Therapeutic alternatives with CPAP in obstructive sleep apnea

Obstructive Sleep Apnea (OSA), characterized by airflow cessation (apnea) or reduction (hypopnea) due to repeated pharyngeal obstructions during sleep, causes frequent disruption of sleep and hypoxic events. The condition is linked to many adverse health related consequences, such as neurocognitive and cardiovascular disorders, and metabolic syndrome. OSA is a chronic condition requiring long-term treatment, so treatment using continuous positive airway pressure (CPAP) has become the gold standard in cases of moderate or severe OSA. However, its effectiveness is influenced by patients’ adherence. Surgery for OSA or treatment with oral appliances can be successful in selected patients, but for the majority, lifestyle changes such as exercise and dietary control may prove useful. However, exercise training remains under-utilized by many clinicians as an alternative treatment for OSA. Other interventions such as oral appliance (OA), upper way stimulation, and oropharyngeal exercises are used in OSA. Because the benefit of all these techniques is heterogeneous, the major challenge is to associate specific OSA therapies with the maximum efficacy and the best patient compliance

Obstructive Sleep Apnoea: a dental perspective

Obstructive sleep apnoea (OSA) is regarded as a potentially life threatening breathing disorder characterised by periodic cessation of air intake during sleep. Treatment modalities include conservative measures such as weight loss, change in sleep position and avoidance of alcohol: these may suffice in reducing airway obstruction. Pharmacotherapy has also been used with various grades of success. Nasal continuous positive airway pressure (nCPAP) helps maintain airway patency during sleep by a continuous stream of air under light pressure. Tracheostomy, by its very nature, completely bypasses any pharyngeal obstruction but is associated with a high degree of morbidity. Other surgical procedures such as uvulopalatopharyngoplasty (UPPP), orthognathic surgery, hyoid-myotomy suspension and tongue reduction have also been used. Mandibular advancement splints (MAS) are increasingly being recognised as a suitable management option for those subjects with mild to moderate OSA. A study was undertaken to ascertain the effectiveness of using mandibular advancement splints in the treatment of OSA. Mandibular protrusion using a MAS is frequently, but not invariably, associated with improvement in velo- and oro-pharyngeal airway dimensions in awake subjects.peer-reviewe

Psychometric Properties of Obstructive Sleep Apnea Screening Measures in Patients Referred to a Sleep Clinic

Background: Obstructive Sleep Apnea (OSA) contributes to all-cause and cardiac mortality. There are no current guidelines for OSA screening in outpatient settings. An American Academy of Sleep Medicine task force is focusing on improving detection and categorization of OSA symptoms and severity to promote screening, assessment, and diagnosis of the disorder. The purpose of this study was to identify the psychometric properties of three self-report OSA screening measures (Berlin, Epworth Sleepiness Scale (ESS), STOP Bang) and an objective portable sleep monitor (PSM) compared to apnea-hypopnea index (AHI) levels (≥5, ≥ 15, and ≥ 30) from polysomnogram (PSG). Methods: A methodological design was used. Patients referred to a sleep specialist for an OSA consultation were recruited and enrolled at initial sleep evaluation. Participants completed the three OSA self-report screening measures and those participants who met inclusion criteria were sent home with a PSM for one night measurement. Automatic scoring was used. PSGs were ordered by the physician and AHI results were obtained from the medical record. Results: Participants (N=170) were enrolled (88 male, 82 female; age 54.5, SD 5.0 years). Almost all participants completed the self-report OSA screening measures, approximately half completed PSM measurement, and the majority completed laboratory PSG. The STOP Bang had the highest levels of sensitivity; the ESS had the lowest. The ESS had the highest specificity and reliability level. The PSM measure had the highest positive predictive value (PPV). The PSM measure had the strongest psychometric properties of the screening measures. Conclusions: The STOP Bang was the preferred self-report OSA screening measure because of high sensitivity levels. A positive STOP Bang warrants assessment for OSA. The ESS is the least desirable screening measure. If a patient qualifies, further screening with a PSM is indicated. PSM measurement consistently predicted the presence of OSA but at the expense of low sensitivity at AHI levels ≥ 30. PSM results can guide the referral process from primary or specialty clinicians to sleep specialist

Sleep, Health, and Aging

As people grow older, getting a good night's sleep remains essential to maintaining good health. Insomnia is a common complaint in older adults, and although occasional sleep complaints may not be associated with age, chronic sleep difficulties are experienced more often by older adults than by younger adults

Self-reported health outcomes in patients with obstructive sleep apnoea:Unraveling the role of bio-psycho-social factors

