Facilitators and barriers to getting obstructive sleep apnea diagnosed: perspectives from patients and their partners.

The Lung Centre, Vancouver, British Columbia Correspondence: Dr John A Fleetham, The Lung Centre, 7th Floor, 2775 Laurel Street, Vancouver, British Columbia V5Z 1M9. Telephone 604-875-5653, fax 604-875-5587, e-mail john.fleetham@vch.ca In the current issue of the Canadian Respiratory Journal, Rotenberg et al (1) (pages 170-174) report data from a crosssectional survey sent to otolaryngologists, respirologists and family physicians in Ontario, to characterize wait times for obstructive sleep apnea (OSA) care. The major finding was that patients with suspected OSA in Ontario waited a mean of 11.6 months to initiate continuous positive airway pressure (CPAP) treatment and 16.2 months to initiate surgical therapy. This is much longer than the wait time in the Canadian Thoracic Society (CTS) guidelines, which recommend a maximum wait time of two to four weeks for urgent patients with comorbid disease or daytime sleepiness and a critical safety occupation, and six months for all patients with suspected OSA (2,3). Excessive diagnostic wait times frequently lead to inappropriate or incorrect therapy. Wait times for the diagnosis of sleep apnea in Canada have not improved much since Flemons et al (4) reviewed wait times for the diagnosis of OSA in five countries, including Canada, 16 years previously. To paraphrase what Pack (5) wrote in an associated editorial: “It seems inconceivable that we should tell a patient the following: You are highly likely to have severe sleep apnea, a disorder associated with an increased risk of car crashes, high blood pressure, and probably heart attack and stroke. We have an effective treatment for this disorder. We will arrange a study for you in 11.6 months’ time to assess this”. The even longer wait time for surgical treatment of OSA reported by Rotenberg et al also merits comment. The role of corrective upper airway surgery in the treatment of OSA is controversial. The current CTS guidelines conclude that laser-assisted uvulopalatoplasty is not recommended for the treatment of OSA, but that uvulopalatopharyngoplasty may be considered in selected patients with OSA who have failed CPAP and/or oral appliance therapy. The delay in the diagnosis and treatment of OSA in Ontario needs to be put in the context of the rest of Canada, where the diagnosis and treatment of sleep apnea is provided in a very different manner. Ontario has the highest number of sleep laboratories in Canada and most other parts of the world apart from the United States (4). Moreover, Ontario is one of the few provinces, along with Manitoba and Saskatchewan, in which the provincial medical plan funds CPAP treatment. The majority of centres in Canada outside of Ontario use ambulatory sleep monitoring – in addition to polysomnography – to diagnose OSA. After OSA has been diagnosed, there is no additional delay in the provision of CPAP therapy because this is funded by the patient and does not require approval by a funding agency. The majority of respondents to the survey in the article by Rotenberg et al (1) identified ‘not enough sleep laboratories’ as the reason for long wait times. Many would argue that more sleep laboratories are not what is required – what is necessary is a more appropriate diagnostic strategy that uses clinical prediction equations and ambulatory sleep monitoring (6) in conjunction with polysomnography for patients with comorbid disease or who fail to improve with CPAP treatment. Furthermore, if resources for the management of OSA are to be rationed, a higher priority should be given to treatment than to diagnosis. Patients with OSA use health care services at approximately twice the rate of control subjects for up to 10 years before the diagnosis of OSA (7). CPAP treatment has an incremental cost-effectiveness ratio of $2,618 per quality-adjusted life year over no treatment (8). A ratio of less than $10,000 per qualityadjusted life year is generally considered to be extremely cost effective. While CPAP treatment for OSA is funded in many other countries including the United Kingdom (9) and the United States (10), it is not funded in the majority of Canadian provinces. In 2008, The Lung Association and the CTS jointly recommended funding of CPAP treatment under all provincial and federal health insurance plans for adults and children appropriately diagnosed with OSA; however, little progress has been made over the past two years. It is now time to end the postal code differences that currently exist in Canada with regard to access to the diagnosis and treatment of OSA. editorial

