Complex Sleep Apnea Research Articles

1208 A Case of Complex Sleep Apnea Improved with Cardiac Resynchronization Therapy

1208 A Case of Complex Sleep Apnea Improved with Cardiac Resynchronization Therapy

Enhanced expiratory rebreathing space for high loop gain sleep apnea treatment

The pathophysiology of sleep apnea goes beyond anatomic predisposition to airway collapse and includes additional factors such as arousal threshold and loop gain. High loop gain is a prominent feature in central and complex sleep apnea (with a mixture of obstructive and central features) where relative hypocapnia can lead to respiratory instability and periodic breathing. Existing therapies, including continuous positive airway pressure (CPAP) and adaptive servo-ventilators, often inadequately treat sleep apnea with high loop gain features. Enhanced expiratory rebreathing space (EERS) targets prevention of the hypocapnia that triggers central events in sleep by increasing dead space in amounts less than typical tidal volumes. This is accomplished by covering traditional exhalation ports on positive airway pressure masks and adding small additional tubing with distal exhalation and safety valves. This technique reduces carbon dioxide (CO2) blow-off during arousals and the associated large recovery breaths, typically producing a maximal increase in resting CO2 by 1–2 mmHg, thus increasing the CO2 reserve and making it less likely to encounter the hypocapnic apneic threshold. Typically, the amount of EERS is titrated in response to central events and periodic breathing rather than aiming for a goal CO2 level. Ideally CO2 monitoring is used during titration of EERS and the technique is avoided in the setting of baseline hypercapnia. This method has been used in clinical practice at our sleep center for over 15 years, and retrospective data suggests an excellent safety profile and high rates of successful therapy including in patients who have previously failed CPAP therapy. Limitations include decreased effectiveness in the setting of leak and decreased tolerance of the bulkier circuit. EERS represents a simple, affordable modification of existing positive airway pressure modalities for treatment of central and complex sleep apnea. Areas of future study include randomized controlled trials of the technique and study of use of EERS in combination with adaptive ventilation, and pharmacologic adjuncts targeting high loop gain physiology.

A Case of De Novo Positional Complex Sleep Apnea Syndrome (CompSAS)

Obstructive sleep apnea (OSA) is well known to often improve with non-supine positioning as opposed to supine positioning. Emerging research supports a role for sleep position management in patients with central sleep apnea (CSA) as well. We report a case of de novo complex sleep apnea syndrome (CompSAS) in a 78-year-old female, who presented after a car accident due to unclear syncope. Diagnostic polysomnography (PSG) showed moderate OSA. A CompSAS developed under automatic positive airway pressure (APAP), while 4 years of downloaded data showed good adherence. No significant benefit was reported under adaptive servo ventilation (ASV) and BiPAP-ST, while a reduction in CSA in the non-supine position was noticed. Oxygen and sleep positional therapy (SPT) were considered, resulting in a significant improvement in CSA and sleep quality. Further research on the prevalence of positional CSA is needed.

0981 Complex Sleep Apnea in a Patient with ROHHAD

Abstract Introduction Rapid onset obesity with hypothalamic dysregulation, hypoventilation, and autonomic dysregulation (ROHHAD) is a rare disorder associated with sleep disordered breathing. Patients often have obstructive sleep apnea (OSA) and nocturnal hypoventilation (NH). We present a case with a unique sleep disordered breathing pattern demonstrating both severe central and obstructive sleep apnea demonstrated on two separate polysomnograms with no evidence of significant NH. Report of case(s) The patient is a now 8 year old girl who was initially diagnosed with ROHHAD in October 2020 at age 5 years with symptoms of rapid weight gain, hypothalamic dysfunction (hyperprolactinemia), and autonomic dysfunction (recurrent fever, and hypertension). Diagnostic polysomnography in May 2020 demonstrated severe OSA (oAHI 23.4/hr) as well as central sleep apnea (CAI 63.9/hr). The SaO2 nadir was 88% with 15 minutes spent below 90%. There was no evidence of NH, however the CO2 was greater than 50 mmHg for 9.5% of total sleep time. Subsequent titration study recommended BPAP ST of 14/10 cmH20 with back up rate (BUR) of 12 bpm. The patient had a repeat split night study in May of 2022 at age 7 years. During the diagnostic portion, she demonstrated persistent severe OSA (oAHI 39/hr) and central sleep apnea (CAI 21/hr). There was no evidence of NH with a max TCO2 of 50 mmHg and CO2 > 50 mmHg for 0.2% of total sleep time. BPAP ST of 18/10 cmH20 with BUR of 12 bpm led to resolution of obstructive and central apnea events. Conclusion ROHHAD remains a rare disease which is often associated with sleep disordered breathing. While there have been rare reports of CSA in ROHHAD, there have been none of this severity. CSA may be a representation of autonomic dysfunction, and previous literature has described central pauses in breathing in ROHHAD patients while awake. While she did not have evidence of hypoventilation on either polysomnogram, which is one of the hallmarks of this disease, it has been described that nocturnal hypoventilation may develop later in the course of the disease. Thus, it remains important to routinely screen patients with polysomnograms as their sleep disordered breathing evolves. Support (if any)

