Adequate Continuous Positive Airway Pressure Research Articles

Predictors of Initial CPAP Prescription and Subsequent Course with CPAP in Patients with Central Sleep Apneas at a Single Center.

Guidelines recommend considering an initial trial of continuous positive airway pressure (CPAP) to treat central sleep apnea (CSA). However, practice patterns vary widely. This study investigated predictors for an initial trial of CPAP in patients with central apneas and whether those factors predict adequate treatment response in patients receiving an initial CPAP trial. Charts of patients receiving a diagnostic code for CSA following a sleep study during 2016-2018 at a single center were reviewed. Patient factors, initial treatment prescriptions, and subsequent changes to therapy were extracted from electronic health records. Regression models were used to estimate factors associated with an initial CPAP prescription and the likelihood of an adequate CPAP response (no subsequent therapy change and no discontinuation of therapy) among patients prescribed CPAP. 429/588 (73%) patients with central apneas received an initial trial of CPAP. Younger age, diagnosis by home sleep testing, non-opiate etiology of central apneas, and a lower proportion of central apneas at diagnosis were independently associated with a higher likelihood of an initial CPAP trial. A lower proportion of central apneas was associated with a higher probability of adequate response, while current smoking and opiate-related central apneas predicted an unsuccessful CPAP trial. A new finding was that older age predicted a lower likelihood of an initial CPAP prescription but did not predict an unsatisfactory response to CPAP. Clinicians may incorrectly weigh certain clinical and sleep study characteristics when deciding whether to trial CPAP for patients with central apneas.

From Snoring to Soaring: Unveiling the Positive Effects of Continuous Positive Airway Pressure Ventilation on Cardiovascular Health in Patients With Obstructive Sleep Apnoea Through a Systematic Review.

Increased cardiovascular (CV) morbidity and death are linked to obstructive sleep apnoea (OSA). The primary method of treating OSA is continuous positive airway pressure (CPAP). CPAP has some debatable outcomes on CV events in people suffering from OSA. The current study investigates how CPAP affects CV outcomes. The goalis to evaluate CPAP's effectiveness in lowering CV outcomes in OSA patients.We used a computer to search the PubMed, PubMed Central Library, Science Direct, and Google Scholar databases for studies comparing the effects of CPAP and a control group on CV outcomes in OSA patients. These included randomised control trials (RCT), narrative reviews, systematic reviews, case-control studies, observational studies and meta-analyses. A total of 52,937 patients were included in the final analysis of six RCTs, four observational studies, 10 meta-analyses, one case-control study, two systematic reviews and one narrative review. The weighted mean follow-up lasted for a period of between three months and nine years. The risk of major cardiovascular adverse events (MACE) was the same for both the CPAP and control groups.According to subgroup analysis, patients with lower MACE adherence rates (four hours per night) were more likely to use CPAP. The risk of all-cause mortality, CV-related complications causing mortality, acute myocardial infarction acute stroke, or hospitalisations for angina was the same in the CPAP and control groups.The primary outcome was that in patients with therapy with CPAP in addition to usual care and usual care alone did not prevent CV events in patients with moderate-to-severe OSA and existing CV illness. Patients with OSA who utilise CPAP may not experience fewer CV events. Patients who use CPAP consistently (four hours per night) could benefit from improved CV results. Future research must assess how well-adherent patients with severe OSA and low CV event rates respond to CPAP therapy. In patients who use CPAP for more than four hours each night, CPAP therapy may minimise the risk of MACE and stroke. Additional randomised trials requiring adequate CPAP time adherence are needed to support this perception. Despite the fact that there is no evidence to support the claim that CPAP therapy improves CVoutcomes, bias difficulties, CPAP adherence problems, and the patient groups included in each RCT may have made it more difficult to generalise the findings to all patients. Future research is therefore needed to look at these relevant results.

