Prospective Trial of CPAP in Community-Dwelling Adults with Down Syndrome and Obstructive Sleep Apnea Syndrome

Adults with Down syndrome (DS) are predisposed to obstructive sleep apnoea (OSA), but the effectiveness and acceptability of continuous positive airway pressure treatment (CPAP) in this group has rarely been formally assessed. This study was designed as a pilot randomised, parallel controlled trial for one month, continuing as an uncontrolled cohort study whereby the control group also received the intervention. Symptomatic, community-dwelling DS individuals exhibiting ≥10 apnoeas/hypopneas per hour in bed on a Type 3 home sleep study were invited to participate in this study, with follow-up at 1, 3, 6, and 12 months from baseline. Measurements of sleepiness, behaviour, cognitive function and general health were undertaken; the primary outcome was a change in the pictorial Epworth Sleepiness Scale (pESS) score. Twenty-eight participants (19 male) were enrolled: age 28 ± 9 year; body mass index 31.5 ± 7.9 kg/m2; 39.6 ± 32.2 apnoeas/hypopneas per hour in bed; pESS 11 ± 6/24. The pilot randomised controlled trial at one month demonstrated no change between the groups. At 12 months, participant (p = 0.001) pESS and Disruptive (p 0.0001), Anxiety/Antisocial (p = 0.024), and Depressive (p = 0.008) behaviour scores were reduced compared to baseline. Improvement was noted in verbal (p = 0.001) and nonverbal intelligence scores (p = 0.011). General health scores also improved (p = 0.02). At the end of the trial, 19 participants continued on treatment. Use of CPAP in adults with DS and OSA led to a number of significant, sustained improvements in sleepiness and behavioural/emotional outcomes at 12 months

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

Suicidal ideation in patients with obstructive sleep apnoea and its relationship with disease severity, sleep-related problems and social support

We aimed to assess the prevalence of suicidal ideation and to examine the relationships between obstructive sleep apnoea severity, sleep-related problems, social support and suicidal ideation in obstructive sleep apnoea patients. We included 149 patients (68% male; mean age, 48.99 +/- 9.57 years) with diagnosed obstructive sleep apnoea (Apnoea-Hypopnoea Index > 5) based on full-night polysomnography. The prevalence of suicidal ideation among obstructive sleep apnoea patients was 20.1 per cent. Structural equation modelling showed that suicidal ideation in obstructive sleep apnoea was strongly related to poor sleep quality and high fatigue levels. No relationship between social support and suicidal ideation in obstructive sleep apnoea patients was found

Obstructive sleep apnea and depression

There are high rates of depression in people with obstructive sleep apnea (OSA) in both community and clinical populations. A large community study reported a rate of 17% and reports for sleep clinic samples range between 21% and 41%. A large cohort study found OSA to be a risk factor for depression, but we are unaware of any longitudinal study of the reverse association. However correlations have not generally been found in smaller studies. Several possible causal mechanisms linking OSA and depression have been proposed but not established. Patients who have depression as well as OSA appear worse off than those with OSA only, and depressive symptoms persist in at least some patients in short term studies of treatment for OSA. Direct treatment of depression in OSA might improve acceptance of therapy, reduce sleepiness and fatigue and improve quality of life, but intervention trials are required to answer this question

Prevalence and treatment of obstructive sleep apnoea/hypopnoea syndrome in adults with Down syndrome