Effectiveness of Mandibular Advancement Device in Complex Sleep Apnea: A Case Report

Effectiveness of Mandibular Advancement Device in Complex Sleep Apnea: A Case Report

0839 Complex Sleep Apnea Improved with Decompression of a Chiari I Malformation in a Pediatric Patient

Abstract Introduction Chiari malformation (CM) occurs when a portion of the cerebellum herniates through the foramen magnum. CM is categorized as two types. Type 1 involves the cerebellar tonsils and type 2 involves the cerebellum and brain stem. Those with CM can be asymptomatic to having debilitating neurologic symptoms such as dysphagia, tinnitus, emesis, balance difficulty, muscle weakness, and/or headache. Central sleep apnea (CSA) and obstructive sleep apnea (OSA) have been associated with CM. It is postulated that the sleep disordered breathing (SDB) is due to compression of the medulla which houses the breathing center and cranial nerves that play a role in nocturnal breathing. OSA has been thought to be related to muscle weakness of the lower airway in those with CM. After resolving CM with surgical decompression, residual OSA is common requiring treatment with positive airway pressure therapy. Report of Cases: A 3-year-old male with a history of OSA and tonsillar hypertrophy. Polysomnography (PSG) was performed after tonsillectomy and adenoidectomy indicating severe OSA (oAHI 17.7/hr) and CSA (CSAI 29.9/hr). A titration study was conducted and bilevel positive airway pressure spontaneous/timed (BPAP ST) 10/6 cmH2O with a backup rate of 12 breaths per minute was utilized further resolving his SDB and daytime sleepiness. After months of BPAP ST therapy, he presented to an urgent care with symptoms of somnolence, emesis, and nystagmus of the left eye. Magnetic resonance imaging of the brain revealed a 2 cm herniation of the cerebellar tonsils indicating CM type 1. Neurosurgery performed surgical decompression without complication. Post-operative PSG indicated significant improvement of OSA (oAHI of 3.45/hr) and resolution of CSA (0.9/hr). BPAP ST therapy was discontinued with the resolution of his daytime sleepiness and SDB. Conclusion This case demonstrates a patient with severe OSA and CSA due to an undiagnosed CM type 1. OSA and CSA are associated with CM; however, residual OSA typically exists status post decompression and can require positive airway pressure therapy for treatment. Our case demonstrates the need for consideration of CM in patients with complex sleep apnea and that surgical decompression can improve both OSA and CSA in these patients. Support (If Any)

0848 Two Are Better Than One: Treatment of Complex Sleep Apnea with Two Distinct Sleep Neurostimulators

Abstract Introduction Complex sleep apnea refers to the emergence of central apnea when obstructive apneas have been adequately treated. While a combination of medications and noninvasive positive airway pressure ventilation is frequently used in patients with this syndrome, the optimal treatment has not yet been fully elucidated. With the advent of nerve stimulation therapy, it is now possible to target specific physiologic mechanisms and provide precise and adjustable therapy. We present a case in which two distinct nerve stimulators were used to successfully treat a patient with complex sleep apnea. Report of Cases: We present a case in which a ptient with complex slepe apnea was successfully treated by implantation of two distinct nerve stimulators: hypoglossal nerve stimulation therapy for obstructive sleep apnea and phrenic nerve stimulation therapy for concomitant central sleep apnea. Conclusion Complex sleep apnea was successfully treated in this patient with the combination of hypoglossal and phrenic nerve stimulation therapy as evidenced by a reduction in both the obstructive and central apnea hypopnea indices. This patient also had significant clinical improvement with decreased excessive daytime sleepiness and improved daytime functioning as evidenced by decreased Epworth Sleepiness Score, improved patient reported daytime activity, decreased apnea hypopnea index, and increased total sleep time. This case provides evidence for the efficacy and safety of the simultaneous use of hypoglossal and phrenic nerve stimulation for the treatment of complex sleep apnea. Is also highlights the importance of obtaining a laboratory polysomnographic evaluation in all patients prior to any sleep device implantation. Further study is needed, however, to establish the long-term efficacy of this approach to treatment. Support (If Any) I am seeking financial support and assistance for meeting attendance and travel for the June sleep meeting from Inspire Sleep Apnea and other travel assistance funds.