Safety and pharmacodynamics of a single infusion of danavorexton in adults with obstructive sleep apnea experiencing excessive daytime sleepiness despite adequate use of CPAP

BackgroundSleep disruptions experienced by patients with obstructive sleep apnea (OSA) can lead to excessive daytime sleepiness (EDS) and significantly impact patients’ quality of life. EDS may persist despite use of continuous positive airway pressure (CPAP) therapy. Small molecules that target the orexin system, which has a known role in sleep-wake regulation, show therapeutic potential for the treatment of EDS in patients with hypersomnia. This randomized, placebo-controlled, phase 1b study aimed to investigate the safety of danavorexton, a small-molecule orexin-2 receptor agonist, and its effects on residual EDS in patients with OSA. MethodsAdults with OSA aged 18–67 years with adequate CPAP use were randomized to one of six treatment sequences of single IV infusions of danavorexton 44 mg, danavorexton 112 mg, and placebo. Adverse events were monitored throughout the study. Pharmacodynamic assessments included maintenance of wakefulness test (MWT), Karolinska Sleepiness Scale (KSS), and the psychomotor vigilance test (PVT). Results and conclusionAmong 25 randomized patients, 16 (64.0%) had treatment-emergent adverse events (TEAEs) and 12 (48.0%) had TEAEs considered related to treatment, all mild or moderate. Seven patients (28.0%) had urinary TEAEs: three, seven, and none while taking danavorexton 44 mg, danavorexton 112 mg, and placebo, respectively. There were no deaths or TEAEs leading to discontinuation. Improvements in mean MWT, KSS, and PVT scores were observed with danavorexton 44 mg and 112 mg vs placebo. These findings show that danavorexton can improve subjective and objective measures of EDS in patients with OSA and residual EDS despite adequate CPAP use.

EFFICACY OF ARMODAFINIL IN PATIENTS WITH MODERATE TO SEVERE OSA AND RESIDUAL EXCESSIVE DAYTIME SLEEPINESS AFTER SUBOPTIMAL USAGE OF CPAP TREATMENT

TYPE: Late Breaking Abstract TOPIC: Sleep Disorders PURPOSE: Large number of obstructive sleep apnea (OSA) patients treated with continuous positive airway pressure (CPAP) still experienced excessive daytime sleepiness (EDS), which affects quality of life and may discourage CPAP treatment. Armodafinil, wakefulness promoting agent, is approved for treating EDS in OSA patients who still experience EDS despite adequate CPAP usage. To date, there are no studies investigating effectiveness of early administration of Armodafinil with suboptimal CPAP usage. METHODS: A 12-week prospective cohort study was conducted on 30 OSA patients with suboptimal CPAP usage (2-<4 hours/night) who still experienced EDS. All patients received 150-mg Armodafinil daily and continued using CPAP. Efficacy and side effects were evaluated. RESULTS: 17/30 patients were analyzed for preliminary results after 4 weeks of Armodafinil therapy. Epworth Sleepiness Scale (ESS) was significantly decreased from 13±2.72points at baseline therapy to 6.40±3.50 points (p<0.001). Clinical Global Impression (CGI) rated by investigator and by patients were significantly decreased from 3.73±0.70 to 1.73±0.45 (p<0.001) and decreased from 3.35±0.63 to 1.78±0.57 (p<0.001); respectively. Pittsburg Sleep Quality Index (PSQI) was also significantly decreased from 9.67±3.99 to 6.13±3.06 (p<0.001). No serious side effects were observed. CONCLUSIONS: This is the first study conducted in moderate to severe OSA patients with residual EDS after suboptimal usage of CPAP treatment, in which administration of Armodafinil for 4-week- period was generally well tolerated with mild and self-limiting side effects. Armodafinil significantly reduced daytime sleepiness and improved sleep quality. Efficacy of Armodafinil at 12- week-period will be further analyzed. CLINICAL IMPLICATIONS: Early administration of Armodafinil can decrease EDS in subopimal CPAP usage patients. DISCLOSURE: No significant relationships. KEYWORD: Excessive daytime sleepiness

P139 Co-morbid insomnia and sleep apnoea (COMISA): Identifying patients that are responsive to continuous positive airway pressure therapy