Exercise capacity is impaired in obstructive sleep apnea (OSA). There are conflicting reports on the effect of continuous positive airway pressure (CPAP) on maximal exercise capacity. The objective of this review was to determine if there is a change in exercise capacity and anaerobic threshold following CPAP treatment in OSA patients. We conducted a systematic review and meta-analyses to summarize the changes in peak rate of oxygen uptake (V̇O₂ peak) or maximum rate of oxygen uptake (V̇O2 max) and anaerobic threshold (AT) during cardiopulmonary exercise testing following CPAP intervention in patients with OSA. A systematic literature review was conducted to identify published literature on markers of V̇O₂ peak, V̇O₂ max, and AT pre- vs post-CPAP using a web-based literature search of PubMed/MEDLINE, Embase, CINAHL, and Cochrane review (CENTRAL) databases. Two independent reviewers screened the articles for data extraction and analysis. The total search of all the databases returned 470 relevant citations. Following application of eligibility criteria, 6 studies were included in the final meta-analysis for V̇O₂ peak, 2 studies for V̇O₂ max, and five studies for AT. The meta-analysis showed a mean net difference in V̇O₂ peak between pre- and post-CPAP of 2.69 mL·kg-1·min-1, P = .02, favoring treatment with CPAP. There was no difference in V̇O₂ max or AT with CPAP treatment (mean net difference 0.66 mL·kg-1·min-1 [P = .78] and -144.98 mL·min-1 [P = .20] respectively). There is a paucity of high-quality studies investigating the effect of CPAP on exercise capacity. Our meta-analysis shows that V̇O₂ peak increases following CPAP treatment in patients with OSA, but we did not observe any change in V̇O₂ max or AT. Our findings should be considered preliminary and we recommend further randomized controlled trials to confirm our findings and to clarify the peak and maximum rates of oxygen uptake adaptations with CPAP therapy.

Effect of nasal continuous positive airway pressure in uncontrolled nocturnal asthmatic patients with obstructive sleep apnea syndrome

Mild Obstructive Sleep Apnea Syndrome Should Not Be Treated

Chinese guideline for the diagnosis and treatment of childhood obstructive sleep apnea (2020).

Update on Obstructive Sleep Apnea: Implications for Neuropsychiatry.

The Effect of OSA Therapy on Glucose Metabolism: It's All about CPAP Adherence!

Refining the diagnosis of obstructive sleep apnoea

To determine if the type of continuous positive airway pressure (CPAP) mask interface influences CPAP treatment efficacy, adherence, side effects, comfort and sleep quality in patients with moderate-severe obstructive sleep apnea (OSA). This took place in a hospital-based tertiary sleep disorders unit. It is a prospective, randomized, crossover trial comparing three CPAP interfaces: nasal mask (NM), nasal mask plus chinstrap (NM-CS) and oronasal mask (ONM) each tried in random order, for 4 weeks. After each 4-week period, patient outcomes were assessed. Participants had a new diagnosis of obstructive sleep apneas. Forty-eight patients with moderate-severe OSA (32 males, mean ± standard deviation apnea-hypopnea index (AHI) 55.6 ± 21.1 events/h, age 54.9 ± 13.1 years, body mass index 35.8 ± 7.2 kg/m2) were randomized. Thirty-five participants completed the full study, with complete data available for 34 patients. There was no statistically significant difference in CPAP adherence; however, residual AHI was higher with ONM than NM and NM-CS (residual AHI 7.1 ± 7.7, 4.0 ± 3.1, 4.2 ± 3.7 events/h respectively, main effect P = .001). Patient satisfaction and quality of sleep were higher with the NM and NM-CS than the ONM. Fewer leak and mask fit problems were reported with NM (all chi-square P < .05), which patients preferred over the NM-CS and ONM options (n = 22, 9 and 4 respectively, P = .001). The CPAP adherence did not differ between the three different mask interfaces but the residual AHI was lower with NM than ONM and patients reported greater mask comfort, better sleep, and overall preference for a NM. A nasal mask with or without chinstrap should be the first choice for patients with OSA referred for CPAP treatment. Registry: Australian and New Zealand Clinical Trials Registry, URL: https://www.anzctr.org.au, title: A comparison of continuous positive airway pressure (CPAP) interface in the control of leak, patient compliance and patient preference: nasal CPAP mask and chinstrap versus full face mask in patients with obstructive sleep apnoea (OSA), identifier: ACTRN12609000029291.