0836 Atypical presentation of Biot’s breathing in a patient with Arnold Chiari Malformation II with complex sleep apnea/Sleep hypoventilation/hypoxemia not on opioid and with no history of meningitis

Abstract Introduction Sleep disordered breathing is very common in Arnold Chiari malformation but Biots’s breathing has not been reported in these cases. Report of Cases: 3-year-old with history of Arnold Chiari II malformation with hydrocephalus (s/p VP shunt and surgical decompression), spina bifida myelomeningocele (s/p in utero repair), subglottic stenosis with prior tracheostomy and eventual decannulation presented for evaluation of sleep disordered breathing. Presenting symptoms included witnessed apneas, cyanosis, daytime sleepiness and frequent awakenings. Physical examination was largely unremarkable. Initial PSG demonstrated complex sleep apnea, with an AHI 20.6, REM AHI 57.8 per hour of sleep, ETCO2 peak of 69 cm H20 and an O2 saturation nadir of 34%, with sleep related hypoventilation/hypoxemia and Biot's breathing in the absence of opioid use and CNS infection. During titration study, Biot’s breathing, complex apnea and sleep related hypoventilation/hypoxemia responded well to BiPAP ST of IPAP 18 cm H20 and EPAP 14 cm H20 BUR of 12 and oxygen of 1 L/min. She later developed intolerance to BiPAP due to high pressures and was decreased to BIPAP 13/11 cm H2O. Later the patient discontinued the use of BIPAP due to intolerance and was switched to night time O2 at 3-4 L/min. Per the parents, the patient has been maintaining her oxygen saturation in the absence of BIPAP therapy with oxygen use. Due to COVID, patient was unable to follow up but will be scheduled for a repeat PSG in the near future. She followed with Neurosurgery for Arnold Chiari II and they recommended no surgical intervention at this time due to functional VP shunt. Conclusion This is an atypical presentation of Biot’s breathing in the absence of CNS infections and opioid use in a patient with Arnold Chiari malformation II. Patient has complex sleep apnea, initially well controlled with BiPAP ST, but developed BiPAP intolerance. She is on oxygen with good control of hypoxemia in the absence of BiPAP therapy. Support (If Any)

Management of Obstructive Sleep Apnea in Patients With Heart Failure.

Sleep apnea is traditionally classified as obstructive sleep apnea (OSA), which occurs when the upper airway collapses due to the relaxation of oropharyngeal musculature, and central sleep apnea occurs when the brainstem cannot stimulate breathing. Most sleep apnea in patients with heart failure (HF) results from coexisting OSA and central sleep apnea (CSA), or complex sleep apnea syndrome. OSA and CSA are common in HF and can be involved in its progression by exposure to the heart to intermittent hypoxia, increased preload and afterload, activating sympathetic, and decreased vascular endothelial function. A majority of treatments have been investigated in patients with CSA and HF; however, less or short-term randomized trials demonstrated whether treating OSA in patients with HF could improve morbidity and mortality. OSA could directly influence the patient's recovery. This review will focus on past and present studies on the various therapies for OSA in patients with HF and summarize CSA treatment options for reasons of reference and completeness. More specifically, the treatment covered include surgical and non-surgical treatments and reported the positive and negative consequences for these treatment options, highlighting possible implications for clinical practice and future research directions.

Opioids and obstructive sleep apnea.

Freire C, Sennes LU, Polotsky VY. Opioids and obstructive sleep apnea. J Clin Sleep Med. 2022;18(2):647-652.