Abstract Introduction Co-morbid insomnia and sleep apnoea (COMISA) is a prevalent and debilitating condition that is difficult to treat. COMISA patients have lower average adherence to continuous positive airway pressure (CPAP) therapy compared to patients with sleep apnoea alone. However, a sub-sample of COMISA patients may show adequate CPAP use that improves both the insomnia and sleep apnoea. It is important to identify this group of CPAP-responsive COMISA patients to guide personalised-medicine approaches. Methods Seventy-three COMISA patients (AHI≥15; ICSD-3 insomnia; 55% male, Age M=57y) completed questionnaires, home-based polysomnography, and one-week sleep diaries before and 6-months after commencing CPAP therapy. No patients accessed CBTi. We investigated baseline predictors of CPAP adherence (min/night) and overall change in Insomnia Severity Index (ISI) scores during treatment. Results Average CPAP adherence was 205 minutes/night (SD=153). 56% of patients used CPAP at least 4h/night. Average CPAP adherence was predicted by higher baseline AHI (r=0.39), arousal index (r=0.28), N1 sleep (r=0.32) and age (r=0.26), and lower N3 sleep (r=-0.28). The ISI decreased from baseline (17.9, CI=1.2) to 6-month follow-up (11.6, CI=1.3; p&amp;lt;0.001). There was a significant positive association between ISI reduction and CPAP use (r=0.31). 26% of patients reported an ISI&amp;lt;8 at 6-month follow-up. Conclusion Approximately half of COMISA patients show CPAP adherence of ≥4h/night and one quarter experience insomnia remission with CPAP. CPAP use is positively associated with AHI, light sleep, and age at baseline, and reduction of insomnia severity during treatment. Future randomized controlled trials are required to confirm the results of this small un-controlled study.

P033 Randomised controlled trial on the efficacy of Audio-visual Health Educational materials on CPAP ADherence: The AHEAD trial

Abstract OSA is a prevalent chronic disease with significant health implications, for which achieving &amp;gt;4 hours/night on continuous positive airway pressure (CPAP) is essential for effective treatment. Educational videos to improve CPAP adherence are of interest as a low-cost intervention, however trials have shown mixed results. This study aimed to compare CPAP usage following standard of care education (SOCE), with the usage following the addition of educational videos, customised to incorporate low health literacy communication, motivational and self-efficacy techniques. Methods Adults with OSA recommended treatment with CPAP, were recruited and randomised in a single blinded method, to watch short educational videos following their in laboratory CPAP study or SOCE. The primary outcome was CPAP usage at 2mths and secondary outcomes were usage at 12mth and proportion of patients with adequate usage &amp;gt;4hrs/night. Results 195 patients met the eligibility criteria and were randomised to video education (n = 96) or to SOCE (n = 99). There was no significant difference in compliance at 2mths (median usage 1.7hrs IQR 0–6.2 SOCE, 4.4hrs IQR 0–6.7 video education p = 0.1), however at 12mths there was increased usage in the video education arm (median 0hrs IQR 0–5.4 standard of care, 3.8hrs IQR 0–6.87 p = 0.05). The proportion with adequate CPAP usage &amp;gt;4hrs/night at 12mths was higher in the video education group (33, 33% versus 48, 50% p = 0.01). Conclusions Long-term adherence to CPAP is enhanced by the addition of educational videos that incorporate low health literacy communication and motivational techniques, compared to SOCE.

The impact of sleep disorders on microvascular complications in patients with type 2 diabetes (SLEEP T2D): the protocol of a cohort study and feasibility randomised control trial

