Investigation and management of residual sleepiness in CPAP-treated patients with obstructive sleep apnoea: the European view

Excessive daytime sleepiness (EDS) is a major symptom of obstructive sleep apnoea (OSA), defined as the inability to stay awake during the day. Its clinical descriptors remain elusive, and the pathogenesis is complex, with disorders such as insufficient sleep and depression commonly associated. Subjective EDS can be evaluated using the Epworth Sleepiness Scale, in which the patient reports the probability of dozing in certain situations; however, its reliability has been challenged. Objective tests such as the multiple sleep latency test or the maintenance of wakefulness test are not commonly used in patients with OSA, since they require nocturnal polysomnography, daytime testing and are expensive. Drugs for EDS are available in the United States but were discontinued in Europe some time ago. For European respiratory physicians, treatment of EDS with medication is new and they may lack experience in pharmacological treatment of EDS, while novel wake-promoting drugs have been recently developed and approved for clinical use in OSA patients in the USA and Europe. This review will discuss 1) the potential prognostic significance of EDS in OSA patients at diagnosis, 2) the prevalence and predictors of residual EDS in treated OSA patients, and 3) the evolution of therapy for EDS specifically for Europe

Effectiveness of remote monitoring in improving CPAP compliance and the impact of preexisting organisation of standard care: a randomised controlled trial

Purpose : Continuous positive airway pressure (CPAP) is often the treatment of choice for obstructive sleep apnea (OSA). Short-term adherence and early perceived benefits are the best predictors of long-term adherence. The aim of this study was to determine the effect of telemonitoring in the first period of treatment with CPAP (auto-titrating PAP) on compliance and the long-term outcome. Methods: Patients aged between 18–75 years old with symptomatic severe OSA (apnea–hypopnea index (AHI) ≥ 30) requiring CPAP therapy were included in this single-blind, single-centre, randomised, controlled trial. They were divided into 2 groups (telemonitored standard clinical care versus standard clinical care without telemonitoring). Results: A total of 230 patients (115 patients/group) were included (mean age 54 ± 16.6 years, BMI 32.6 ± 5.4 kg/m2, ESS 13.1 ± 6.2, AHI 47.5 ± 14.8/hr). At week 10 compliance was similar in both groups (telemonitoring vs control 6:27 and 6:35 h, respectively, p = 0.57), as were AHI (2.4; 2.4/hr, p = 0.89) and ESS (5.8; 4.9, p = 0.22). The number of contacts of a patient with a healthcare professional was significantly higher during the follow-up from week 3 until week 10 (0.25; 0.13, p = 0.03). The number of patients who could be evaluated after 1 year was equally distributed in both groups (104; 104, p = 1.00), as were compliance (6:43; 6:49 h, p = 0.59) and residual AHI (1.9; 2.2/hr, p = 0.41). Conclusions: In patients with severe OSA with standard intensive follow-up during the initial weeks of CPAP therapy and good compliance, telemonitoring did not improve CPAP compliance nor the clinical outcome in the short or long term. The practical consequences can be highly relevant for patients and healthcare professionals

Multi-night home assessment of sleep structure in OSA with and without insomnia

OBJECTIVE: To explore sleep structure in participants with obstructive sleep apnea (OSA) and comorbid insomnia (COMISA) and participants with OSA without insomnia (OSA-only) using both single-night polysomnography and multi-night wrist-worn photoplethysmography/accelerometry.METHODS: Multi-night 4-class sleep-staging was performed with a validated algorithm based on actigraphy and heart rate variability, in 67 COMISA (23 women, median age: 51 years) and 50 OSA-only (15 women, median age: 51) participants. Sleep statistics were compared using linear regression models and mixed-effects models. Multi-night variability was explored using a clustering approach and between- and within-participant analysis.RESULTS: Polysomnographic parameters showed no significant group differences. Multi-night measurements, during 13.4 ± 5.2 nights per subject, demonstrated a longer sleep onset latency and lower sleep efficiency for the COMISA group. Detailed analysis of wake parameters revealed longer mean durations of awakenings in COMISA, as well as higher numbers of awakenings lasting 5 min and longer (WKN ≥5min) and longer wake after sleep onset containing only awakenings of 5 min or longer. Within-participant variance was significantly larger in COMISA for sleep onset latency, sleep efficiency, mean duration of awakenings and WKN ≥5min. Unsupervised clustering uncovered three clusters; participants with consistently high values for at least one of the wake parameters, participants with consistently low values, and participants displaying higher variability. CONCLUSION: Patients with COMISA more often showed extended, and more variable periods of wakefulness. These observations were not discernible using single night polysomnography, highlighting the relevance of multi-night measurements to assess characteristics indicative for insomnia.</p