704 The Association of Sleep Disorders in Patients with Chronic Pain Disorders

Abstract Introduction Sleep and pain are interrelated and have a bidirectional relationship. The study was performed to identify the impact of sleep disorders on pain perception. Methods The institutional review board approved the study. Patients evaluated in the Pain Clinic between 1/1/2014 and 12/31/2017 who had polysomnography done were identified by database search. Chart review identified demographics, initial pain score, pain treatments, sleep disorder diagnosis, treatments of sleep disorder and pain scores after sleep treatments. Numerical pain score (NPS) and insomnia severity index (ISI) were used as a measure of pain and sleep quality, respectively. The descriptive statistics were presented by percentages, mean and standard deviations. Regression analysis was performed between initial NPS and ISI. T-test compared change in NPS for compliant and non-compliant subjects, before and after sleep treatments. Linear regression model identified factors associated with changes in pain perception after sleep treatments. Results Of the 320 participants identified, complete data was available for 180 subjects. The average age was 55.9±13.9; 51.41% were female; 60.2% were Caucasian and 26.64% were Hispanic. Initial NPS was 8.8±1.7, average ISI was 15.00±6.41, average BMI was 35.4±10.2. Ninety-five percent had a diagnosis of obstructive sleep apnea (OSA), 27.81% had restless leg syndrome, and 7.19% had complex sleep apnea. Since most patients had OSA, details of positive airway pressure (PAP) treatments were also investigated. Of 84% of subjects treated with PAP, compliance data were available for 53%, which showed 69% (n=55) being complaint with PAP. Initial NPS correlated positively with ISI (R2: 0.064±0.024, p<0.01). No difference in NPS was found in groups based on compliance, before and after PAP treatments. Regression model identified that BMI was the most significant factor in the change in NPS following sleep treatment (R2: 0.083±0.034, p = 0.03). Conclusion The study identified that the severity of pain is associated with poor quality of sleep. While this study failed to identify improvement in pain perception after successful OSA treatment, limited number of subjects in our study were compliant with PAP treatment which may have impacted the results. Future prospective studies are needed to understand the complex association between improvement in sleep quality and pain perception. Support (if any):

860 Variable Sleep Apnea Syndromes Complicated by Neurosurgeries in a Patient with Chiari Malformation Type 1

Abstract Introduction Chiari malformations (CM) are congenital conditions defined by craniocervical junction anatomic anomalies with downward displacement of cerebellar structures. Sleep-disordered breathing (SDB) including obstructive sleep apnea (OSA), bradypnea, central sleep apnea (CSA), and hypoventilation are described in CM patients. Report of case(s) 31-year-old male with history of CM type 1 presented to the sleep medicine clinic for management of OSA and CSA diagnosed at age 16. PSG showed an apnea-hypopnea index (AHI) of 14.2, RDI of 29, and no central events. He was started on auto-CPAP with pressures of 5–20 with subsequent visits showing high residual AHI. A subsequent CPAP-titration study resulted in a pressure of 16cm H2O yielding AHI of 0. CPAP pressure was fixed, but a high residual AHI persisted despite excellent compliance. A split-night study resulted in a BiPAP prescription, for which a titration study noted PAP-emergent CSA. He was started on auto Bilevel with IPAP of 30, EPAP of 8 and backup rate of 12bpm. Despite treatment, elevated AHI persisted so he was switched to adaptive servo-ventilation (ASV) with nightly oxygen blended in resulting in controlled complex sleep apnea. SDB management was complicated by multiple neurosurgical decompressions. During the most recent procedure, he was found to have syringomyelia, syringobulbia, and a mass at the brainstem. Surgery, including placement of a 4th ventricle stent and mass excision, initially led to a decrease of residual AHI to a low of 0.7, before progressively increasing to 15. A repeat PSG demonstrated severe OSA (AHI of 35), without evidence of CSA or nocturnal hypoventilation. ASV was resumed and patient’s AHI progressively decreased to an average of 8, with improvement in his sleep apnea symptoms. Conclusion SDM in CM patients can be explained by condition-related anatomical changes and depression of respiratory centers due to possible extrinsic compression leading to complex sleep apnea presentations. While it is unclear why this patient’s sleep apnea improved then worsened after his latest decompression surgery, we believe that CSF recirculation and postoperative inflammation may be responsible. Close monitoring of SDB in patients with CM is important as they may require advanced therapies for proper control. Support (if any):