BackgroundObstructive sleep apnoea (OSA) is very common in patients with type 2 diabetes (T2D). We and others have shown that OSA was associated with diabetes-related microvascular complications in patients with T2D in cross-sectional and longitudinal studies and that compliance with continuous positive airway pressure (CPAP) reduced the progression of microvascular complications. Hence, we hypothesised that adequate CPAP reduces the development of microvascular complication in patients with T2D.MethodsSLEEP T2D is a cohort study with embedded feasibility, open-label, parallel-arm, randomised control trial (RCT) over 2 years. The primary aim is the feasibility of conducting a definitive RCT assessing the impact of CPAP on chronic kidney disease and other microvascular complications in patients with T2D. The main parameters are to assess willingness of participants to be randomised, follow-up rates, CPAP adherence/compliance, to optimise the choice of outcome measures for a substantive trial, and to identify the parameters for sample size calculations. The secondary aims of the study are related to the impact of CPAP, sleep-related disorders, and sleep chronotype on a variety of diabetes-related end points. The study participants were recruited from the T2D services in multiple NHS trusts across England. The main exclusion criteria for the cohort study are as follows: T1D, eGFR < 15 mL/min/1.73 m2, known OSA, active malignancy or chronic kidney disease from reasons other than diabetes, pregnancy, professional drivers, and a history of falling asleep whilst driving within last 2 years. The main exclusion criteria from the RCT were as follows: Apnoea-Hypopnoea Index < 10 and Epworth Sleepiness Score ≥ 11. Study participants were extensively phenotyped clinically and biochemically. The OSA diagnosis was based on multichannel portable device (ApneaLink AirTM, Resmed).DiscussionThe feasibility RCT will help us design the future RCT to assess the impact of CPAP on diabetes-related microvascular complications. The cohort study will generate preliminary data regarding the impact of sleep quality, duration, and chronotype on diabetes-related outcomes which could lead to further mechanistic and interventional studies.Trial registrationISRCTN, ISRCTN12361838. Registered 04 April 2018, Protocol version: v5.0 02.12.19.

Changes in sleepiness and 24-h blood pressure following 4 months of CPAP treatment are not mediated by ICAM-1.

Continuous positive airway pressure (CPAP) therapy reduces circulating intercellular adhesion molecule 1 (ICAM-1) in adults with obstructive sleep apnea (OSA). ICAM-1 levels may affect the daytime sleepiness and elevated blood pressure associated with OSA. We evaluated the association of changes from baseline in ICAM-1 with changes of objective and subjective measures of sleepiness, as well as 24-h ambulatory blood pressure monitoring (ABPM) measures, following 4 months of CPAP treatment. The study sample included adults with newly diagnosed OSA. Plasma ICAM-1, 24-h ABPM, Epworth Sleepiness Scale (ESS), and psychomotor vigilance task (PVT) were obtained at baseline and following adequate CPAP treatment. The associations between changes in natural log ICAM-1 and changes in the number of lapses on PVT, ESS score, and 24-h mean arterial blood pressure (MAP) were assessed using multivariate regression models, controlling for a priori baseline covariates of age, sex, BMI, race, site, smoking status, physical activity, anti-hypertensive medications, AHI, and daily hours of CPAP use. Among 140 adults (83% men),mean (± SD) body mass index (BMI) was 31.5± 4.2 kg/m2, and apnea-hyopnea index (AHI) was 36.8± 15.3 events/h.Sleepiness measures, although not ICAM-1 or ABPM measures, improved significantly following CPAP treatment. We observed no statistically significant associations between the change in ICAM-1 and changes in sleepiness, MAP, or other ABPM measures. Changes in ICAM-1 levels were not related to changes in sleepiness or ABPM following CPAP treatment of adults with OSA. Future work should explore whether or notother biomarkers may have a role in mediating these treatment outcomes in adults with OSA.

Effect of continuous positive airway pressure on maximal exercise capacity in patients with obstructive sleep apnea: a systematic review and meta-analysis.

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.

