Review and perspective on sleep-disordered breathing research and translation to clinics

Copyright © 2023 The Authors. Published by Elsevier Ltd.. All rights reserved.Sleep-disordered breathing, ranging from habitual snoring to severe obstructive sleep apnea, is a prevalent public health issue. Despite rising interest in sleep and awareness of sleep disorders, sleep research and diagnostic practices still rely on outdated metrics and laborious methods reducing the diagnostic capacity and preventing timely diagnosis and treatment. Consequently, a significant portion of individuals affected by sleep-disordered breathing remain undiagnosed or are misdiagnosed. Taking advantage of state-of-the-art scientific, technological, and computational advances could be an effective way to optimize the diagnostic and treatment pathways. We discuss state-of-the-art multidisciplinary research, review the shortcomings in the current practices of SDB diagnosis and management in adult populations, and provide possible future directions. We critically review the opportunities for modern data analysis methods and machine learning to combine multimodal information, provide a perspective on the pitfalls of big data analysis, and discuss approaches for developing analysis strategies that overcome current limitations. We argue that large-scale and multidisciplinary collaborative efforts based on clinical, scientific, and technical knowledge and rigorous clinical validation and implementation of the outcomes in practice are needed to move the research of sleep-disordered breathing forward, thus increasing the quality of diagnostics and treatment.Peer reviewe

The effect of therapy on arousal from sleep in patients with respiratory sleep disorders

Vibrotactile positional therapy (PT) is a relatively new treatment for positional obstructive sleep apnoea (POSA). It uses vibrotactile stimulus to encourage the sleeper to change position when supine. The overall aim of this thesis was to investigate the efficacy of vibrotactile PT as a clinical treatment for patients with POSA. To achieve this, different experimental approaches were used, including a systematic review and meta-analysis, a clinical trial, and a physiological study. The systematic review was carried out to evaluate the effect of vibrotactile PT on apnoea hypopnoea index (AHI), percentage of time spent in supine (%Tsupine), and patient-centred outcomes in patients with POSA compared to baseline. The results showed that vibrotactile PT was effective in reducing both AHI and %Tsupine. Although the Epworth Sleepiness Scale and the Functional Outcomes of Sleep Questionnaire minimally improved, these changes did not reach clinically important differences; however, limited data were found on quality of life (SF-36) vitality score. A prospective, three-month, multicentre, randomised, parallel, double-blind trial (The POSA Trial, ISRCTN51740863) was developed to investigate the effect of vibrotactile PT on AHI, quality of life and daytime functioning at follow-up, adjusted for the baseline, in patients with POSA compared to sham-vibrotactile PT. Baseline data (AHI, quality of life and daytime functioning) obtained from the participants recruited at the Royal Brompton Hospital are presented in the thesis. The mean baseline AHI for RBH participants was in the mild OSA category compared to the patients in the systematic review; however, a higher baseline %Tsupine was found. The baseline patient-centred outcomes were also comparable to those found in the systematic review. A physiological study in healthy participants (n=27) was carried out to investigate the effect of vibrotactile stimulus on arousability from sleep. A novel analysis method was developed to measure arousability. This included the duration from the vibrotactile stimulus to the position change using polysomnography. The results of this study showed heterogenous arousability responses to the vibrotactile stimulus with different phenotypes. Compared to males, healthy females took longer to respond to the vibrotactile stimulus and, therefore, were more resilient to arousability. In summary, the findings of this thesis have shown that vibrotactile PT devices are effective in treating patients with POSA. However, limited data on sensitive patient-centred outcomes exist. The POSA trial will provide data to address this evidence gap. Furthermore, the physiological findings in people without OSA showed that males are more arousable than females. This information may be of value when considering personalisation of clinical treatment. Future research of POSA will need to consider the arousability phenotype when planning treatment options.Open Acces

Sleep Disordered Breathing in Children with Autism Spectrum Disorder: An In-Depth Review of Correlations and Complexities

