Home Sleep Apnea Testing Research Articles

Sleep Technology.

Pediatric sleep providers frequently encounter issues related to sleep technology in clinical settings. In this review article, we discuss technical issues related to standard polysomnography, research on putative complementary novel metrics derived from polysomnographic signals as well as research on home sleep apnea testing in children and consumer sleep devices. Although developments across several of these domains are exciting, it remains a rapidly evolving area. When evaluating innovative devices and home sleep testing approaches, clinicians should be mindful of accurately interpreting diagnostic agreement statistics to apply these technologies appropriately.

Sleep apnea severity in patients undergoing atrial fibrillation ablation: Home sleep apnea-test and polysomnography comparison.

Sleep apnea (SA) is highly prevalent and should be treated in patients referred for catheter ablation (CA) of atrial fibrillation (AF). Watch-type peripheral arterial tonometry (WP) for home SA testing has demonstrated a high correlation of the apnea-hypopnea index (AHI) with Polysomnography (PSG), but the evidence of its accuracy in AF patients is not adequate. This study was conducted under a retrospective, single-center, observational design. We included 464 consecutive AF patients (age 65 ± 11 years, 76.5% male, 45.0% paroxysmal-AF) who received both WP and PSG during the periprocedural period of the CA. We compared the AHI using the WP (WP-AHI) to that using PSG (PSG-AHI). The WP-AHI was 25.9 ± 12.7 and PSG-AHI 31.4 ± 18.9 (r = .48). Among 325 patients with a WP-AHI < 30, 116 (35.7%) exhibited a PSG-AHI ≥ 30. Only 12.5% of the patients were indicated for continuous positive airway pressure (CPAP) treatment only by the WP-AHI, while 70.9% were indicated for CPAP by the PSG-AHI according to the Japanese health insurance system. The best cut-off value of the WP-AHI was 18.1 to predict a PSG-AHI ≥ 20 with an area under the curve of 0.72 (95% confidence interval, 0.67-0.76). The WP-AHI and PSG-AHI were weakly correlated in AF patients receiving CA. About one-third of the patients with moderate SA using the WP was diagnosed with severe SA evaluated by PSG. The majority required PSG for the CPAP indication.

NOCTURNAL HYPOXIA INDEXES ARE ASSOCIATED WITH LEFT VENTRICULAR REMODELING AND DIASTOLIC DYSFUNCTION IN OBSTRUCTIVE SLEEP APNEA PATIENTS

Objective: Echocardiography features of obstructive sleep apnea (OSA) are heart derangements as higher left ventricular mass index (LVMI) and left ventricular end-diastolic diameter, lower left ventricular ejection fraction (LVEF), and impaired diastolic function. The apnea/hypopnea index (AHI), the parameter currently used to define diagnosis and severity of OSA, poorly predicts cardiovascular damage, cardiovascular events, and mortality. Thus, we aimed to assess, if, in addition to AHI, other polygraphic indices of OSA presence and severity might serve as better predictors of echocardiographic cardiac remodeling. Design and method: We enrolled two cohorts of subjects referred for suspected OSA to the outpatient facilities of the IRCCS Istituto Auxologico Italiano, Milano, and of the Clinica Medica 3, Padova. All patients underwent home sleep apnea testing and echocardiography. Based on the AHI the cohort was divided into no-OSA (AHI&lt;15 events/hour) and moderate-severe OSA (AHI&gt; = 15 events/hour). A stepwise multiple regression analysis was used to identify the covariates among age, gender, body mass index, past medical history, and polygrapic variables, independently associated to four echocardiographic variables, e.g., LVMI, LVEF, left ventricular end-diastolic volume (LVEDV), early and late ventricular filling velocity ratio (E/A). Results: We recruited 162 patients and found that compared to patients with no-OSA, those with moderate-severe OSA showed higher LV remodeling [LVEDV 48.4±11.5 ml/m2 vs. 54.1±14.0 ml/m2, respectively, p = 0.005] and lower LVEF (65.3±5.8 % vs. 61.6±7.8%, respectively, p = 0.002), whereas we could not find any difference in LVMI and E/A. At multivariate linear regression analysis, the only polygraphic independent predictor of LVEDV was the percentage of time with SatO2 &lt; 90% (↓ = 0.262), whereas, the independent predictors of E/A were AHI (↓ = -0.379) and oxygen desaturation index (↓ = -0.422). None of the polygraphic variables was associated to LVMI and LVEF at multivariate linear regression analysis. Conclusions: Our study shows that nocturnal hypoxia-related indexes were associated with left ventricular remodeling and diastolic dysfunction in OSA patients. If confirmed in future studies with a wider sample of patients included, these results support the adoption of hypoxia indexes in the evaluation of OSA patients, particularly those at a greater cardiovascular risk.