Central sleep apnea (CSA) may occasionally occur in patients with obstructive sleep apnea during titration with a continuous positive airway pressure (CPAP) device. To determine the prevalence and the natural history of CPAP-emergent CSA. This is a retrospective study of 1286 patients with a diagnosis of OSAwho underwent titration with a positive airway device during a 1-year period. Patients were seen in consultation and underwent full-night attended polysomnography followed by full-night attended CPAP titration. Four weeks after CPAP therapy, patients returned to the clinic for follow-up, and objective adherence to CPAP was recorded. In patients who had CSA on CPAP, a second full-night attended CPAP titration was recommended. Eighty-four of the 1286 patients developed a central apnea index (CAI) of 5 or greater per hour while on CPAP. The incidence of CSA varied from 3% to 10% monthly, with an overall incidence of 6.5%. Forty-two of the 84 patients returned for a second CPAP titration. In 33 patients, CSA was eliminated. In each of the remaining 9 patients, the CAI remained at 5 or greater per hour, with an average of 13 per hour. These patients characteristically had the most severe OSA, and 5 had a CAI of 5 or more per hour at baseline. Two of the 9 patients were on opioids In this large retrospective study of 1286 patients with a diagnosis of OSA, 6.5% had CPAP-emergent or persistent CSA. However, CPAP-emergent CSA was generally transitory and was eliminated within 8 weeks after CPAP therapy. The prevalence of CPAP-persistent CSA was about 1.5%. Severity of OSA, a CAI of 5 or greater per hour, and use of opioids were potential risk factors.

Obstructive sleep apnea is the most common sleep-related breathing disorder worldwide and remains underdiagnosed. Its multiple associated comorbidities contribute to a decreased quality of life and work performance as well as an increased risk of death. Standard treatment seems to have limited effects on cardiovascular and metabolic aspects of the disease, emphasising the need for early diagnosis and additional therapeutic approaches. Recent evidence suggests that the dysregulation of circadian rhythms, processes with endogenous rhythmicity that are adjusted to the environment through various cues, is involved in the pathogenesis of comorbidities. In patients with obstructive sleep apnea, altered circadian gene expression patterns have been demonstrated. Obstructive respiratory events may promote circadian dysregulation through the effects of sleep disturbance and intermittent hypoxia, with subsequent inflammation and disruption of neural and hormonal homeostasis. In this review, current knowledge on obstructive sleep apnea, circadian rhythm regulation, and circadian rhythm sleep disorders is summarised. Studies that connect obstructive sleep apnea to circadian rhythm abnormalities are critically evaluated. Furthermore, pathogenetic mechanisms that may underlie this association, most notably hypoxia signalling, are presented. A bidirectional relationship between obstructive sleep apnea and circadian rhythm dysregulation is proposed. Approaching obstructive sleep apnea as a circadian rhythm disorder may prove beneficial for the development of new, personalised diagnostic, therapeutic and prognostic tools. However, further studies are needed before the clinical approach to obstructive sleep apnea includes targeting the circadian system.

Obstructive sleep apnea (OSA) is a common pediatric condition characterized by recurrent partial or complete cessation of airflow during sleep, typically due to inadequate upper airway patency. Continuous positive airway pressure (CPAP) is a therapeutic option that reduces morbidity. Despite efforts to promote use, CPAP adherence is poor in both pediatric and adult populations. We sought to determine whether demographics, insurance status, OSA severity, therapeutic pressure, or comorbid conditions were associated with pediatric CPAP adherence. A retrospective review of adherence download data was performed on all pediatric patients with initiation or adjustment of CPAP treatment over a one-year period with documented in-laboratory CPAP titration. Patients were grouped as CPAP adherent or non-adherent, where adherence was defined as > 70% nightly use and average usage ≥ 4 hours per night. Differences between the groups were analyzed by χ(2) test. Overall, nearly half of participants were CPAP adherent (49%, 69/140). Of the demographic data collected (age, ethnicity, sex, insurance status), only female sex was associated with better adherence (60.9% vs 39.5% of males adherent; odds ratio [OR] = 2.41, 95%CI = 1.20-4.85; p = 0.01). Severity of OSA (diagnostic apnea-hypopnea index [AHI] and degree of hypoxemia), therapeutic pressure, and residual AHI did not impact CPAP adherence (p > 0.05). Patients with developmental delay (DD) were more likely to be adherent with CPAP than those without a DD diagnosis (OR = 2.55, 95%CI = 1.27-5.13; p = 0.007). Female patients with trisomy 21 tended to be more adherent, but this did not reach significance or account for the overall increased adherence associated with female sex. Our study demonstrates that adherence to CPAP therapy is poor but suggests that female sex and developmental delay are associated with better adherence. These findings support efforts to understand the pathophysiology of and to develop adherence-promoting and alternative interventions for pediatric OSA.