Sa1944 – Differences of Gastrointestinal (GI) Symptoms Between Obstructive Sleep Apnea (OSA) Patients with Adequate Continuous Positive Airway Pressure (CPAP) Treatment and Patients with No Prior Cpap Treatment

Sa1944 – Differences of Gastrointestinal (GI) Symptoms Between Obstructive Sleep Apnea (OSA) Patients with Adequate Continuous Positive Airway Pressure (CPAP) Treatment and Patients with No Prior Cpap Treatment

Split-night polysomnography at Fundación Santa Fe de Bogotá

Introduction: The obstructive sleep apnea-hypopnea syndrome (OSAHS) is usually established using polysomnography (PSG). Most patients diagnosed with this condition receive treatment with continuous positive airway pressure (CPAP). The conventional approach requires performing a full-night PSG and CPAP titration over a two-night stay in a sleep laboratory, which is costly and may present scheduling difficulties. However, the combined use of polysomnography and CPAP titration in a single night, procedure known as split-night polysomnography (SNPSG), is less-expensive and is a time saving strategy for diagnosis and treatment.Objectives: To characterize the SNPSG studies conducted in the sleep laboratory of the Hospital Universitario Santa Fe de Bogotá (HUFSFB) and assess their performance in the diagnosis and treatment of OSAHS.Materials and methods: Retrospective, observational and longitudinal study performed on a sample of 221 patients.Results: 208 (94.1%) SNPSG studies were compatible with OSAHS. Most cases (54.7%) had a hypopnea apnea index (AHI) ≥30. Adequate CPAP titration was achieved in 78% of patients who had severe AHI (p=0.00).Conclusions: OSAHS was diagnosed and an adequate CPAP titration was achieved in most of the SNPSG studies of the analyzed sample.

Comparison of three continuous positive airway pressure (CPAP) interfaces in healthy Beagle dogs during medetomidine–propofol constant rate infusions

ObjectiveTo compare the efficacy of three continuous positive airway pressure (CPAP) interfaces in dogs on gas exchange, lung volumes, amount of leak during CPAP and rebreathing in case of equipment failure or disconnection. Study designRandomized, prospective, crossover, experimental trial. AnimalsTen purpose-bred Beagle dogs. MethodsDogs were in dorsal recumbency during medetomidine–propofol constant rate infusions, breathing room air. Three interfaces were tested in each dog in a consecutive random order: custom-made mask (M), conical face mask (FM) and helmet (H). End-expiratory lung impedance (EELI) measured by electrical impedance tomography was assessed with no interface (baseline), with the interface only (No-CPAP for 3 minutes) and at 15 minutes of 7 cmH2O CPAP (CPAP-delivery). PaO2 was assessed at No-CPAP and CPAP-delivery, partial pressure of inspired carbon dioxide (PICO2; rebreathing assessment) at No-CPAP and the interface leak (ΔPleak) at CPAP-delivery. Mixed-effects linear regression models were used for statistical analysis (p<0.05). ResultsDuring CPAP-delivery, all interfaces increased EELI by 7% (p<0.001). Higher ΔPleak was observed with M and H (9 cmH2O) in comparison with FM (1 cmH2O) (p<0.001). At No-CPAP, less rebreathing occurred with M (0.5 kPa, 4 mmHg) than with FM (1.8 kPa, 14 mmHg) and with H (1.4 kPa, 11 mmHg), but also lower PaO2 was measured with M (9.3 kPa, 70 mmHg) than with H (11.9 kPa, 90 mmHg) and FM (10.8 kPa, 81 mmHg). Conclusions and clinical relevanceAll three interfaces can be used to provide adequate CPAP in dogs. The leak during CPAP-delivery and the risk of rebreathing and hypoxaemia, when CPAP is not maintained, can be significant. Therefore, animals should always be supervised during administration of CPAP with any of the three interfaces. The performance of the custom-made M was not superior to the other interfaces.

A meta-analysis of continuous positive airway pressure therapy in prevention of cardiovascular events in patients with obstructive sleep apnoea.