0470 Factors Associated with Discordant Initial Home Sleep Apnea Testing and Polysomnography

Abstract Introduction Nocturnal polysomnography (PSG) is the gold standard for diagnosing obstructive sleep apnea (OSA). Home sleep apnea tests (HSAT) have been incorporated in the diagnostic algorithm in patients with a high pre-test suspicion of OSA. While many studies have compared HSATs with PSGs, it is not well understood what factors may be responsible for inconclusive HSAT results. Methods We performed a retrospective chart review of adult patients who underwent a non-diagnostic HSAT evaluation, who subsequently tested positive for OSA (on PSG) between 1/1/2022 and 11/1/2022. We collected demographic and sleep study data. Patients who did not have a follow up PSG were excluded. Results A total of 20 patients were reviewed. 80% had a negative HSAT with a positive subsequent PSG. The average age was 33.9 years (SD +/- 11.3 years). 43% were male and 50% were Caucasian. The average BMI was 29 kg/m2 (SD +/- 5.3 kg/m2). The average Epworth Sleepiness Scale score (ESS) was 8 (median 6.5) with only 31% reporting an ESS &amp;gt;10. The average HSAT recording time was 449.1 minutes. The average respiratory disturbance index (RDI) on the follow up PSG was 17.7 events/hour of sleep (SD +/- 12). Only 1 patient was diagnosed with severe OSA. 38% were diagnosed with anxiety in this cohort. Other co-morbidities were insignificant. Of all the HSATs performed, 40% were denied for an initial PSG evaluation and converted to an HSAT evaluation. Conclusion HSATs are validated in patients with a high pretest probability of OSA. Anxiety was found in one third of patients included (possibly contributing to a negative initial HSAT). Patient demographics however were also not remarkable for a high risk of OSA in this group (e.g. non-obese, &amp;lt; 55 years, female). The subsequent diagnosis for OSA was also only mild or moderate (93.8%) in this lower risk cohort. Hence, another explanation for the initial negative HSAT evaluation may have been the insurance denial of the initial PSG request (40%). Denials of low risk patients for PSG may contribute to a misuse of resources. We also need to educate referring physicians to follow appropriate HSAT ordering criteria (based on high OSA risk factors). Support (if any)

0556 Simultaneous comparison of unedited and manually edited HSAT with level 1 PSG in persons with hospitalized TBI

Abstract Introduction Previous studies have shown automatic scoring of portable level 3 sleep study provides similar findings when compared to polysomnography (PSG), establishing home sleep apnea tests (HSAT) as an adequate screening tool for OSA. Accuracy of level 3 studies with Nox T3 portable sleep studies (Noxturna Inc., Atlanta GA) may improve with manual editing to include total sleep time (TST). No other studies have compared unedited versus manually edited HSAT with level 1 in-lab PSG performed simultaneously. This study evaluates if added manual editing optimizes the diagnostic accuracy of HSAT in classifying the severity of OSA, using both AASM and CMS criteria. Methods Secondary analysis of six-center (n=206) sleep apnea diagnostic comparative effectiveness trial. Participants underwent simultaneous administration of level 1 PSG (Philips Alice 6 LDx Diagnostic Sleep system) and Nox T3 portable sleep study with centralized scoring using AASM and CMS criteria. All HSAT were autoscored and then edited by the registered polysomnographic technician. Editing entailed establishing start and stop recording times based on accompanying actigraphy data (reduction in movement) in the portable device and elimination of recording artifact. Results Using AASM criteria, poor sensitivity OSA (AHI≥5) was observed using unedited vs PSG (p=.01) compared to manually edited HSAT vs. PSG (p=.06). No statistically significant difference was observed using AHI≥15 or via categorization across four levels of OSA (none, mild, moderate, or severe). In contrast, CMS criteria comparisons to PSG showed poor specificity of OSA (AHI≥5) for unedited (p=.003) compared to edited (p=.372) HSAT studies. As expected, total sleep time was overestimated using T3 actigraphy devices compared to the criterion standard across both edited and unedited studies (p=.001, .001 respectively). Conclusion Improvements in sensitivity and specificity of OSA were noted using edited versus unedited T3 HSAT when compared to Level 1 PSG using both AASM and CMS criteria. Results support need for manualized editing of HSAT in persons with hospitalized TBI. Support (if any) PCORI (CER-1511-33005), GDHS (W91YTZ-13-C-0015)

0686 High prevalence of sleep apnea in mental disorders – a need for use of sleep evaluation tools in psychiatric health care