Obstructive sleep apnoea/hypopnoea syndrome (OSAHS) is characterised by repeated cycles of upper airway obstruction during sleep, leading to diurnal symptoms. Individuals with Down syndrome (DS) are predisposed to this as the DS phenotype overlaps with OSAHS risk factors. Around 2-4% of the general adult population and 55% of children with DS have OSAHS but, to date, no large-scale study has assessed OSAHS prevalence or efficacy of treatment in DS adults. This study aimed to: 1) Systematically assess subjective and objective OSAHS prevalence; 2) Assess the effectiveness of continuous positive airway pressure (CPAP) in an adult DS population. Standard questionnaires including pictorial Epworth Sleepiness Scale (pESS) and Developmental Behaviour Checklist for Adults (DBC-A) were sent to UK adults aged ≥16yr with DS and their caregivers. All questionnaire responders were invited to undergo home polygraphy. Symptomatic adults with DS with ≥10 apnoeas/hypopnoeas per hour in bed (AH) on home polygraphy were invited to participate in a prospective randomised controlled trial (RCT) of CPAP v. lifestyle advice, with review at 1, 3, 6 and 12m. Participants in the lifestyle arm were offered CPAP at 1m. Standard measurements of sleepiness, behaviour, cognitive function and general health were undertaken. Standard statistical analyses were conducted, with significance set at p<0.001 to control for multiple testing. Of 5270 questionnaires sent, 1105 responses were valid (21%). Responders (55% males) were overweight/obese young adults: mean BMI 29.0±6.8kg/m2; mean age 28±9 years. Women had a higher BMI (p<0.0001), but collar size was greater in men (p<0.0001). Mean pESS scores were broadly within the normal range (7±5/24). No significant gender differences in OSAHS symptoms were noted. Individuals with probable OSAHS had higher pESS and DBC-A scores, and significantly more symptoms of OSAHS. Subjective OSAHS prevalence was estimated at 35%. Of the 790 individuals invited, 149 underwent polygraphy, with 134 valid studies obtained: mean AH 21.8(10.9-42.7); mean oximetry desaturation index (ODI) 6.6(2.3-20.0). No significant gender differences were observed. Forty-two percent of participants met standard clinical diagnostic criteria for OSAHS. Twenty-eight eligible adults with DS (19 male) were randomised: age 28±9yr; BMI 31.5±7.9kg/m2; AH 28.6(14.8-47.9); ODI 7.3(1.8-21.9); pESS 11±6/24. Groups did not differ significantly at baseline. By 12m, 4 participants had withdrawn (all remaining participants on CPAP). The pESS (p=0.001), DBC-A Disruptive (p<0.0001) and Kaufmann Brief Intelligence Test verbal subscale (p=0.001) scores improved significantly. This first large study of OSAHS prevalence in the adult DS population estimates a prevalence of 35-42% - around 10 times higher than in the general adult population. Sustained, significant improvements in sleepiness, cognitive function and behavioural/emotional outcomes with CPAP use over a 12m period were demonstrated during this first RCT of CPAP in adults with DS. A larger trial of CPAP in this population is warranted

ERS International Congress 2020 Virtual: highlights from the Allied Respiratory Professionals Assembly

This article provides an overview of outstanding sessions that were (co)organised by the Allied Respiratory Professionals Assembly during the European Respiratory Society International Congress 2020, which this year assumed a virtual format. The content of the sessions was mainly targeted at allied respiratory professionals, including respiratory function technologists and scientists, physiotherapists, and nurses. Short take-home messages related to spirometry and exercise testing are provided, highlighting the importance of quality control. The need for quality improvement in sleep interventions is underlined as it may enhance patient outcomes and the working capacity of healthcare services. The promising role of digital health in chronic disease management is discussed, with emphasis on the value of end-user participation in the development of these technologies. Evidence on the effectiveness of airway clearance techniques in chronic respiratory conditions is provided along with the rationale for its use and challenges to be addressed in future research. The importance of assessing, preventing and reversing frailty in respiratory patients is discussed, with a clear focus on exercise-based interventions. Research on the impact of disease-specific fear and anxiety on patient outcomes draws attention to the need for early assessment and intervention. Finally, advances in nursing care related to treatment adherence, self-management and patients’ perspectives in asthma and chronic obstructive pulmonary disease are provided, highlighting the need for patient engagement and shared decision making. This highlights article provides readers with valuable insight into the latest scientific data and emerging areas affecting clinical practice of allied respiratory professionals.European CommissionFWOCenter for Innovative Care and Health Technology (ciTechCare) of the Polytechnic of Leiria - Fundacao para a Ciencia e Tecnologia (FCT) UIDB/05704/2020 UIDP/05704/202

Behavioural adherence in the treatments of disorders of sleep and wakefulness - a biopsychosocial approach