467 Positive Airway Pressure Tracking Systems: Outcomes of Polysomnographic Testing Prompted by the Residual Apnea Hyponea Index

Abstract Introduction To assess positive airway pressure (PAP) adherence and efficacy, tracking systems have been developed to monitor hours of CPAP use, mask leak, and residual apnea-hypopnea index (AHI) while patients are on treatment. No formal guidelines however have been developed on how to interpret and utilize this information. We looked at treatment outcomes after an in-laboratory sleep study reevaluation was made based on clinical symptoms and the residual AHI. Methods We performed a retrospective chart review of adult patients evaluated with an in-laboratory polysomnogram (PSG) based on a clinical concern for inadequately treated obstructive sleep apnea (OSA) and the residual AHI obtained from the PAP tracking system. We documented the outcomes of the repeat study and follow-up AHI after the new intervention (if recommended). We excluded patients non-adherent to PAP. Results Nine patients were identified between January 2015 and 2020 at the McGovern Medical School Outpatient Sleep Clinic. All nine patients were male with an average age of 69.2 years (range 44–84). The average AHI on the diagnostic study (CMS criteria) was 37.1 events/hour (range 17.4–67.1). The average residual AHI prompting reevaluation was 9 events/hour (median 15.9). All patients had a change in treatment based on recommendations made after their sleep study. The clinical suspicion for central events on the tracking system was confirmed on PSG on three patients who were subsequently switched to adaptive servo-ventilation. Two patients were found to have central events without a previous suspicion for central events. Four were prescribed a higher pressure or BPAP for suspected untreated OSA confirmed on the repeat PSG. All of the patients had a decreased residual AHI (average 6.3 events/hour) after treatment changes were made. Conclusion Reevaluation with a PSG after concerns of the residual AHI led to a change in diagnosis (complex sleep apnea) or the need for higher treatment pressures in our cohort. This lead to the optimization of therapy and a decrease in AHI on the tracking system post-intervention, hence justifying the repeat PSG. Exact guidelines however need to be set to standardize the recommendations with a potential cut-off residual AHI after which a repeat PSG is the standard. Support (if any):

853 Severe Obstructive Sleep Apnea after Treatment with Phrenic Nerve Implant for Central Sleep Apnea: A Case for Dual Stimulation?

Abstract Introduction The remedē® system is a transvenous phrenic nerve stimulator used to treat central sleep apnea (CSA). It is a safe and effective implantable device that has demonstrated significant improvements in objective sleep and quality of life. While complex sleep apnea represents development of central sleep apnea during treatment with continuous positive airway pressure (CPAP) for obstructive sleep apnea, and has been well-described in the literature, we present a novel case of predominantly central sleep apnea treated with phrenic nerve stimulation with augmentation of obstructive events thereafter. This patient is, at the time of submission, being evaluated for hypoglossal nerve stimulation. Report of case(s) A 63-year-old male patient with a past medical history of hypertension, atrial fibrillation, asthma, chronic obstructive pulmonary disease, GERD, obesity, and prior pulmonary embolism presented to the sleep medicine clinic with complaints of difficulty initiating and maintaining sleep, snoring, multiple nocturnal awakenings, excessive daytime sleepiness, and physical fatigue. On exam, BMI was 30.4, and airway classification was Mallampati 4. Split night polysomnography revealed severe mixed sleep apnea with an overall apnea hypopnea index (AHI) of 58.6 and a central AHI of 53.8 per hour after successful PAP titration at 7 cm H2O. He underwent phrenic nerve stimulator implantation and activation without complications. Phrenic nerve stimulation titration study four months after activation showed a normal central AHI of 4.6 per hour at a therapeutic voltage of 1.6 to 1.9mA, but significantly worse OSA with obstructive AHI of 53.1. In follow up, he reported intolerance of CPAP due to significant nasal congestion as well as asthma. Presently, he is scheduled for drug induced sleep endoscopy to visualize airway obstruction and is being evaluated for Inspire hypoglossal nerve stimulation and nasal surgery. Conclusion The treatment of sleep apnea has recently evolved rapidly with the development of implantable devices to treat both central and obstructive sleep apnea. We present a novel case of the first known patient to be considered for dual nerve stimulation for sleep apnea. Further study needs to be done to determine the safety and efficacy of concurrent implantable devices for the simultaneous treatment of OSA and CSA. Support (if any):