Abstract Introduction Sleep apnea is a prevalent disorder but it is frequently overlooked in diagnosing mental disorders. The aim of the present study was to screen for sleep apnea in a group of patients referred for diagnosing mental disorders or non-restorative sleep and to assess the accuracy with which such testing can be replaced with commonly used screening questionnaires for sleep apnea. Methods 104 patients were investigated – 58 with mental disorders (26 with affective disorders, 26 with schizophrenia spectrum disorders, 3 with anxiety disorders, 3 with neurocognitive disorders; mean age 37.5±9.5 years, 24% females, BMI 32.8±6.5 kg/m2) and 46 with non-restorative sleep (mean age 41.2±14.6, 39% females, BMI 26.3±4.8 kg/m2). The patients were screened for sleep apnea with a home sleep apnea test (HSAT) based on peripheral arterial tonometry (PAT) and were asked to fill in the Sleep Apnea Scale from Sleep Disorders Questionnaire (SDQ-SA), the STOP-BANG and the Berlin questionnaires (BQ), and the Epworth Sleepiness Scale (ESS). Results Apnea-Hypopnea Index of &amp;gt; 5/h was found in 57 (55%) patients: 36 (62%) patients with mental disorders and 21 (45%) patients with non-restorative sleep. An increased risk for sleep apnea was found in 45 patients (43.3%) using SDQ-SA, 64 (61.5%) using BQ, 80 (76.9%) patients using STOP-BANG with the cut-off of 3 points and 30 (28.8%) with the cut-off of 5 points. Positive predictive values were: 65.9% for SDQ-SA, 71.0% for BQ, 68.8% for STOP-BANG with the cut-off of 3 point and 75.9% with the cut-off of 5 points. Negative predictive values were 49.1%, 63.0%, 83.3% and 51.4% respectively. Diagnostic accuracy was highest for STOP-BANG with the cut-off of 3 points – 72.3% and lowest for SDQ-SA – 56.6%. Excessive Daytime Sleepiness was found in 44 (42.3%) of patients. Three patients (2.9%) refused or did not complete the HSAT. Conclusion Inclusion of HSAT in the diagnostic process revealed high prevalence of sleep apnea in patients with mental disorders. Psychiatrists should be encouraged to include HSAT in evaluation of patients. Such testing is patient-friendly and using only screening questionnaires does not provide high enough diagnostic accuracy. Support (if any)

0568 Trends in OSA Disease Severity Over Nearly Two Decades: Update on the VA San Diego Experience

Abstract Introduction The Veterans Health Administration (VA) is one of the largest integrated healthcare systems in the United States. Key risk factors for obstructive sleep apnea (OSA) include aging, weight, and male gender, all of which are highly prevalent in the VA population and help to explain the higher rates of OSA in the VA. The Pulmonary Sleep Program at the VA San Diego Healthcare System (VASDHS) started a patient database over twenty years ago for its home sleep apnea testing (HSAT) program. An analysis of ten years of diagnostic HSAT data was reported on over 12,500 patients in 2014. This analysis focuses on an update on the last four years and a comparison to 2014. Methods A retrospective review of the local clinical database of HSAT diagnostic testing was conducted. The database contained 8,928 sleep studies from 2018 to 2022. Invalid studies were removed. Only initial diagnostic studies were included. Results Of the 8,928 diagnostic studies, 2,564 tested negative for OSA (28.7%). Of the 6,364 positive cases, 43.3% were mild, 28.8% were moderate, and 27.9% were severe. The percentages of each OSA severity level were stable across these years (mild: 42%-45%; moderate: 27%-32%; and severe: 26%-29%). The mean AHI did not significantly change from 2018 (24.1+/-20.6) to 2022 (25.1+/-21.2) (overall mean 24.4+/-20.3; range: 5-140). Conclusion Based on this extensive retrospective review of diagnostic testing at a single, high-volume HSAT program, it appears that OSA severity levels have stabilized over these past five years, with the highest percentage of mild OSA cases (~43%) followed by moderate (~29%) and severe (~28%). Our facility saw a significant decrease in severe cases (60% to 30%) and increase in mild OSA (7% to 35%) from 2004 to 2013. Today, over 4 out of every 10 new OSA diagnoses are mild, which has significant treatment implications given that adherence to the two primary medical device options is suboptimal. Identifying patient-centered treatment options for these patients is a priority. Support (if any) VA RR&amp;D D2651-R and the Sleep Medicine Section of the VA San Diego Healthcare System supported this project.

0814 Obstructive sleep apnea in asthmatic children: highly prevalent though no identifiable risk factors

Abstract Introduction Obstructive sleep apnea (OSA) and Asthma often coexist. There is some evidence that adults with asthma are more prone to developing OSA than the general population, as well as OSA may impact asthma control. Different than adults, OSA prevalence is equal in boys and girls, while puberty has strong influence in asthma, especially in pubescent girls. The objectives of this study were to analyze the prevalence of OSA in boys and girls and the impact of asthma severity in OSA prevalence. Methods Asthmatic children attending a tertiary pediatric pulmonology clinic performed clinical evaluation, Pulmonary Function Test, and Home Sleep Apnea Test. OSA was defined as habitual snoring and one or more obstructive respiratory events (OREI) per hour of recording. Control and severity of Asthma were evaluated according to Global Initiative for Asthma and puberal stage using Tanner figures for boys and girls Results We studied 80 consecutive patients, 7 to 18 years-old, mean age 11.6 years (SD: 2.7), 51.3% female. According to BMI z-score, nutritional status was: 2 (2.5%) underweight, 63 eutrophic (79%), and 15 obese (18.5%). Puberty was present in 17 volunteers. Pulmonary Function Tests were obtained from 71 volunteers, 45% presented obstruction pattern. Home Sleep Apnea Tests were available from 76 volunteers, with mean OREI of 1.8 events/h. OSA occurred in 69 volunteers (91%), while 66% were mild, 21% moderate, and 4% severe. We did not find associations of obstructive sleep apnea with sex or asthma severity. Conclusion OSA was highly prevalent among these asthmatic children, but most were mild. Sex and asthma severity were not associated to OSA. Considering the interrelationship of both diseases, it is worth to keep in mind the possibility of OSA among children and teenagers with asthma. Support (if any) AFIP (Associação Fundo de Incentivo à Pesquisa) and CNPq (Conselho Nacional de Pesquisas)