Sleep-disordered breathing is a significant problem affecting the pediatric population. These conditions can affect sleep quality and children’s overall health and well-being. Difficulties in social interaction, communication, and repetitive behavioral patterns characterize autism spectrum disorder. Sleep disturbances are common in children with ASD. This literature review aims to gather and analyze available studies on the relationship between SDB and children with autism spectrum disorder. We comprehensively searched the literature using major search engines (PubMed, Scopus, and Web of Science). After removing duplicates, we extracted a total of 96 records. We selected 19 studies for inclusion after a thorough title and abstract screening process. Seven articles were ultimately incorporated into this analysis. The research findings presented herein emphasize the substantial influence of sleep-disordered breathing on pediatric individuals diagnosed with autism spectrum disorder (ASD). These findings reveal a high incidence of SDB in children with ASD, emphasizing the importance of early diagnosis and specialized treatment. Obesity in this population further complicates matters, requiring focused weight management strategies. Surgical interventions, such as adenotonsillectomy, have shown promise in improving behavioral issues in children with ASD affected by OSA, regardless of their obesity status. However, more comprehensive studies are necessary to investigate the benefits of A&T treatment, specifically in children with ASD and OSA. The complex relationship between ASD, SDB, and other factors, such as joint hypermobility and muscle hypotonia, suggests a need for multidisciplinary treatment approaches. Physiotherapy can play a critical role in addressing these intricate health issues. Early sleep assessments and tailored weight management strategies are essential for timely diagnosis and intervention in children with ASD. Policy initiatives should support these efforts to enhance the overall well-being of this population. Further research is crucial to understand the complex causes of sleep disturbances in children with ASD and to develop effective interventions considering the multifaceted nature of these conditions

Airflow-Oximetry Combined Signal Based Automatic Detection of Sleep Apnea in Adults

University of Technology Sydney. Faculty of Engineering and Information Technology.Sleep apnea, a common sleep disorder, can significantly decrease the quality of life and is closely associated with major health risks such as cardiovascular disease, sudden death, depression, and hypertension. It also elicits brain and physiological changes that vary across the night. Conventional diagnosis of sleep apnea using polysomnography (PSG) is costly and time-consuming, requiring manual scoring of sleep stages and respiratory events. Current automatic diagnostic algorithms used to detect sleep apnea vary in approaches with the use of different physiological signals. An effective, reliable, and accurate automatic method for the diagnosis of sleep apnea will be time-efficient and economical. This thesis is a narration of the work that led to the development of a novel algorithm suitable for the automatic diagnosis of sleep apnea. A systematic literature review of the existing methods (approaches and algorithms) was performed before designing the algorithm. This review presented an overview of methods to diagnose sleep apnea using respiratory and oximetry signals. The review identified the research gaps with indicating the major concerns, challenges, benefits, and limitations of using respiratory and oximetry signals for the diagnosis of sleep apnea. This thesis examined the electroencephalogram (EEG) spectral powers resulting from apnea duration of varying length and reported the changes in the relative powers in EEG frequency bands before and at apnea termination. The study was carried out for the purpose of justifying the usability of EEG for the automatic diagnosis of sleep apnea. It investigated the spectral power changes in delta, theta, alpha, sigma, and beta frequency bands of EEG as a function of apnea duration from 375 events. The study revealed a significant reduction in EEG relative powers (the low frequency theta, alpha, and sigma powers) both before and at apnea termination. The findings from the EEG spectral analysis suggests that the application of EEG signal in sleep apnea diagnosis is not reliable due to the random variations in spectral powers as well as the major challenges associated with EEG acquisition and its processing. Due to the limitations associated with the EEG for an unattended home diagnosis of sleep apnea, the EEG signal was excluded from the automatic detection approach […

Physical activity to the current recommended guidelines and sleep quality of adults with insomnia