Gender differences of clinical and polysomnographic findings with obstructive sleep apnea syndrome

Obstructive sleep apnea syndrome (OSAS) is underdiagnosed in females and gender differences in clinical and polysomnographic findings have not been widely investigated in China. We examined clinical and polysomnographic differences between males and females with OSAS in order to determine the influence of gender on clinical presentation and polysomnographic features. Data were collected from 303 adult patients diagnosed with OSAS (237 males and 66 females) from 2017 to 2019. All the patients completed physical examination, Epworth sleepiness scale, and whole night polysomnography. AVONA, univariate and multivariate logistic regression analyses were conducted to assess gender differences of clinical and polysomnographic findings with OSAS. P < 0.05 was statistically significant. The average age was 48.4 ± 12.6 years for females and 43.4 ± 12.4 years for males. Compared with female patients with OSAS, male patients were taller and heavier, had higher systolic blood pressure in the morning, shorter duration of slow wave sleep, more micro-arousal events, greater AHI, and more complex sleep apnea events. There are obvious gender differences of clinical and polysomnographic characteristics with OSAS. Understanding gender differences will contribute to better clinical recognition of OSAS in females as well as the provision of proper health care and therapeutic practice.

Chronic Sleep Deprivation in a 75-year-old Female Leading to Increased Falls and a Daytime Microsleeps

Falls in the elderly is an ongoing problem and is one of the leading causes for trips to the emergency room, hospitalizations, serious injuries, and expensive health care costs. However, many times the relationship between sleep quality and falls oftentimes is overlooked. Here we present a case of a 75-year-old female admitted for sustaining 4-5 falls per day for many years that was ultimately found to be due to chronic sleep deprivation. She was treated with non-invasive positive pressure ventilation (NIPPV) for her complex sleep apnea and hypercarbia. Subsequent follow-up revealed significant decrease in her number of daily falls down to <1 per day. This case further adds to the data showing a link between treating sleep apnea in the elderly and a reduction in falls. Abbreviations : CT – computed tomography ; CPAP – continuous positive airway pressure ; EPAP – expiratory positive airway pressure ; Lpm – liters per minute ; MSLT – multi-sleep latency test ; NIPPV – non-invasive positive pressure ventilation ; OSA – obstructive sleep apnea ; PFTs – pulmonary function tests ; Pmax – pressure max ; REI – respiratory event index ; REM – rapid eye movement ; SpO2 – oxygen saturation

Multidisciplinary clinic for care of children with complex obstructive sleep apnea

ObjectiveWhile adenotonsillectomy (AT) remains first line therapy for pediatric obstructive sleep apnea (OSA), management of children who are not candidates for AT or who have residual OSA post AT varies and spans across multiple specialties. We aim to report our experience in managing this population through a multidisciplinary sleep clinic composed of specialists in pediatric dentistry, otolaryngology, plastic surgery, and pulmonary/sleep medicine. Study designRetrospective chart review. MethodThe medical records of children attending our complex sleep apnea clinic were reviewed. Data pertaining to demographics, underlying diagnoses, prior evaluation and treatment, recommendations, and initial therapy were collected. ResultTwo-hundred and thirty patients (mean age 10.7 ± 5.1 years, 62.2% male) were assessed. Underlying conditions included Trisomy 21 (n = 65, 28.2%), other genetic syndromes (n = 37, 16.1%), obesity in an otherwise typically developing child (n = 36, 15.2%), cerebral palsy (n = 27, 11.7%), and craniofacial syndromes (n = 7, 3.0%). Mean obstructive apnea hypopnea index (OAHI) was 14.2 events/hour at first clinic visit, and the majority of children had previously undergone at least one upper airway surgery (n = 168, 73.0%), primarily adenotonsillectomy. Recommended initial treatment plans included positive airway pressure (PAP) therapy (n = 108, 47.0%), surgery (n = 75, 32.6%), allergy management (n = 52, 22.6%), and/or weight loss (n = 34, 14.8%). Patients prescribed PAP therapy with follow up data were found to be adherent 43.9% of the time. Surgical patients with post-operative polysomnography had pre-operative OAHI 15.6 ± SD13.4 decrease to 10.7 ± 14.2 events/hour (p = 0.61). ConclusionGenetic conditions and obesity were the most common underlying diagnoses cared for in the complex sleep apnea clinic. Patients presented with severe OSA, most having already had upper airway surgery. Management plans were frequently adjusted, and we observed improvement in SDB in a sub-segment of patients, suggesting benefit to a coordinated, multi-disciplinary approach.