0511 An observational retrospective study of the efficacy of oral appliance therapy (OAT) in treating obstructive sleep apnea (OSA)

Abstract Introduction Obstructive sleep apnea (OSA) affects approximately 15-30% of males and 10-15% of females in North America. While positive airway pressure (PAP) therapy remains the standard in the treatment of OSA, oral appliance therapy (OAT) has emerged as a viable non-invasive alternative. However, there are limited data on OAT efficacy published, and therefore many sleep clinicians question its efficacy. We conducted a 14-month single-center consecutive chart review to evaluate OAT efficacy. Methods A manual chart review was performed for records from 11/1/2020 to 12/10/2022. Potential charts were identified in the electronic health record by searching for prescriptions for OAT and orders for home sleep apnea tests (HSAT). If there was a test performed after the prescription was written, the chart was reviewed manually for previous test results and verified that post-OAT testing was conducted. Extracted information included age, BMI, gender, pre-OAT HSAT apnea-hypopnea index (AHI), and post-OAT HSAT AHI. The 4% desaturation criteria for AHI was used in accordance with current Medicare guidelines. A paired t-test was performed after ensuring there were no outliers and a normal distribution. Results There were 10 patients included in the analysis: 6 women, 4 men. The average age was 61.1 years (95% CI 49.9-72.3), and average BMI was 28.9 (95% CI 253-32.4). Prior to intervention, 2 patients had moderate OSA with the rest mild (average pre-OAT AHI 13). After OAT device, 4 patients had mild OSA and the rest did not have residual OSA (average post-OAT AHI 4). The results of the paired t-test showed that the mean AHI was statistically significantly different between the two groups (t=-4.54 with df=9, p=0.0014). The mean difference was -8.1 with 95% confidence interval for the true difference in the population mean AHI of -12.1, -4.06. Conclusion The results demonstrate efficacy of OAT in treating OSA. Clinicians should consider OAT as both primary and secondary therapy for mild-to-moderate OSA. Support (if any) N/A

0982 Atrial fibrillation diagnosed from a home-based sleep study in a patient with REM behavior disorder

Abstract Introduction Atrial fibrillation (A-Fib) is the most common form of cardiac arrhythmia and is a major cause of stroke. Obstructive sleep apnea (OSA) is an established risk factor of A-Fib, but sleep disruption with frequent awakenings was recently identified as another risk factor, independent from OSA. Home sleep apnea test (HSAT) is widely used to diagnose OSA with low cost and short wait time, and HSAT that uses peripheral arterial tonometry (PAT) can reveal cardiac arrhythmia. Here we report a case of A-Fib detected by PAT-based HSAT in a patient with REM sleep disorder. Report of case(s) A 60-year-old man with hypertension, depression, anxiety, tobacco and alcohol use disorders presented to sleep clinic for frightening vivid dreams and violent dream enactments that gradually developed over the last two years. A diagnostic polysomnography study showed mild OSA, normal heart rhythm, and no epoch of REM sleep without atonia (RSWA). In the following four years, he used CPAP therapy, imagery rehearsal therapy, high-dose melatonin, doxepin and hydroxyzine. However, the frightening dreams and dream enactments persisted despite full adherence to CPAP. To reassess OSA, the patient took a PAT-based HSAT, which showed not only mild OSA, but one episode of irregularly irregular PAT-derived pulsation variations that lasted three hours and started and stopped abruptly. We therefore ordered longitudinal cardiac monitoring, which showed multiple asymptomatic episodes of A-Fib during nighttime. After treatments for A-Fib were started, a polysomnography study with effective CPAP titration showed one episode of A-Fib with rapid ventricular response that lasted 2.5 hours during non-REM sleep, and multiple epochs of RSWA. The diagnosis of REM sleep behavior disorder (RBD) was thus established. Conclusion We reported concurrent developments of RBD and asymptomatic paroxysmal A-Fib in a man in his early sixties. Our case suggests a potential association between RBD and A-Fib, which has not been studied but is conceivable, given that RBD causes frequent awakenings with surges of sympathetic activity. Our case also highlights the advantage of PAT in capturing not only OSA but cardiac arrhythmia. Clinical interpreters of PAT-based HSAT can seize the opportunity to diagnose A-Fib and prevent stroke. Support (if any)