Objective:Obstructive sleep apnea (OSA) may be a modifiable risk factor for late-life cognitive impairment. We previously demonstrated that non-Hispanic Black older adults are less likely to be diagnosed with OSA despite having equal or greater health risk for OSA compared to non-Hispanic White older adults, and this disparity in diagnosis was strongest among individuals with lower education. Here, we aimed to determine 1) whether there are racial differences in continuous positive airway pressure (CPAP) treatment, 2) how CPAP treatment may influence OSA-cognition associations, and 3) whether CPAP differentially influences OSA-cognition associations across racial groups.Participants and Methods:Cross-sectional data were obtained from 424 socioeconomically diverse community-dwelling adults ages 55-83 (63.4±3.2 years, 41.7% male, 53.5% Black) from the Michigan Cognitive Aging Project. Physician-diagnosed OSA and current CPAP use were self-reported. Global cognition was operationalized as a composite of five factor scores derived from a comprehensive neuropsychological battery. Racial group differences were investigated with chi-square and Fisher’s exact tests with statistical significance set at the .05 level. Associations between OSA and cognition (adjusted for age, gender, race, and years of education) were investigated with linear regressions. Subsequent models isolated effects of uncontrolled OSA by excluding individuals using CPAP. Racial differences in OSA-cognition associations were investigated with race-stratified models.Results:Fewer Black participants (9.2%) reported diagnosed OSA compared to White participants (12.3%; x2 (1, N=424) =5.314, p=.021, cp=.112). In the whole sample, 47.3% of participants with diagnosed OSA reported CPAP use, and this proportion did not differ across race (x2 [1, N=86] =.048, p=.826). In the whole sample, OSA diagnosis was only associated with cognition when CPAP users were excluded (excluding CPAP users: ß=-.085, SE=.037, p=.024; including CPAP users: ß=-.067, SE=.036, p=.062). In race-stratified models, diagnosed OSA was only associated with cognition among Black participants, and this association was stronger when CPAP users were excluded (excluding CPAP users: ß=-.142, SE=.060, p=.018; including CPAP users: ß=-.126, SE=.058, p=.030). Diagnosed OSA was not associated with cognition among White participants, irrespective of whether CPAP users were included (excluding CPAP users: ß=-.084,SE=.068, p=.215; including CPAP users: ß=-.056, SE=.064, p=.378).Conclusions:Our findings support CPAP treatment as a potential intervention to mitigate late-life cognitive impairment among those with OSA. Despite being less likely to receive a diagnosis of OSA, Black older adults were equally likely to engage in CPAP treatment as White older adults when diagnosed. The detrimental impact of OSA on cognition may be more salient among Black older adults, which may reflect racial disparities in cardiovascular risk and/or resources that promote cognitive reserve. However, CPAP appears to be an effective treatment to reduce OSA-related cognitive impairment for Black older adults, highlighting the critical importance of diagnosis and treatment in this group. Intervention efforts that abate racial inequalities in access to quality healthcare in order to facilitate acquisition of a formal OSA diagnosis and CPAP treatment may help to reduce preventable cognitive health disparities among older adults.

Resistant Hypertension in Obstructive Sleep Apnea: Is Continuous Positive Airway Pressure the Next Step?

Patients with severe OSA consume greater amounts of cholesterol, protein, and fat as well as have greater caloric expenditure. However, it is not known whether their activity levels or diet change after treatment with CPAP. To investigate this issue, serial assessments of activity and dietary intake were performed in the Apnea Positive Pressure Long-term Efficacy Study (APPLES); a 6-month randomized controlled study of CPAP vs. sham CPAP on neurocognitive outcomes. Subjects were recruited into APPLES at 5 sites through clinic encounters or public advertisement. After undergoing a diagnostic polysomnogram, subjects were randomized to CPAP or sham if their AHI was ≥ 10. Adherence was assessed using data cards from the devices. At the Tucson and Walla Walla sites, subjects were asked to complete validated activity and food frequency questionnaires at baseline and their 4-month visit. Activity and diet data were available at baseline and after 4 months treatment with CPAP or sham in up to 231 subjects (117 CPAP, 114 Sham). Mean age, AHI, BMI, and Epworth Sleepiness Score (ESS) for this cohort were 55 ± 13 [SD] years, 44 ± 27 /h, 33 ± 7.8 kg/m(2), and 10 ± 4, respectively. The participants lacking activity and diet data were younger, had lower AHI and arousal index, and had better sleep efficiency (p < 0.05). The BMI was higher among women in both CPAP and Sham groups. However, compared to women, men had higher AHI only in the CPAP group (50 vs. 34). Similarly, the arousal index was higher among men in CPAP group. Level of adherence defined as hours of device usage per night at 4 months was significantly higher among men in CPAP group (4.0 ± 2.9 vs. 2.6 ± 2.6). No changes in consumption of total calories, protein, carbohydrate or fat were noted after 4 months. Except for a modest increase in recreational activity in women (268 ± 85 vs. 170 ± 47 calories, p < 0.05), there also were no changes in activity patterns. Except for a modest increase in recreational activity in women, OSA patients treated with CPAP do not substantially change their diet or physical activity habits after treatment. .