Obstructive sleep apnoea (OSA) and insomnia are the two most prevalent sleep disorders. Their respective treatments Continuous Positive Airway Pressure (CPAP) and Cognitive Behaviour Therapy for insomnia (CBT-I), are effective, but at the same time challenging. It is this challenge that may translate to poor adherence, which ultimately leads to a reduction in treatment effectiveness. The evaluation of these treatments should not fall short of understanding effectiveness by only considering efficacy; the effort to establish what influences adherence makes up a large part of that goal. The aim of this thesis is to contribute to the literature by adopting a biopsychosocial approach (BPS). That is, the consideration of biomedical, psychological and social factors and how they interact to influence behaviour. The implications for both CPAP and CBT-I adherence literature were tested in the context of four experimental studies. Semi-structured interviews were conducted with 11 CPAP users, with 5 individuals completing the three required interviews prior to, at 1 week and 3 months after treatment initiation. The core themes emerging from a thematic analysis were ‘internal conflict around acceptance and adherence’, ‘integration of CPAP into life’ and ‘motivators and resources for CPAP use’. The interviews with 11 individuals having completed a CBT-I program revealed three important issues: ‘Making sense of CBT-I’, ‘Ongoing evaluation of components’ and ‘Obstacles to implementation’. Both studies reveal potential psychological and social factors contributing to adherence to CPAP and CBT-I, which need to be considered in a BPS framework. A patient-level meta-analysis of three randomised placebo-control studies showed that the relationship between CPAP adherence and improvements in daytime sleepiness was caused by both physiological (high use of real CPAP reduced sleepiness more than high use of placebo and more than low use of real CPAP) and psychological effects (high use of placebo was superior to low use of placebo), possibly as a result of an expectation of benefit. The results support the importance of considering both biomedical and psychosocial factors and their interactive effects on adherence. The translation of the BPS approach to clinical practice will be facilitated by the development of brief, reliable and valid measures to assess psychological iii and social variables in addition to the existing biomedical tools. The Stage of Change Scale for Insomnia (SOCSI) assessing components of the transtheoretical model (stage of change, self-efficacy, decisional balance and processes of change), was constructed and cognitively pre-tested in 13 individuals completing CBT-I. The reliability and validity of this comprehensible scale was subsequently examined in the context of a sleep restriction trial. Insomnia-related symptoms at post-treatment and follow-up, which were significantly different from baseline in the 27 individuals with insomnia, were associated with actigraphdetermined adherence to the agreed bed window. The SOCSI was deemed a valid tool with participants in the self-identified action/maintenance stage revealing significantly better adherence, higher motivation and self-efficacy than those in the contemplation and preparation stage. Test-retest reliability of the SOCSI was excellent and the content analysis of open-box responses revealed information for further validation of decisional balance and processes of change scales. This thesis provides novel information about the variables that influence adherence to CPAP and CBT-I. It distinguishes itself from previous efforts by acknowledging the need for the adoption of a BPS framework. This approach is necessary to successfully advancing not only the CPAP and CBT-I adherence literature individually, but potentially the adherence field in general

Sleep-time predictors of cardiovascular complications in surgical peripheral arterial disease