Obstructive sleep apnoea (OSA) is a heterogeneous and complex disease; it‘s management, however, is still based on limited effective treatment options. The aim of this thesis was to examine the bio-psycho-social factors that have been identified as key determinants in the adaptation to various chronic diseases, but evidence in OSA is lacking. The acquired knowledge further contributes to a better understanding of the associations between bio-psycho-social factors and selected self-reported health outcomes in OSA patients, i.e. quality of life, functional status, work functioning, and psychological distress — with particular interest in suicidal ideation. The results of our meta-analysis confirmed that continuous positive airway pressure treatment may help to improve physical OSA symptoms, whereas the existing psychological impairment cannot be alleviated. Our study revealed a high prevalence of psychological distress in OSA patients, among others suicidal ideation and anxiety. Thus, the necessity of monitoring psychological symptoms in OSA during clinical care should be highlighted. Another finding was that external resources, such as social support or coping self-efficacy for the ability to get support, explained less variance in health outcomes when compared to intra-individual resources, such as personal mastery, problem focused coping self-efficacy, or the ability to stop unpleasant emotions and thoughts. Therefore, encouraging mastery and dispelling adequate coping self-efficacy may be paramount in improving functional status and addressing psychological distress in OSA. Finally, the obtained knowledge may help to facilitate recommendations for current clinical practice and research related to OSA management and treatment as dictated by the complex needs of patients

Developments in diagnosis and treatment of obstructive sleep apnea

Identificatie van fenotypen en endotypen draagt bij tot een beter begrip van de complexe pathofysiologie en heterogene klinische presentatie van obstructieve slaapapneu (OSA). Het algemene doel van dit proefschrift was om de toegevoegde waarde te bepalen van potentiële voorspellers; risicofactoren geassocieerd met OSA en factoren die het behandelresultaat beïnvloeden. Middels het vaststellen van voorspellers kan de specificiteit en sensitiviteit van diagnostiek worden verhoogd. Daarnaast kunnen deze voorspellers richting geven tijdens de keuze uit de verschillende behandelopties, wat vervolgens zou kunnen leiden tot toename van het behandelsucces. De onderzochte fenotypen zijn: snurkgeluiden, gebitsparameters en positieafhankelijkheid. Snurkgeluiden voorspellen niet de aanwezigheid van een obstructie op elk niveau van de bovenste luchtweg zoals gevonden tijdens een slaapendoscopie. Gebitsparameters dragen niet bij aan de OSA screening of de voorspelling van het behandelsucces middels een mandibulair repositie apparaat (MRA). Positieafhankelijk OSA voorspelt niet of een patiënt al dan niet een geschikte kandidaat is voor een MRA behandeling. Ook is de voorspellende waarde van specifieke manoeuvres en hulpmiddelen tijdens een slaapendoscopie onderzocht. De nieuwe generatie MRA voorspelt zijn eigen behandelsucces en, door de gevonden gelijkenis met de standaard MRA, ook dat van een standaard op maat gemaakte MRA. De ernst van OSA vóór de behandeling middels nervus hypoglossus stimulatie (NHS) en follow-up middels dagtitraties hebben beiden geen (negatieve) invloed op het resultaat van de NHS-behandeling. Hierdoor kan de indicatie voor HNS worden verruimd en de logistiek voor follow-up worden vereenvoudigd met betere werkomstandigheden voor somnotechnologen zonder de kwaliteit van de titratie in gevaar te brengen

Screening the Commercial Motor Vehicle Driver for Sleep Apnea

Abstract The transportation industry has the third highest occupational risk for death and disability (BLS, 2010) with 7% of Commercial Motor Vehicle Drivers (CMVD) falling asleep while driving (NHTSA, 2006). One contributing factor may be undiagnosed Obstructive Sleep Apnea (OSA) (Tregear et al, 2009). In 2006, a Joint Task Force (JTF) published screening recommendations for OSA, which led to a change in the Department of Transportation screening practices within a local Occupational Medicine clinic. The purpose of this study was to: (a) determine what percentage of drivers having had a positive clinical screening examination (met two of three objective measures) tested positive for a diagnosis of OSA (b) determine what percentage of drivers diagnosed with OSA had an Apnea-Hypopnea-Index (AHI) greater than or equal to 20 abnormal breaths per hour, meeting the threshold for mandatory treatment, (c) determine the relationship between Body Mass Index (BMI), hypertension and neck circumference with a diagnosis of OSA. The electronic medical records of 182 drivers were reviewed. Of these, 143 were found eligible for the study with the following findings: 63% (n = 90) clinically screened positive and underwent confirmatory testing by Polysomnography (PSG). Of these, 92% (n = 83) were found to have OSA, and 48% (n = 43) met the threshold for mandatory treatment. The study found no correlation between a diagnosis of OSA and BMI. Hypertension was found to have an inverse relationship. Neck circumference was found to have a significant positive correlation. No drivers self-reported daytime sleepiness and would have been missed using the current recommendations. Screening the CMVD for OSA with self-reported symptoms of sleepiness is not adequate. This study shows the importance of neck circumference as the best predictor of identifying OSA

Sleep/wake activity and energy expenditure in overweight and obese obstructive sleep apnea patients : a pre- and post-CPAP comparison.