Home PAP devices in patients infected with COVID-19.

Citation:Kryger MH, Thomas R. Home PAP devices in patients infected with COVID-19. J Clin Sleep Med. 2020;16(7):1217–1219.

Application of impulse-radio ultra-wideband radar as a non-contact portable monitoring device for the diagnosis of obstructive sleep apnea

Objective:To compare the effect of impulse-radio ultrawideband（IR-UWB） radar technology and polysomnography（PSG） in sleep assessment. Method:A total of 79 OSA patients were randomly divided into two groups: 40 patients in group A received PSG and IR-UWB, and 39 patients in group B received micromovement sensitive mattress（MSM） and IR-UWB. Pearson correlation and ROC curve were used for statistics. Result:AHI PSG and AHI MSM were significantly correlated with AHI IR-UWB（r=0.91, P＝0.00; r=0.92, P＝0.00）. Bland-Altman analysis showed that AHI IR-UWB value was highly consistent with AHI PSG value（95.00%）, and AHI IR-UWB value（97.44%）. The sensitivity and specificity of AHI IR-UWB compared with PSG were 70.40% and 89.90%, respectively. The area under ROC curve was 0.915. Conclusion:IR-UWB has a high diagnostic value for adult OSA in terms of minimum blood oxygen saturation, average blood oxygen saturation, average number of central sleep apnea, average number of complex sleep apnea, average heart rate, sleep efficiency, REM sleep duration, average AHI, etc. It is an economic and practical sleep evaluation tool.

Changes in insomnia severity with advanced PAP therapy in patients with posttraumatic stress symptoms and comorbid sleep apnea: a retrospective, nonrandomized controlled study

BackgroundSleep disorders frequently occur in posttraumatic stress disorder (PTSD) patients. Chronic insomnia is a common feature of and criteria for the diagnosis of PTSD. Another sleep disorder, obstructive sleep apnea (OSA), also occurs frequently in PTSD, and emerging research indicates OSA fuels chronic insomnia. Scant research has investigated the impact of OSA treatment on insomnia outcomes (Insomnia Severity Index, ISI) in trauma survivors.MethodsOSA patients with moderately severe posttraumatic stress symptoms were studied in a retrospective chart review. Ninety-six patients who failed CPAP therapy due to expiratory pressure intolerance or complex sleep apnea or both underwent manual titration with advanced PAP modes [autobilevel (ABPAP); adaptive servo-ventilation (ASV)], which were subsequently prescribed. PAP use measured by objective data downloads divided the sample into three groups: compliant regular users (C-RU): n = 68; subthreshold users (SC-RU): n = 12; and noncompliant users (NC-MU): n = 16. The average follow-up was 11.89 ± 12.22 months. Baseline and posttreatment ISI scores were analyzed to assess residual insomnia symptoms as well as cure rates.ResultsThe C-RU group showed significant improvements in insomnia with very large effects compared to those in the NC-MU reference group (P = 0.019). Insomnia severity significantly decreased in all three groups with large effects (C-RU, P = 0.001; SC-RU, P = 0.027; NC-MU, P = 0.007). Hours of weekly PAP use and insomnia severity were inversely correlated (P = 0.001, r = − 0.321). However, residual insomnia symptoms based on established ISI cut-offs were quite common, even among the C-RU group. Post hoc analysis showed that several categories of sedating medications reported at baseline (hypnotics, anti-epileptic, opiates) as well as actual use of any sedating medication (prescription or nonprescription) were associated with smaller insomnia improvements than those in patients not using any sedating agents.ConclusionsIn a retrospective, nonrandomized analysis of a select sample of sleep clinic patients with OSA and PTSD symptoms, advanced PAP therapy was associated with significant improvement in insomnia severity for both compliant and partial users. However, residual insomnia symptoms persisted, indicating that PAP therapy provides only limited treatment. RCTs are warranted to assess the effect of ABPAP and ASV modes of therapy on adherence and sleep outcomes, and their potential impact on posttraumatic stress symptoms. Treatment arms that combine PAP with CBT-I would be expected to yield the greatest potency.