0498 Home automated OSA quantification of night-to-night short term variability: analysis of the associated conditions

Abstract Introduction Single night in-lab polysomnography (PSG) is still the conventional procedure for making obstructive sleep apnea (OSA) diagnosis, or alternatively a home sleep apnea test (HSAT) in patients free from comorbidity. Recent publications drew attention to considerable internight within-subject variability in OSA clinical status, notably but not only with HSAT. Taking benefit of multiple nights recording in home-based setting using measurements of mandibular jaw movement (MJM) combined with automated machine learning analysis, this study aimed to investigate the effect of change in sleep parameters on the internight variability of the apnea hypopnea index (VAHI). Methods 160 adults suspected of having OSA successfully completed 3 sleep tests at home with the Sunrise device (Sunrise, Namur, Belgium). Data analysis implied generalized estimating equation (GEE) regression. Results Even though the internight variability of AHI was not statistically significant at the population level with a mean VAHI of -1.1 ± 7.8 events/h, such variability could lead to misdiagnosis and wrong therapeutic decisions based on a single night. After adjusting for effects of gender, body mass index (BMI), age, total sleep time (TST) and time interval between sleep tests, regression models indicated that sleeping in supine position was positively and independently associated with VAHI, the AHI increased by 0.95 event/h for each 10% of increase in sleeping time in supine position. VAHI was negatively and significantly (p &amp;lt; 0.01) associated with sleep efficiency and deep sleep; VAHI decreased of 0.16 event/h (0.04 to 0.28) and 0.29 event/h (0.17 to 0.42) for each % of increase in sleep efficiency and proportion of deep sleep, respectively. Conclusion At the individual level, position, sleep efficiency and deep sleep are associated with short-term internight variability in AHI. Clinical decision based on a single-night testing may lead to errors in OSA diagnosis with delayed or wrong therapeutic decisions. Support (if any)

0428 Area Deprivation Index, Sleep Disordered Breathing and Incident Major Cardiovascular Events and Mortality in a Large Cohort

Abstract Introduction Epidemiological studies have shown a strong association between sleep disordered breathing (SDB) and increased incidence of cardiovascular morbidity and mortality, however, to date, the variation of SDB across the socioeconomic spectrum and how this variation is associated with major cardiovascular events (MACE) and mortality is unknown. Methods A retrospective cohort study was conducted using the Cleveland Clinic Sleep Laboratory Registry and included MACE-naïve adults who underwent polysomnography or home sleep apnea test. Area Deprivation Index (ADI), a biomarker of neighborhood socioeconomic disadvantage, was calculated by national rank, i.e. 25th, 50th and 75th percentiles; higher quartiles reflecting greater deprivation (ADI-Q1,2,3,4). ANOVA with pairwise testing was used to compare variables across ADI quartiles. Composite of MACE included heart failure, stroke, atrial fibrillation and myocardial Infarction or death. Cox proportional hazard regression models tested the association between ADI and SDB-measures of apnea hypopnea Index (AHI) and sleep-related hypoxia (total sleep time spent&amp;lt; 90%SaO2, T90) with MACE. Covariates included demographics, medications, smoking status, Elixhauser Comorbidity Score, and comorbidities. Censoring was sleep study date or last encounter in the electronic medical record. Asterisk (*) indicates statistical significance after pairwise testing. Interaction testing used competing risk (Fine &amp; Gray method). Results Of 72,443 patients, those living in ADI-Q4, compared to those living in ADI-Q1, were more likely to be younger (*48.9± 3.9 vs 50.4±14.2), female (*59.9% vs 40.1%), African American (*49% vs 4.9%), with lower AHI (*13.5[5.4, 34.1]vs15.1[6.2,33.1]) and lower degree of hypoxia (T90:*2.9[0.40,19.01] vs 4.4[0.50, 25.6]). Model adjusted risk for MACE or death for those in ADI-Q4 was 79% greater than ADI-Q1 (HR=1.79,95%CI:1.51-2.12,p&amp;lt; 0.0001). Likewise, increased AHI severity and T90 above median were associated with 13% and 21% increased risk of MACE or death (HR=1.13,95%CI:1.07-1.19,p&amp;lt; 0.0001; HR=1.21,95%CI:1.51-1.27,p&amp;lt; 0.001) respectively. Interactions were observed between T90 and ADI with the risk of MACE (p=0.0016) or death (p=0.0051). Conclusion Living in areas of increasing socioeconomic deprivation confers an increased risk for MACE or death. Moreover, sleep-related hypoxia seems to modify this association. ADI appears to be useful to identify populations at risk for worse cardiovascular outcomes and to inform risk stratification for targeted interventions to decreased sleep-health disparities. Support (if any)