Overweight and obesity is a major contributing factor in an estimated 70% of all obstructive sleep apnea (OSA) cases. Approximately five percent of the adult population has OSA, and the numbers continue to soar with the rising prevalence of obesity. As a primary therapy, continuous positive airway pressure (CPAP) has demonstrated improvement in many comorbidities associated with both OSA and obesity. Although anecdotal and clinical references support increased energy, activity, and weight loss as a potential benefit of CP AP treatment, there remains little evidence to endorse CP AP as a significant weight-reduction measure for overweight and obese OSA patients. The purpose of this study was to examine sleep/wake activity and energy expenditure, pre- and post-CP AP treatment, in adult overweight and obese patients with OSA. A prospective, observational, longitudinal study design was employed to assess 24-hour actigraphic measures of sleep/wake activity and energy expenditure prior and subsequent to CPAP therapy. Analysis of variance (ANOVA) using repeated measures was performed to identify overall differences between pre-CP AP and one week post-CPAP and pre-CPAP and one month and post-CPAP sleep activity, wake activity, and 24-hour energy expenditure. Sixty-nine subjects were consented, with a total of 35 subjects completing the study. Data analyses revealed statistically significant mean differences in sleep activity, wake activity, and energy expenditure from pre-CPAP to post-CPAP at one week and one month. At baseline, and continuing through one week post-CPAP and one month post-CPAP, the CPAP compliant group demonstrated less sleep activity, more wake activity, and expended more energy than the CPAP noncompliant group. This study concluded that CP AP use is a statistically significant factor affecting sleep activity time, wake activity time, and energy expenditure. Regardless of CP AP compliance and length of use, the entire post-CPAP group demonstrated more sleep activity, had less wake activity, and burned fewer calories. From a clinical perspective, the results of this study do not support the use of CP AP as a potential weight loss measure in overweight and obese OSA patients, and emphasize the need for the inclusion of behavioral weight management and weight loss strategies in an at-risk population for comorbid illnesses

Executive dysfunction in children affected by obstructive sleep apnea syndrome: an observational study

Introduction: The role of sleep in cognitive processes can be considered clear and well established. Different reports have disclosed the association between sleep and cognition in adults and in children, as well as the impact of disturbed sleep on various aspects of neuropsychological functioning and behavior in children and adolescents. Behavioral and cognitive dysfunctions can also be considered as related to alterations in the executive functions (EF) system. In particular, the EF concept refers to self-regulatory cognitive processes that are associated with monitoring and controlling both thought and goal directed behaviors. The aim of the present study is to assess the impact of the obstructive sleep apnea syndrome (OSAS) on EF in a large sample of school aged children. Materials and methods: The study population comprised 79 children (51 males and 28 females) aged 7–12 years (mean 9.14 ± 2.36 years) with OSAS and 92 healthy children (63 males and 29 females, mean age 9.08 ± 2.44 years). To identify the severity of OSAS, an overnight respiratory evaluation was performed. All subjects filled out the Italian version of the Modified Card Sorting Test to screen EFs. Moreover, to check the degree of subjective perceived daytime sleepiness, all subjects were administered the Pediatric Daytime Sleepiness Scale (PDSS). Results: No significant differences between the two study groups were found for age (P = 0.871), gender (P = 0.704), z-score of body mass index (P = 0.656), total intelligence quotient (P = 0.358), and PDSS scores (P = 0.232). The OSAS children showed a significantly higher rate of total errors (P , 0.001), perseverative errors (P , 0.001), nonperseverative errors (P , 0.001), percentage of total errors (P , 0.001), percentage of perseverative errors (P , 0.001), and percentage of nonperseverative errors (P , 0.001). On the other hand, OSAS children showed a significant reduction in the number of completed categories (P = 0.036), total correct sorts (P = 0.001), and categorizing efficiency (P , 0.001). The Pearson’s correlation analysis revealed a significant positive relationship between all error parameters and apnea-hypopnea index, oxygen desaturation index, and percentage of mean desaturation of O2 with a specular negative relationship between the error parameters and the mean oxygen saturation values, such as a significant negative relationship between apnea-hypopnea index, oxygen desaturation index, percent of mean desaturation of O2, and the number of completed categories. Conclusion: Our study identified differences in the executive functioning of children affected by OSAS and is the first to identify a correlation between alteration in respiratory nocturnal parameters and EF that has not yet been reported in developmental age. These findings can be considered as the strength and novelty of the present report in a large pediatric population