revenue. It highlights the need for further research and development of evidence-based clinical practice standards to ensure best practice policies are in place for this rapidly evolving patient population.
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Affiliation(s)
- Bernie Y Sunwoo
- Department of Medicine, Division of Pulmonary, Allergy and Critical Care Medicine, Division of Sleep Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA.
| | - Mary Mulholland
- Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Ilene M Rosen
- Department of Medicine, Division of Pulmonary, Allergy and Critical Care Medicine, Division of Sleep Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Lisa F Wolfe
- Division of Pulmonary and Critical Care Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL
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Keenan BT, Maislin G, Sunwoo BY, Arnardottir ES, Jackson N, Olafsson I, Juliusson S, Schwab RJ, Gislason T, Benediktsdottir B, Pack AI. Obstructive sleep apnoea treatment and fasting lipids: a comparative effectiveness study. Eur Respir J 2014; 44:405-14. [PMID: 24833762 DOI: 10.1183/09031936.00043614] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Obstructive sleep apnoea (OSA) is associated with cardiovascular disease. Dyslipidaemia has been implicated as a mechanism linking OSA with atherosclerosis, but no consistent associations with lipids exist for OSA or positive airway pressure treatment. We assessed the relationships between fasting lipid levels and obesity and OSA severity, and explored the impact of positive airway pressure treatment on 2-year fasting lipid level changes. Analyses included moderate-to-severe OSA patients from the Icelandic Sleep Apnoea Cohort. Fasting morning lipids were analysed in 613 untreated participants not on lipid-lowering medications at baseline. Patients were then initiated on positive airway pressure and followed for 2 years. Sub-classification using propensity score quintiles, which aimed to replicate covariate balance associated with randomised trials and, therefore, minimise selection bias and allow causal inference, was used to design the treatment group comparisons. 199 positive airway pressure adherent patients and 118 non-users were identified. At baseline, obesity was positively correlated with triglycerides and negatively correlated with total cholesterol, and low-density and high-density lipoprotein cholesterol. A small correlation was observed between the apnoea/hypopnoea index and high-density lipoprotein cholesterol. No effect of positive airway pressure adherence on 2-year fasting lipid changes was observed. Results do not support the concept of changes in fasting lipids as a primary mechanism for the increased risk of atherosclerotic cardiovascular disease in OSA.
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Affiliation(s)
- Brendan T Keenan
- Center for Sleep and Circadian Neurobiology, University of Pennsylvania, Philadelphia, PA, USA Joint first authors
| | - Greg Maislin
- Center for Sleep and Circadian Neurobiology, University of Pennsylvania, Philadelphia, PA, USA Division of Sleep Medicine, Dept of Medicine, University of Pennsylvania, Philadelphia, PA, USA Joint first authors
| | - Bernie Y Sunwoo
- Center for Sleep and Circadian Neurobiology, University of Pennsylvania, Philadelphia, PA, USA Division of Sleep Medicine, Dept of Medicine, University of Pennsylvania, Philadelphia, PA, USA Division of Pulmonary, Allergy and Critical Care, Dept of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Erna Sif Arnardottir
- Dept of Respiratory Medicine and Sleep, Landspitali - The National University Hospital of Iceland, Reykjavik, Iceland Faculty of Medicine, University of Iceland, Reykjavik, Iceland
| | - Nicholas Jackson
- Center for Sleep and Circadian Neurobiology, University of Pennsylvania, Philadelphia, PA, USA
| | - Isleifur Olafsson
- Dept of Clinical Biochemistry, Landspitali - The National University Hospital of Iceland, Reykjavik, Iceland
| | | | - Richard J Schwab
- Center for Sleep and Circadian Neurobiology, University of Pennsylvania, Philadelphia, PA, USA Division of Sleep Medicine, Dept of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Thorarinn Gislason
- Dept of Respiratory Medicine and Sleep, Landspitali - The National University Hospital of Iceland, Reykjavik, Iceland Faculty of Medicine, University of Iceland, Reykjavik, Iceland
| | - Bryndis Benediktsdottir
- Dept of Respiratory Medicine and Sleep, Landspitali - The National University Hospital of Iceland, Reykjavik, Iceland Faculty of Medicine, University of Iceland, Reykjavik, Iceland Joint senior authors
| | - Allan I Pack
- Center for Sleep and Circadian Neurobiology, University of Pennsylvania, Philadelphia, PA, USA Division of Sleep Medicine, Dept of Medicine, University of Pennsylvania, Philadelphia, PA, USA Joint senior authors
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Abstract
STUDY OBJECTIVES To evaluate reliability of single objective tests in assessing sleepiness. DESIGN Subjects who completed polysomnography underwent a 4-nap multiple sleep latency test (MSLT) the following day. Prior to each nap opportunity on MSLT, subjects performed the psychomotor vigilance test (PVT) and divided attention driving task (DADT). Results of single versus multiple test administrations were compared using the intraclass correlation coefficient (ICC) and adjusted for test administration order effects to explore time of day effects. Measures were explored as continuous and binary (i.e., impaired or not impaired). SETTING Community-based sample evaluated at a tertiary, university-based sleep center. PARTICIPANTS 372 adult commercial vehicle operators oversampled for increased obstructive sleep apnea risk. INTERVENTIONS N/A. MEASUREMENTS AND RESULTS AS CONTINUOUS MEASURES, ICC WERE AS FOLLOWS: MSLT 0.45, PVT median response time 0.69, PVT number of lapses 0.51, 10-min DADT tracking error 0.87, 20-min DADT tracking error 0.90. Based on binary outcomes, ICC were: MSLT 0.63, PVT number of lapses 0.85, 10-min DADT 0.95, 20-min DADT 0.96. Statistically significant time of day effects were seen in both the MSLT and PVT but not the DADT. Correlation between ESS and different objective tests was strongest for MSLT, range [-0.270 to -0.195] and persisted across all time points. CONCLUSIONS Single DADT and PVT administrations are reliable measures of sleepiness. A single MSLT administration can reasonably discriminate individuals with MSL < 8 minutes. These results support the use of a single administration of some objective tests of sleepiness when performed under controlled conditions in routine clinical care.
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Affiliation(s)
- Bernie Y Sunwoo
- Department of Medicine, Division of Pulmonary and Critical Care, University of Pennsylvania, Philadelphia, PA 19104, USA.
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