Effectiveness of remote monitoring in improving CPAP compliance and the impact of preexisting organisation of standard care : a randomised controlled trial

Abstract: Purpose Continuous positive airway pressure (CPAP) is often the treatment of choice for obstructive sleep apnea (OSA). Short-term adherence and early perceived benefits are the best predictors of long-term adherence. The aim of this study was to determine the effect of telemonitoring in the first period of treatment with CPAP (auto-titrating PAP) on compliance and the long-term outcome.Methods Patients aged between 18-75 years old with symptomatic severe OSA (apnea-hypopnea index (AHI) >= 30) requiring CPAP therapy were included in this single-blind, single-centre, randomised, controlled trial. They were divided into 2 groups (telemonitored standard clinical care versus standard clinical care without telemonitoring).Results A total of 230 patients (115 patients/group) were included (mean age 54 +/- 16.6 years, BMI 32.6 +/- 5.4 kg/m2, ESS 13.1 +/- 6.2, AHI 47.5 +/- 14.8/hr). At week 10 compliance was similar in both groups (telemonitoring vs control 6:27 and 6:35 h, respectively, p = 0.57), as were AHI (2.4; 2.4/hr, p = 0.89) and ESS (5.8; 4.9, p = 0.22). The number of contacts of a patient with a healthcare professional was significantly higher during the follow-up from week 3 until week 10 (0.25; 0.13, p = 0.03). The number of patients who could be evaluated after 1 year was equally distributed in both groups (104; 104, p = 1.00), as were compliance (6:43; 6:49 h, p = 0.59) and residual AHI (1.9; 2.2/hr, p = 0.41).Conclusions In patients with severe OSA with standard intensive follow-up during the initial weeks of CPAP therapy and good compliance, telemonitoring did not improve CPAP compliance nor the clinical outcome in the short or long term. The practical consequences can be highly relevant for patients and healthcare professionals

Sleep Characteristics In Patients With Comisa Compared To Osa And Insomnia

Study objectives: Obstructive sleep apnea (OSA) and insomnia frequently co-exist, which complicates treatment, for example resulting in a worse compliance to continuous positive airway pressure (CPAP) therapy. Early recognition of comorbid insomnia and sleep apnea (COMISA) is important since both sleep disorders can aggravate each other and COMISA is associated with increased risk of all-cause mortality. Research is needed to identify characteristics that can be used to recognize patients with COMISA, in order to optimize treatment approach from the start. The aim of this study is to investigate differences in sleep structure between patients with pure OSA, pure insomnia and COMISA. Methods: We obtained polysomnography data from 326 patients from the SOMNIA database. The group included patients with OSA (n=199), insomnia (n=47) and COMISA (n=80). We compared statistics related to sleep stages, awakenings and sleep disordered breathing (SDB) events between the three patient groups. Results: Wake after sleep onset (WASO) was significantly longer for the COMISA group compared to OSA (median, 83.3 vs 60.0 minutes, p&lt;0.01). No significant differences were found in the total number of awakenings and the number of short (up to and including 2 minutes) and medium-length awakenings (2.5 up to and including 4.5 minutes). The number of long awakenings (five minutes or longer) and WASO containing only long awakenings were significantly higher for the COMISA group compared to OSA (median, 3.0 vs 2.0 awakenings, p&lt;0.01, and median, 43.3 vs 25.5 minutes, p&lt;0.001). The apnea-hypnopnea index (AHI) and the 4% oxygen desaturation index in COMISA were -as expected- higher compared to insomnia (median, 16.6 vs 6.8 events/hour, p&lt;0.001, and median, 4.5 vs 0.8 desaturations/hour, p&lt;0.001), but lower compared to OSA (median, 16.6 vs 21.6 events/hour, p=0.0136, and median, 4.5 vs 8.5 desaturations/hour, p=0.01). Conclusions: Patients with COMISA seem to present with a milder form of OSA, but nevertheless presented a more disturbed sleep structure, mainly characterized by prolonged awakenings. Further research is needed into these sleep characteristics that may lead to a better understanding of the mechanisms involved, earlier diagnosis and better treatment strategies