ABSTRACT Patients with peripheral arterial disease (PAD) undergoing surgical revascularisation are in high risk of postoperative cardiovascular complications and death, due to advancing age and multiple comorbidities in the population. In addition, PAD needing surgery represents a severe form of systemic atherosclerosis but the exact underlying pathophysiology of acute myocardial infarction (AMI) in these patients is unclear and predicting outcome especially in the long-term is challenging. Obstructive sleep apnoea (OSA) is increasingly common in the general population and independently associated with various manifestations of cardiovascular disease or their risk factors; OSA is highly prevalent in patients with coronary artery disease (CAD), stroke, hypertension and diabetes. To expand this knowledge, we determined the prevalence and severity (in terms of the apnoeahypopnoea index, AHI) of OSA in surgical PAD as well as its impact on the incidence of major adverse cardiovascular and cerebrovascular events (MACCE) in this patient group. Heart rate variability (HRV) reflects fluctuations in sympathetic and parasympathetic activation responsible for neurocirculatory control in various physiological and pathophysiological situations. Depressed HRV is associated with increased cardiovascular morbidity and mortality following AMI and major surgery. In this study, the alterations of nocturnal HRV and their association with the severity of OSA and incidence of MACCE in patients with PAD was assessed, including the fractal correlation properties of HRV. HRV in a control group of 15 healthy subjects was also examined. Patients scheduled for sub-inguinal vascular surgery (n=84, age 67±9 years) underwent polysomnography and HRV analyses. OSA was detected in 86% of patients and in 56% it was moderate or severe. Age, male gender, depressed left ventricular function and decreasing high density lipoprotein/cholesterol ratio (HDL/Chol) predicted the presence and severity of OSA. The latter two remained significant after adjusting for age and gender. OSA with AHI ≥20/hour, used as a cut-off in the outcome analyses, predicted a higher risk of MACCE (p=0.001) along with pre-existing CAD (p=0.001), decreasing HDL/Chol (p=0.048) and <4 years history of PAD (p=0.018). HRV was altered in patients with PAD when compared to controls but the time domain measures were mostly unchanged. In the frequency domain, low frequency power was generally lower, high frequency power was mostly higher and fractal correlation was consistently lower. Very low frequency power was increased the most in patients with AHI 10-20/hour when compared to <10/hour while those with AHI ≥20/hour had lower fractal correlation in the morning. Patients suffering a MACCE had lower high frequency power during S3-4 and rapid eye movement sleep. In conclusion, OSA is associated with worsening atherosclerosis and predicts MACCE after vascular surgery. HRV alterations, although associated with PAD, have limited predictive value. Keywords: atherosclerosis, peripheral arterial disease, sleep apnoea, heart rate variabilityTIIVISTELMÄ Unenaikaiset sydänkomplikaatioiden ennustetekijät kirurgista hoitoa vaativassa perifeerisessä valtimotaudissa Perifeeristä valtimotautia sairastavilla potilailla on suuri leikkauksenjälkeisten sydänkomplikaatioiden riski johtuen yhä iäkkäämmästä väestöstä sekä lukuisista rinnakkaissairauksista. Lisäksi perifeerinen valtimotauti merkitsee vaikea-asteista yleistynyttä ateroskleroosia, mutta sydäninfarktin tarkka syntymekanismi näillä potilailla on epäselvä ja erityisesti pitkän aikavälin ennusteen arviointi on haastavaa. Obstruktiivinen uniapnea yleistyy väestössä ja sillä on itsenäinen yhteys useisiin sydän- ja verisuonisairauksiin ja niiden riskitekijöihin; uniapnea on erittäin yleinen sepelvaltimotauti-, aivohalvaus-, verenpainetauti- ja diabetespotilailla. Tämän tietopohjan laajentamiseksi tässä tutkimuksessa määritettiin uniapnean esiintyvyys ja vaikeusaste (määrittäjänä apnea-hypopneaindeksi, AHI) vaikea-asteista yleistynyttä ateroskleroosia sairastavilla potilailla sekä sen vaikutus vakavien sydän- ja aivotapahtumien ilmaantuvuuteen. Sydämen sykevaihtelu kuvastaa autonomisen hermoston toiminnan muutoksia, jotka puolestaan vastaavat verenkierron säätelystä erilaisissa fysiologisissa ja patofysiologisissa tilanteissa. Alentunut sykevaihtelu on yhteydessä lisääntyneeseen kardiovaskulaariseen sairastuvuuteen ja kuolleisuuteen sairastetun sydäninfarktin tai suuren leikkauksen jälkeen. Tässä tutkimuksessa arvioitiin yöllisen sydämen sykevaihtelun muutosten yhteyttä uniapnean vaikeusasteeseen sekä vakavien sydän- ja aivotapahtumien ilmaantuvuuteen, mukaan lukien sykevaihtelun fraktaalikorrelaatio-ominaisuudet. Tutkimuksessa analysoitiin sykevaihtelu myös 15 terveen henkilön vertailuryhmältä. Nivustason alapuoliseen verisuonileikkaukseen meneville potilaille (n=84, ikä 67±9 vuotta) tehtiin unipolygrafia ja sykevaihteluanalyysi. Uniapnea todettiin 86 %:lla potilaista ja 56 %:lla se oli kohtalainen tai vaikea. Ikä, miessukupuoli, heikentynyt vasemman kammion toiminta ja alentunut HDL-kolesterolin suhde kokonaiskolesteroliin ennustivat uniapneaa ja sen vaikeutumista; 2 viimeksi mainittua säilyivät merkitsevinä ikä- ja sukupuolivakioinnin jälkeen. AHI ≥20/tunti, joka valittiin kynnysarvoksi päätetapahtumaanalyyseihin, ennusti merkitsevästi vakavia sydän- ja aivotapahtumia (p=0.001). Muita merkitseviä tekijöitä olivat sepelvaltimotauti (p=0.001), alentunut HDL-suhde (p=0.048) ja lyhyt (alle 4 vuotta) perifeerisen valtimotaudin kesto ennen leikkaushoidon tarvetta (p=0.018). Sykevaihtelu oli muuttunut valtimotautipotilailla verrattuna kontrolleihin, mutta aikakenttäparametrit säilyivät lähes ennallaan. Pienitaajuuksinen sykevaihtelu oli yleisesti vähäisempää, suuritaajuuksinen enimmäkseen voimakkaampaa ja fraktaalikorrelaatio johdonmukaisesti heikompaa. Hyvin pienitaajuuksinen vaihtelu oli eniten lisääntynyt AHI 10-20/tunti -alaryhmässä verrattuna AHI <10/tunti -ryhmään, mutta AHI ≥20/tunti -potilailla aamun fraktaalikorrelaatio oli heikompaa. Potilaiden, jotka saivat vakavia sydän- ja aivotapahtumia, suuritaajuusvaihtelu oli heikompaa syvän unen ja vilkeunen aikana. Johtopäätöksinä todetaan, että uniapnea on yhteydessä vaikeutuvaan valtimotautiin sekä ennustaa vakavia sydän- ja aivotapahtumia verisuonileikkauksen jälkeen sykevaihtelun muutosten ennustearvon ollessa tässä aineistossa hyvin rajallinen. Avainsanat: ateroskleroosi, perifeerinen valtimotauti, uniapnea, sykevaihtel