To assess whether continuous positive airway pressure (CPAP) therapy reduces major adverse cardiovascular events (MACE) in patients with moderate-to-severe obstructive sleep apnoea (OSA). A total of 235 articles were recovered using MEDLINE, EMBASE and Cochrane library (inception-December 2016) and references contained in the identified articles. Seven randomized controlled trials (RCTs) were selected for final analysis. Analysis of 4268 patients demonstrated non-significant 26% relative risk reduction in MACE with CPAP [risk ratio (RR) 0.74; 95% confidence interval (CI) 0.47-1.17; P = 0.19, I2 = 48%]. A series of sensitivity analyses suggested that increased CPAP usage time yielded significant risk reduction in MACE. and stroke. Subgroup analysis revealed that CPAP adherence time ≥4 hours (h)/night reduced the risk of MACE by 57% (RR 0.43; 95% CI 0.23-0.80; P = 0.01, I2 = 0%). CPAP therapy showed no beneficial effect on myocardial infarction (MI), all-cause mortality, atrial fibrillation/flutter (AF), or heart failure (HF) (P > 0.05). CPAP had positive effect on mood and reduced the daytime sleepiness [Epworth Sleepiness Scale (ESS): mean difference (MD) -2.50, 95% CI - 3.62, -1.39; P < 0.001, I2 = 81%]. CPAP therapy might reduce MACE and stroke among subjects with CPAP time exceeding 4 h/night. Additional randomized trials mandating adequate CPAP time adherence are required to confirm this impression.

Obstructive Sleep Apnea-Hypopnea and Cardiovascular Diseases in Adults

Cardiovascular diseases (CVD) are the main cause of death worldwide representing 30% of all global deaths. Obstructive sleep apnea hypopnea (OSAH) has been associated with several serious cardiovascular comorbidities. OSAH occurs in 17% to 24% of North American American adults that increase the risk of sudden cardiac deaths between 12 midnight and 6 a.m. OSAH is considered as an independent risk factor for CVD such as systemic hypertension, pulmonary arterial hypertension, coronary artery disease, stroke, cardiac arrhythmias, heart failure, which raise both cardiovascular morbidity and mortality and the increase demand for healthcare resources. Several mechanisms have been suggested to link OSAH and vascular diseases including increases in sympathetic activation, oxidative stress, inflammation, endothelial dysfunction, coagulation, and metabolic dysregulation. This review will provide insights on mechanisms by which OSAH might contribute to pathogenesis of cardiovascular disease. Continuous positive airway pressure (CPAP) is considered the gold standard in the treatment of OSAH with improved metabolic and CV endpoints. To a lesser extent oral appliance therapy and upper airway or mandibular advancement surgery are palliative measures that leave the patient with significant residual apnea hypopnea. There is increasing evidence that adequate CPAP therapy leads to a significant reduction in cardiovascular morbidity. Moderate to severe OSAH not treated with CPAP was an independent risk factor for relapse of a CVD event, and adequate CPAP treatment improved cardiovascular outcomes in elderly patients.

Sleep apnea in Chiari I malformation

A 36-year-old non-obese woman consulted her physician for recent excessive daytime sleepiness (EDS) with Epworth sleepiness scale (ESS) at 13/24, morning headache and heavy snoring. Polysomnography revealed moderate mixed sleep apnea syndrome with an Apnoea–Hypopnoea Index (AHI) of 23/h (Figure 1). Despite adequate continuous positive airway pressure (CPAP) therapy, the patient reported an aggravation of EDS and headache. A second polysomnography with CPAP, conclude to moderate complex sleep apnea syndrome by revealing the persistence of numerous central sleep apnea (AHI of 21/h) but no evidence of obstructive events. The patient reported a sensation of unrefreshing sleep and EDS (ESS at 17/24) with no symptoms suggesting cardiac failure, periodic limb movement disorder or narcolepsy. Physical examination, including neurologic and cardiac examinations, was normal. Routine blood tests, arterial blood gas analysis and echocardiography were performed and showed no significant abnormalities.

Effect of Wakefulness-Promoting Agents on Sleepiness in Patients with Sleep Apnea Treated with CPAP: A Meta-Analysis.