Systematic reviews have consistently found that moderate intensity physical activity levels at or above a threshold value of 150 minutes per week reliably deliver cardiovascular, metabolic and musculo-skeletal health benefits. As a result, this threshold value has been widely adopted as an aspirational, public health goal throughout the world. However, while epidemiological and laboratory studies have established clear links between physical activity and sleep outcomes, the evidence base does not yet provide guidelines on minimum levels of exercise likely to reduce insomnia symptoms and improve sleep quality. Such a guideline, if evidence based, could greatly clarify advice, and accelerate the use of physical activity goals to improve sleep outcomes in behavioural sleep medicine and public health. This thesis examined the current public-health recommendation of 150 minutes of moderate intensity activity per week in relation to sleep outcomes. To commence, it established a population-level pattern of the relationship between levels of physical activity and sleep quality by reviewing relevant epidemiological evidence. Exploratory analyses were then conducted using data from an ongoing longitudinal study of physical activity and health outcomes among older people (aged 65 years and above) in which respondents were classified as walking at or above, or below the recommended threshold of 150 minutes per week. In regression models controlling for health and demographic factors, these analyses showed that higher levels of walking were significantly and independently associated with a lower likelihood of either reporting insomnia symptoms (OR = 0.67 (95% CI = 0.45 0.91) p=0.04), or experiencing poor sleep efficiency (OR = 0.70 (95% CI = 0.52 0.94 p=0.02). Using the same data, the predictive validity of this activity threshold was then confirmed in a 27-year survival analysis which showed a significantly decreased all-cause mortality risk associated with the higher level of walking (HR = 0.75 (95% CI = 0.65 - 0.86) p<0.01). These findings offered proof of concept that physical activity-sleep relationships operated on a continuum, with sleep benefits possible even at relatively low levels of activity. Experimental evidence on the acute and sustained effects of physical activity on sleep quality was then analysed and discussed. Outcomes from this review, together with the preliminary analyses described above, were then used to inform the design of a randomised controlled trial to investigate the effects on sleep quality of increasing physical activity to currently recommended levels among sedentary people with insomnia. A total of 41 sedentary adults meeting DSM-IV criteria for insomnia (30 female; mean age 59.8±9.5) were randomised to a physical activity group (≥150 minutes moderate intensity activity/week) or a waiting list control group. The principal outcome was Insomnia Severity Index (ISI) change 6 months post baseline; secondary outcomes were anxiety (using the State Trait Anxiety Inventory) and depression (Beck Depression Inventory II). Physical activity was assessed using Actigraph GTX3+ accelerometers. Outcomes were assessed in univariate general linear models, adjusted for baseline confounders. Activity and sleep assessments did not differ at baseline. At 6 months post baseline the intervention group engaged in 213 min/week of moderate intensity PA, compared to the control group (82 min/week). Compared to the control group, the intervention group showed significant improvement in the ISI score at 6 months F(1,28) = 5.16, p=0.03), adjusted means difference = 3.37, with an adjusted Cohen's d =.78 (95% CI 0.10 1.45). There was a significant improvement in trait anxiety, and depression outcomes post-intervention, F(6,28)=4.41, p=0.05, and F(6,28)=5.61, p=0.02, respectively. The results showed that increasing activity in line with current guidelines could deliver clinically significant improvements in sleep quality and mood outcomes among inactive adults with insomnia. While the effect sizes are modest, the pattern of results reported here allow for two conclusions with clear implications for public health: 1) measures to increase levels of physical activity above the currently recommended threshold of 150 minutes per week could usefully be added to other approaches to insomnia management; and 2) the likelihood of improved sleep quality should be routinely added to those evidence-based cardiovascular and metabolic benefits most frequently associated with increased physical activity in behaviour change initiatives

Tai Chi/Qi Gong in Mental Health Treatment and Prevention: A review of Meta-Analytic Evidence and an Analysis of Evidence Congruence with Training Practices

In a review of the literature, Abbot and Lavretsky (2013) concluded that Tai Chi and Qi Gong, two complementary and alternative therapies, improved mental and behavioral health-related outcomes. Their review inspired a number of meta-analytical reviews and follow up randomized controlled trials (RCT) that focused on specific outcome categories defined in their paper. My thesis expands Abbot and Lavretsky’s review by examining the results of these posterior meta-analyses and RCT studies. In addition, I replicate the methodological searches provided by each included meta-analysis to bolster their findings with more recent publications. Creating an updated meta-analysis of my own to support or refute Abbot and Lavretsky’s claims, I add to the argument on Tai Chi and Qi Gong’s therapeutic effect on treating mental illness. Tai Chi and Qi Gong appear to be therapeutically beneficial across a range of mental health issues, and are indicated as a safe alternative of treatment. Future studies should include more methodological rigor (blinding, randomization, and reporting) and study these complementary and alternative therapies effect on additional disorders

Sleep and inflammation in resilient aging.

Sleep quality is important to health, and increasingly viewed as critical in promoting successful, resilient aging. In this review, the interplay between sleep and mental and physical health is considered with a focus on the role of inflammation as a biological pathway that translates the effects of sleep on risk of depression, pain and chronic disease risk in aging. Given that sleep regulates inflammatory biologic mechanisms with effects on mental and physical health outcomes, the potential of interventions that target sleep to reduce inflammation and promote health in aging is also discussed

Sleep Dysfunction in Fibromyalgia and Therapeutic Approach Options

Fibromyalgia, characterised by persistent pain, sleep disturbance, fatigue and cognitive dysfunction, is a central sensitivity syndrome that also involves abnormality in peripheral generators and in the hypothalamic pituitary adrenal axis. Heterogeneity of clinical expression of fibromyalgia with a multifactorial aetiology has made the development of effective therapeutic strategies challenging. Non-restorative sleep associated with poor sleep quality is a characteristic of fibromyalgia which is linked to symptom severity. A relationship between sleep disorder and central sensitization could be a possible factor involved in development, exacerbation and/or maintenance of fibromyalgia. Association between disordered sleep and the risk of fibromyalgia suggests that limiting sleep problems would reduce the incidence of the condition. Therapeutic approaches with treatments that consolidate or deepen sleep may be preferential to improve sleep in patients with fibromyalgia. Thus, disordered sleep appears fundamental to the pathophysiology of fibromyalgia and as such the risk of sleep disturbances needs to be proactively assessed and when identified in this patient group be actively managed to improve health outcomes for patients with fibromyalgia