Childhood Obesity and Obstructive Sleep Apnea

The global epidemic of childhood and adolescent obesity and its immediate as well as long-term consequences for obese individuals and society as a whole cannot be overemphasized. Obesity in childhood and adolescence is associated with an increased risk of adult obesity and clinically significant consequences affecting the cardiovascular and metabolic systems. Importantly, obesity is additionally complicated by obstructive sleep apnea (OSA), occurring in up to 60% of obese children. OSA, which is diagnosed using the gold standard polysomnogram (PSG), is characterised by snoring, recurrent partial (hypopneas) or complete (apneas) obstruction of the upper airway. OSA is frequently associated with intermittent oxyhemoglobin desaturations, sleep disruption, and sleep fragmentation. There is emerging data that OSA is associated with cardiovascular burden including systemic hypertension, changes in ventricular structure and function, arterial stiffness, and metabolic syndromes. Thus, OSA in the context of obesity may independently or synergistically magnify the underlying cardiovascular and metabolic burden. This is of importance as early recognition and treatment of OSA in obese children are likely to result in the reduction of cardiometabolic burden in obese children. This paper summarizes the current state of understanding of obesity-related OSA. Specifically, this paper will discuss epidemiology, pathophysiology, cardiometabolic burden, and management of obese children and adolescents with OSA

The diagnosis and treatment of sleep disordered breathing in patients with cardiovascular disease in England: current pathways and barriers to optimal care

Cardiovascular disease (CVD) is a major health burden accounting for more than 30% of deaths worldwide, but there have been significant advances in its management in recent years. These have been adopted into clinical practice guidelines, however, there is a mismatch between the widely perceived ‘best practice’ and how patients are actually managed in clinical practice. In most healthcare systems, the delivery of care is not standardised. Sleep disordered breathing (SDB) is highly prevalent in patients with CVD and can further potentiate their cardiovascular risk and lead to adverse cardiovascular mortality. A literature review of the association between cardiovascular disease and SDB will be evaluated in relation to pathophysiology, screening, diagnosis and treatment in this thesis. The current evidence for the management of SDB in CVD will also be reviewed. SDB has been traditionally considered as a discipline in respiratory medicine, therefore there are diagnosis and treatment challenges and most patients with SDB are undiagnosed and untreated. Patients with both CVD and SDB are likely to have multiple comorbidities requiring complex management strategies. Thus, the main aim of this thesis is to identify these practice barriers to diagnosis and treatment in patients with SDB and CVD, using both quantitative and qualitative methodology. Publicly available data sources related to SDB (such as Hospital Episode Statistics [HES data] and NHS RightCare), were used help understand the variation in service provision and diagnostic rates. To identify the barriers to diagnosis and treatment of patients with SDB and CVD, mixed-methods were used (i.e. both quantitative and qualitative methodology). For primary care, previously conducted GP and patient surveys were analysed and semi-structured interviews of healthcare professionals were carried out to identify barriers in secondary and tertiary care. In the past two decades, large number of QI tools have been widely in the management of cardiovascular disease with aim of overcoming barriers, however, we do not know whether they change cardiovascular outcome. Thus, a secondary aim of this thesis is to identify effective QI methodology and utilise them to improve and redesign local practice. A systematic review (of randomised/cluster controlled trials) was also carried out with the aim of exploring the impact of QI methodology on CVD outcome. Although the current evidence suggests that treating patients with SDB using PAP therapy may not have strong benefits as previously thought, the diagnosis of SDB is still important in patients with CVD because it reflects a group with higher CV risk. There are a variety of barriers that could delay the diagnosis and treatment of SDB, such as the lack of local access to sleep studies, lack of guidelines and hard outcome data, patient perceptions and cultural barriers between HPs. QI methods can be used to potentially overcome these barriers and care pathways seems to be the most effective.Open Acces