0943 Sleep Medicine Tweet-by-Tweet, an Electronic Platform for Collaborative Medical Education

Abstract Introduction Twitter is a novel and accessible platform for the dissemination of medical education, and it is used by many medical practitioners (1). Many physicians have used Twitter as a means of meeting continuing medical education needs. This can manifest as Twitter-based Journal Clubs, curated conference data and webinars (2). Methods I have created a Sleep Medicine Medical Education Twitter account @SleepyNeuroDoc to share complex cases in all areas of sleep medicine, including sleep-disordered breathing, movement disorders in sleep, circadian rhythm disorders and nocturnal epilepsy. I share notable images of polysomnogram outputs, home sleep apnea tests, compliance data, neuro-imaging, electroencephalogram, cardiopulmonary coupling and more. This digital education platform allows rapid circulation of unique cases and promotes in-depth scholarly discussion, with no geographical limit. Polls are conducted for complex topics to facilitate knowledge exchange and consumer engagement. This educational twitter is followed by the entire spectrum of professions within the sleep medicine care team, including physicians, allied health, and researchers. To date, there are 40 cases posted. Results We conducted online questionnaires with consumers of this Twitter account, and the results so far indicate greater practitioner comfort with management of various sleep medicine conditions. Some consumers report having changed their approach to practice. Conclusion Our work suggests that this unique use of a social medical platform is beneficial for continuing medical education and knowledge exchange in the field of Sleep Medicine.

Correlation between dental arch form and OSA severity in adult patients: an observational study

BackgroundThe role of interdental widths and palatal morphology on the development of obstructive sleep apnea (OSA) has not been well investigated in adult patients yet. The aim of this paper was to assess the morphology of maxilla and mandibular dental arches on three-dimensional (3D) casts and to correlate these measurements with the severity of OSA.MethodsSixty-four patients (8 women and 56 men, mean age 52.4) with a diagnosis of mild-to-moderate OSA were retrospectively enrolled. On each patient, home sleep apnea test and 3D dental models were collected. Apnea-hypopnea index (AHI) and oxygen desaturation index (ODI) were recorded, as well as the dental measurements including inter-molar distance, anterior and posterior widths of maxillary and mandibular arches, upper and lower arch lengths, palatal height, and palatal surface area. The respiratory and dental variables were then correlated.ResultA statistically inverse correlation was found between ODI and anterior width of lower arch, maxillary arch length, palatal height, and palatal area. AHI showed a significant inverse correlation with anterior width of mandibular arch and maxillary length.ConclusionA significant inverse correlation between maxillary and mandibular morphology and respiratory parameters was shown in the present paper.

0433 Home sleep apnea testing in patients with a LVAD: Is it feasible?

Abstract Introduction Sleep related breathing disorders, including central sleep apnea (CSA), are frequent in patients with heart failure however, only limited data is known about the effect of left ventricular assist device (LVAD) placement on OSA and even less about the accuracy of home sleep apnea testing in this population (HSAT). Performing the gold standard polysomnography (PSG) is challenging in this cohort due to logistics, especially during the COVID-19 pandemic. Extending HSAT to the LVAD population would be beneficial, yet initial tests with the WatchPat® were deemed inconclusive. We decided to evaluate the validity of NOX-T3 device for HSAT compared to PSG. Methods This was a single center prospective, observational study that included LVAD patients who screened positive on the STOP-BANG questionnaire. A sleep study was indicated based on consultation with a sleep physician and a standard PSG was ordered. During the PSG, the NOX-T3 was also applied with the results analyzed and compared after test completion. Results In this preliminary analysis, 4 patients (3 male, 1 female) with a LVAD completed a PSG along with the NOX-T3. The overall severity of sleep apnea indicated by apnea hypopnea index during the PSG and the respiratory event index during the NOX-T3 were similar in this small cohort. In 2 of the 4 patients, the oximetry finding (minutes with oxygen saturations at or below 88%) were also similar during both the PSG and the NOX-T3. Conclusion Based on this preliminary analysis, data obtained with the NOX-T3 system were valid and compared well to the standard of care PSG in patients with a LVAD. We plan to enroll at least 10 patients in this ongoing trial, further studies will be needed to validate these results. Performing HSAT with the NOX-T3 in this unique population if PSG is not feasible would be of significant value given the morbidity of sleep apnea in this population. Support (if any)

1009 Surgery: Problem and Solution. Temporomandibular Joint Reconstruction For Treating Obstructive Sleep Apnea After Cosmetic Surgery

Abstract Introduction Orthognathic surgery is often considered for the treatment of obstructive sleep apnea (OSA); however, in some circumstances, specific interventions may precipitate OSA. Report of case(s) A 34 year-old female presented with complaints of snoring and fragmented sleep. She had undergone bimaxillary osteotomy and mandibuloplasty for cosmetic reasons outside of the country in 2019. Prior to the surgery, she was asymptomatic and did not snore. Post operatively, she developed snoring, witnessed apneas, fragmented sleep, and daytime sleepiness. A home sleep apnea test revealed severe obstructive sleep apnea with Respiratory Event Index (REI) 66.4/hr. She was initially treated with Positive Airway Pressure (PAP) while seeking oral surgery consultation. PAP via nasal mask was initially effective with residual Apnea Hypopnea Index (AHI) of 3/hr., but the patient developed difficulty tolerating PAP due to aerophagia, nausea, and eructation, despite limiting pressures to 5-7cm H2O. In 2022, the patient successfully underwent temporomandibular joint (TMJ) reconstruction with total joint prosthesis, TMJ fat grafting, bilateral coronoidectomy, maxillary osteotomy with bone plate and grafting, and partial inferior turbinatectomy. She reported resolution of snoring and significant symptomatic improvement after surgical revision. Repeat home sleep apnea testing 1 month after the surgery revealed REI 0.6/hr. Conclusion This case illustrates the potential for development of OSA following orthognathic surgery. Patients and providers should be aware of this potential complication when pursuing surgical intervention. Support (if any)