An Energy Aware and Secure MAC Protocol for Tackling Denial of Sleep Attacks in Wireless Sensor Networks

Wireless sensor networks which form part of the core for the Internet of Things consist of resource constrained sensors that are usually powered by batteries. Therefore, careful energy awareness is essential when working with these devices. Indeed,the introduction of security techniques such as authentication and encryption, to ensure confidentiality and integrity of data, can place higher energy load on the sensors. However, the absence of security protection c ould give room for energy drain attacks such as denial of sleep attacks which have a higher negative impact on the life span ( of the sensors than the presence of security features. This thesis, therefore, focuses on tackling denial of sleep attacks from two perspectives A security perspective and an energy efficiency perspective. The security perspective involves evaluating and ranking a number of security based techniques to curbing denial of sleep attacks. The energy efficiency perspective, on the other hand, involves exploring duty cycling and simulating three Media Access Control ( protocols Sensor MAC, Timeout MAC andTunableMAC under different network sizes and measuring different parameters such as the Received Signal Strength RSSI) and Link Quality Indicator ( Transmit power, throughput and energy efficiency Duty cycling happens to be one of the major techniques for conserving energy in wireless sensor networks and this research aims to answer questions with regards to the effect of duty cycles on the energy efficiency as well as the throughput of three duty cycle protocols Sensor MAC ( Timeout MAC ( and TunableMAC in addition to creating a novel MAC protocol that is also more resilient to denial of sleep a ttacks than existing protocols. The main contributions to knowledge from this thesis are the developed framework used for evaluation of existing denial of sleep attack solutions and the algorithms which fuel the other contribution to knowledge a newly developed protocol tested on the Castalia Simulator on the OMNET++ platform. The new protocol has been compared with existing protocols and has been found to have significant improvement in energy efficiency and also better resilience to denial of sleep at tacks Part of this research has been published Two conference publications in IEEE Explore and one workshop paper

Feasibility of Sleep Self-Management Intervention in Pregnancy Using a Personalized Health Monitoring Device: Protocol for a Pilot Randomized Controlled Trial

Background: Sleep disruptions are common during pregnancy and associated with increased risk of adverse maternal outcomes such as preeclampsia, gestational diabetes, prolonged labor, and cesarean birth. Given the morbidity associated with poor sleep, cost-effective approaches to improving sleep that can be disseminated in community or clinical settings are needed. Personal health monitor (PHM) devices offer an opportunity to promote behavior change, but their acceptability and efficacy at improving sleep in pregnant women are unknown. Objective: The goal of the paper is to describe the protocol for an ongoing pilot randomized controlled trial that aims to establish the feasibility, acceptability, and preliminary efficacy of using a PHM device (Shine 2, Misfit) to promote sleep during pregnancy. Methods: The proposed pilot study is a 12-week, parallel arm, randomized controlled trial. Pregnant women, at 24 weeks gestation, will be randomized at a 1:1 ratio to a 12-week sleep education plus PHM device group or a sleep education alone comparison group. The primary outcomes will be measures of feasibility (ie, recruitment, enrollment, adherence) and acceptability (ie, participant satisfaction). The secondary outcomes will be self-reported sleep quality and duration, excessive daytime sleepiness, fatigue, and depressive symptoms. Results: Recruitment for this study began in September 2017 and ended in March 2018. Data collection for the primary and secondary aims was completed in August 2018. We anticipate that the data analysis for primary and secondary aims will be completed by December 2019. The results from this trial will inform the development of a larger National Institutes of Health grant application to test the efficacy of an enhanced version of the sleep intervention that we plan to submit in the year 2020. Conclusions: This study will be the first to apply a PHM device as a tool for promoting self-management of sleep among pregnant women. PHM devices have the potential to facilitate behavioral interventions because they include theory-driven, self-regulatory techniques such as behavioral self-monitoring. The results of the study will inform the development of a sleep health intervention for pregnant women. Trial Registration: ClinicalTrials.gov NCT03783663; https://clinicaltrials.gov/ct2/show/NCT03783663 (Archived by WebCite at http://www.webcitation.org/779Ou8hon) International Registered Report Identifier (IRRID): DERR1-10.2196/1245