To perform a meta-analysis of the effect of wakefulness-promoting agents (modafinil and armodafinil) in patients with residual sleepiness after CPAP therapy for obstructive sleep apnea. We conducted a systematic search of MEDLINE (1966 to September 2014), EMBASE (1980 to September 2014) and Cochrane Database for randomized placebo controlled trials on modafinil or armodafinil in patients who met established criteria for diagnosis of obstructive sleep apnea, adequate continuous positive airway pressure use, and who complained of residual sleepiness. Risk of bias was assessed. Primary outcomes were the Epworth Sleepiness Scale and mean sleep latencies on the maintenance of wakefulness test. Secondary outcomes were the Clinical Global Impression of Change, change in daily continuous positive airway pressure use, and the frequency of headaches. Out of 118 abstracts screened and 12 full text articles reviewed, we included 6 studies (total of 1,479 participants) in our final meta-analysis: Three evaluated modafinil, and three armodafinil. Risk of bias was unclear in one or more key domains for four studies. When compared with placebo, wakefulness promoting agents decreased Epworth Sleepiness Scale by 2.51 points (95% CI, 2.00-3.02), increased sleep latency in maintenance of wakefulness test by 2.73 minutes (95% CI, 2.12-3.34), increased the reporting of minimal improvement on the Clinical Global Impression of Change by 26% (RR 1.59; 95% CI, 1.36-1.86), and increased the risk of headaches by 8% (RR 1.98; 95% CI, 1.48-2.63). Also, there was a trend for decreased continuous positive airway pressure after treatment with these agents. Wakefulness promoting agents improve objective and subjective measures of sleepiness, wakefulness, perception of disease severity in patients with residual sleepiness after CPAP therapy for OSA, and are generally well tolerated.

Routine Postoperative Monitoring after Bariatric Surgery in Morbidly Obese Patients with Severe Obstructive Sleep Apnea: ICU Admission is not Necessary.

Obstructive sleep apnea (OSA) occurs in 70-80% of bariatric surgery patients. Patients with severe OSA (apnea/hypopnea index (AHI) >30/h) are postoperatively admitted to an intensive care unit (ICU) for continuous monitoring, to prevent complications. The aim of this study was to assess the necessity of routine postoperative monitoring at an ICU of severe OSA patients after bariatric surgery, attempting to prevent and detect cardiorespiratory complications. Patients undergoing bariatric surgery from November 2010 to July 2013 were entered into a database. Minimal follow-up was 1 month. Poly(somno)graphy (P(S)G) was routinely performed. Patients with severe OSA were admitted to the ICU for the first postoperative night. Oxygen saturation was continuously measured. The database was reviewed regarding patient characteristics, CPAP use, re-intubations, desaturations (saturation <90% and severe <85%), and complications. Severe OSA was present in 151 of the 794 patients, and all 151 were admitted to the ICU. Thirty who underwent revisional surgery were excluded. Forty-seven percent was male, median age was 51 years (27.0-68.0), and median body mass index (BMI) was 46.6 (kg/m(2)) (34.0-77.6). No deaths, re-intubations, or cardiopulmonary complications occurred. Eighty-two (67.8%) patients used continuous positive airway pressure (CPAP). Twenty-one (17.4%) patients experienced desaturations with a median of 2.0 (1-8). Six patients (5.0%) had one episode of severe desaturation. Patients with severe OSA and adequate CPAP use are at low risk of cardiopulmonary complications after (laparoscopic) bariatric surgery. Routine admission to an ICU might be superfluous. However, continuous digital oximetry remains essential.

Adequate continuous positive airway pressure therapy reduces mortality in Chinese patients with obstructive sleep apnea.