0485 The clinical utility of echocardiography in identifying patients with heart failure at a single academic sleep center

Abstract Introduction Heart failure and sleep disordered breathing are prevalent in the United States and often co-exist; diagnostic strategy and management for sleep disordered breathing may change based on the presence, absence and type of heart failure. The goal of this study was to evaluate how many additional patients would be identified with either heart failure with reduced (HFrEF) or preserved (HFpEF) ejection fraction through existing echocardiogram results when this diagnosis is not explicitly stated in the medical records for patients evaluated at a single academic sleep center. Methods A retrospective chart review was performed for all patients undergoing for a sleep study and/or a PAP device from February 2012 through September 2019 at the University of Arizona. Sleep disordered breathing was identified through either polysomnography (PSG) or home sleep apnea testing (HSAT). Patients were identified with heart failure with reduced ejection fraction if an echocardiogram (TTE) listed ejection fraction Results 2,817 patients were evaluated (age 57 (±16 years), 53% male and 77% Caucasian). Ninety-nine patients (3.51%) were noted to have HFrEF based on past medical history and an additional 38 patients were identified through TTE. One hundred and fifteen patients (4.08%) were noted to have HFpEF based on past medical history and an additional 265 patients were identified through TTE. Among these, a majority had OSA (77% HFrEF and 83% HFpEF), followed by combined OSA and CSA (7% HFrEF and 5% HFpEF), and primary CSA (5% HFrEF and 3% HFpEF). Of the patients identified after having reviewed TTE results, 6 (16%) with HFrEF and 42 (16%) with HFpEF developed treatment emergent central sleep apnea. Conclusion Existing echocardiography data in the electronic medical record can identify additional patients with HFrEF and HFpEF which may impact clinical diagnosis and management of sleep disordered breathing. Support (if any) AASM Foundation (203-JF-18), NIH (HL126140, 2L30HL154400-023), University of Arizona (5299903; 5833261; 4258021)

0834 Association of Sleep Disordered Breathing and Hemodynamics of World Symposium on Pulmonary Hypertension Groups in PVDOMICS Cohort

Abstract Introduction As sleep disordered breathing(SDB)-related pathophysiology of intermittent hypoxia, autonomic dysfunction and intrathoracic pressure alterations, etc. likely exerts differential influences across World Symposium on Pulmonary Hypertension(WSPH) groups that have yet to be characterized , we postulate differing SDB-pulmonary hemodynamics relationships across these groups. Methods Pulmonary Vascular Disease Phenomics(PVDOMICS-NCT02980887), a multicenter cohort study, included patients with mean pulmonary artery pressure(mPAP) on right heart catheterization(RHC) ≥ 25mmHg and home sleep apnea testing(HSAT) within 6 weeks of RHC. SDB measures included apnea-hypopnea index(AHI, 3% desaturation hypopnea definition used) and % recording time&amp;lt; 90% SpO2(TRT&amp;lt; 90%). Pulmonary hemodynamic indices included:mPAP, mean pulmonary capillary wedge pressure(PCWP), right atrial mean pressure(RAP). Linear regression models(beta coefficients±standard error) were constructed to assess sleep indices and RHC measurements with adjustment for age, sex, race, body-mass index(BMI), PH medication and supplemental oxygen use; PH group interaction was analyzed. Results We included 424 participants with available data in the final analytic sample. Groups 2 and 3 were older(65.6±11.9, 64.2±10.8 years, respectively) and Group 5 had the highest % males(71.4%). Group 2 had highest BMI: 34.3±9.2kg/m2 and Group 5 lowest: 28.7±6.4k g/m2. SDB(AHI≥5), was most prevalent in Group 2(71.4%) and least in Group 4(42.9%). TRT&amp;lt; 90% was highest in Group 1(37.0%, [P25=2.2, P75=87.3]) followed by Group 4(35.7% [5.3,82.9]) and lowest in Group 2(6.4% [0.61,41.8]). AHI and RAP association differed across groups, p=0.027 and was strongest in Group 2; per 5-unit increase in AHI, RAP increased by 0.75mmHg (estimate=0.75, standard error[0.15,1.36],p=0.015). TRT&amp;lt; 90% and mPAP had significant cross-group differences, p=0.004. TRT&amp;lt; 90% was associated with mPAP in Groups 1 and 4:per 5-unit increase in TRT&amp;lt; 90%, mPAP increased by 2mmHg(2.10,[1.52,2.68],p&amp;lt; 0.001) and 1.4mmHg(1.40,[0.07,2.73],p=0.039) respectively. Other associations were not significant. Conclusion SDB prevalence differs across WSPH groups and was highest in Group 2 PH. Findings suggest that AHI and TRT&amp;lt; 90%SaO2 differentially contribute to the pathogenesis in PH groups; with AHI associating with RAP, especially in Group 2 PH, and TRT&amp;lt; 90%SaO2 with mPAP in Groups 1 and 4 PH, perhaps via hypoxia-induced pulmonary vasoconstriction and remodeling. Support (if any) Funding: U01 HL125218, U01 HL125205, U01 HL125212, U01 HL125208, U01 HL125175, U01 HL125215, and U01 HL125177 and the Pulmonary Hypertension Association.