Severe obstructive sleep apnea (OSA) is a risk factor for mortality. The ability of continuous positive airway pressure (CPAP) therapy to mitigate this increased risk of death has not been studied in Chinese adults. The objective of our study was to compare mortality in Chinese patients with simple snoring, untreated OSA, and OSA treated with CPAP. We recruited adults with OSA or simple snoring from our sleep medicine clinic. OSA was diagnosed using standard polysomnography. Subjects were followed at least annually for a mean of 8.9 years (SD 1.9). CPAP compliance was checked with the built-in meter. We then assessed all-cause mortality. Five hundred fifty simple snorers, 257 with untreated mild OSA, 316 with untreated moderate OSA, 457 with untreated severe OSA, and 235 with mild to severe OSA treated with CPAP were included. Simple snorers had a much lower mortality rate (2.98 per 1000 person-years [95% CI, 2.93 to 3.02]) than the untreated severe OSA group (11.07 per 1000 person-years [95%CI, 10.86 to 11.29]; P < 0.0001). Compared with simple snorers, fully adjusted mortality was highest in the untreated, severe OSA group (hazard ratio [HR], 3.51 [95%CI, 1.93 to 6.39]). Treatment of severe OSA patients with CPAP eliminated this increase in mortality (HR, 0.81[95%CI, 0.36-1.86]). Severe OSA significantly markedly increases the risk of death in Chinese patients and CPAP treatment with adequate compliance reduces this risk.

High prevalence of obstructive sleep apnea in Marfan's syndrome

Objective To review the current evidence about the prevalence of obstructive sleep apnea in patients with Marfan's syndrome, and discuss some proposed potential mechanisms for this relationship. Data sources The data in this review were mainly from Medline and PubMed articles published in English from 1990 to 2013. The search term was “Marfan's syndrome and sleep apnea”. Study selection Clinical evidence about the epidemiology of obstructive sleep apnea in patients with Marfan's syndrome; the mechanism that causes obstructive sleep apnea; interventional therapy for patients with Marfan's syndrome, and coexisting obstructive sleep apnea. Results A high prevalence of obstructive sleep apnea exists in patients with Marfan's syndrome. The potential reasons are craniofacial abnormalities and lax upper airway muscles, which lead to high nasal airway resistance and upper airway collapse. Obstructive sleep apnea mechanically deteriorates aortic dilatation and accelerates progression of aortic aneurysms. The condition is reversible and rapid maxillary expansion and adequate continuous positive airway pressure therapy are possible effective therapies to delay the expansion of aortic diameter in patients with Marfan's syndrome. Conclusions Obstructive sleep apnea is strongly associated with Marfan's syndrome. Craniofacial abnormalities and lax upper airway are the main mechanisms. Untreated obstructive sleep apnea accelerates progression of aortic dissection and rupture. Effective therapies for obstructive sleep apnea could postpone the aortic dilatation in patients with Marfan's syndrome.

Role of Sleep Apnea and Continuous Positive Airway Pressure Therapy in the Incidence of Stroke or Coronary Heart Disease in Women

It is unknown whether obstructive sleep apnea (OSA) may be a risk factor for incident cardiovascular events in women. We sought to investigate whether OSA increases the incidence of a composite of stroke or coronary heart disease (CHD) in women, and the role of continuous positive airway pressure (CPAP) treatment on this association. This was a prospective, observational study conducted in two Spanish teaching hospitals between 1998 and 2007. Consecutive women referred for suspected OSA and free of previous stroke and CHD were analyzed. Women with an apnea-hypopnea index (AHI) less than 10 comprised the control group, and those with an AHI greater than or equal to 10 were diagnosed with OSA and classified as CPAP-treated (adherence ≥ 4 h/d) or untreated (adherence < 4 h/d or not prescribed). The follow-up ended in December 2010. A total of 967 women were studied (median follow-up, 6.8 yr; interquartile range, 5.2-8.2). The untreated OSA group showed a greater incidence rate of the composite outcome than the control group (2.19 vs. 0.54 per 100 person-years; P < 0.0005). Compared with the control group, the fully adjusted hazard ratios for the composite outcome incidence were 2.76 (95% confidence interval [CI], 1.35-5.62) for the untreated OSA group, and 0.91 (95% CI, 0.43-1.95) for the CPAP-treated group. When the type of cardiovascular event was separately assessed, untreated OSA showed a stronger association with incident stroke (adjusted hazard ratio, 6.44; 95% CI, 1.46-28.3) than with CHD (adjusted hazard ratio, 1.77; 95% CI, 0.76-4.09). In women, untreated OSA is associated with increased incidence of serious cardiovascular outcomes, particularly incident stroke. Adequate CPAP treatment seems to reduce this risk.