0448 Telemedicine Management of Obstructive Sleep Apnea Disorder: A Randomized Controlled Trial

Abstract Introduction Previous studies assessed different components of telemedicine instead of the whole telemedicine management pathway for OSA. The current study aimed to demonstrate that telemedicine management was not clinically inferior to in-person care in China based on the change in Functional Outcomes of Sleep Questionnaire (FOSQ) score following three months of an auto-adjusted positive airway pressure (APAP) treatment. Methods Adults suspected of OSA were randomized to telemedicine (n=178) or in-person (n=178) management. Participants with AHI ≥ 15 events/hour diagnosed by a home sleep apnea test (HSAT) were treated with an APAP with a wireless modem. The participants were followed up by call at week 1 and visit at month 1 and month 3. Results We measured the change in FOSQ score as the primary outcome, with an a priori noninferiority delta of -1, and the mean daily hours of objectively measured APAP adherence, with an a priori noninferiority delta of -45min/day. Of the 356 subjects enrolled, 313 (87.9%) were diagnosed with OSA, and 261 (73.3%) underwent PAP setup. The mean functional outcome score following 3 months improved 1.73 points (95%CI: 1.31, 2.14) in the telemedicine group and 2.05 points (95% CI: 1.64, 2.46) in the in-person group. The lower bound of the one-sided 95% noninferiority confidence interval was -0.812. Mean daily APAP adherence at 3 months was 243.3 minutes/night (95% CI: 223.1, 263.5) in the telemedicine arm and 241.6 minutes/night (95% CI: 221.3, 261.8) in the in-person arm. The lower bound of the one-sided 95% noninferiority confidence interval was -22.2 minutes/night. Compared to in-person management, the telemedicine pathway had lower patients cost and similar health care cost. Conclusion Functional outcome and treatment adherence in patients managed by a comprehensive telemedicine approach is not clinically inferior to that in patients receiving in-person care. Support (if any) ResMed Australia funded the APAP machines. The study was supported by the National Key R&amp;D Program of China (Z161100002616012). Liyue Xu is supported by a grant from the National Natural Science Foundation of China (NSFC 82100104).

1003 Immediate Improvement of Second Degree Heart Block With Effective Treatment of Sleep-Disordered Breathing

Abstract Introduction Cardiac arrhythmia and heart block in particular is commonly found in association with obstructive sleep apnea (OSA). Here we describe real-time responsivity of 2nd degree heart block to treatment of OSA with positive airway pressure (PAP) during a titration study. Report of case(s) Our patient is a 70-year old man without significant cardiovascular disease. He presented with loud snoring and excessive daytime sleepiness. A home sleep apnea test in July 2020 revealed obstructive sleep apnea (respiratory event index 20, oxygen saturation nadir 86%). The patient was treated with auto-adjusting continuous positive airway pressure (APAP) and had symptomatic benefit. His most recent machine data download suggested an elevated residual respiratory event index (REI) of 19.6, 16.5 of which were central. A split-night study was performed to re-characterize the nature of the patient’s obstructive sleep apnea and treatment needs. The baseline portion of the study (AHI 50.8, oxygen saturation nadir 86%) was notable for the presence of frequent 2nd degree heart block (171.0 events/hour of recording). During the titration portion of the study, frequent central sleep apneas emerged with the addition of PAP therapy, consistent with treatment-emergent central sleep apnea. The patient was transitioned to bilevel positive airway pressure spontaneous timed mode (BPAP ST), and a pressure setting of 13/6 cm of water with backup rate of 14 breaths per minute effectively controlled his sleep-disordered breathing. The heart block that had been observed during the baseline portion of the study dramatically improved with the start of BPAP ST. Once the patient’s sleep-disordered breathing was controlled, the patient’s heart block occurred at a rate of only 12.1 events/hour of recording. Conclusion Treatment of sleep apnea has been established to be beneficial for the improvement of cardiac arrhythmias. This case is remarkably instructive in that attainment of an effective treatment setting for sleep-disordered breathing resulted in an almost immediate improvement of heart block. Support (if any)