Lower Apnea-hypopnea Index Research Articles

Mask Ventilation during Induction of General Anesthesia: Influences of Obstructive Sleep Apnea.

Depending on upper airway patency during anesthesia induction, tidal volume achieved by mask ventilation may vary. In 80 adult patients undergoing general anesthesia, the authors tested a hypothesis that tidal volume during mask ventilation is smaller in patients with sleep-disordered breathing priorly defined as apnea hypopnea index greater than 5 per hour. One-hand mask ventilation with a constant ventilator setting (pressure-controlled ventilation) was started 20 s after injection of rocuronium and maintained for 1 min during anesthesia induction. Mask ventilation efficiency was assessed by the breath number needed to initially exceed 5 ml/kg ideal body weight of expiratory tidal volume (primary outcome) and tidal volumes (secondary outcomes) during initial 15 breaths (UMIN000012494). Tidal volume progressively increased by more than 70% in 1 min and did not differ between sleep-disordered breathing (n = 42) and non-sleep-disordered breathing (n = 38) patients. In post hoc subgroup analyses, the primary outcome breath number (mean [95% CI], 5.7 [4.1 to 7.3] vs. 1.7 [0.2 to 3.2] breath; P = 0.001) and mean tidal volume (6.5 [4.6 to 8.3] vs. 9.6 [7.7 to 11.4] ml/kg ideal body weight; P = 0.032) were significantly smaller in 20 sleep-disordered breathing patients with higher apnea hypopnea index (median [25th to 75th percentile]: 21.7 [17.6 to 31] per hour) than in 20 non-sleep disordered breathing subjects with lower apnea hypopnea index (1.0 [0.3 to 1.5] per hour). Obesity and occurrence of expiratory flow limitation during one-hand mask ventilation independently explained the reduction of efficiency of mask ventilation, while the use of two hands effectively normalized inefficient mask ventilation during one-hand mask ventilation. One-hand mask ventilation is difficult in patients with obesity and severe sleep-disordered breathing particularly when expiratory flow limitation occurs during mask ventilation.

The Influence of the Menstrual Phases on Polysomnography.

Purpose: The primary objective of this study is to determine how the phases of the menstrual cycle influence the results of polysomnography (PSG).Methods: Twenty-eight adult subjects who reported regular menstrual periods, last menstrual period (LMP) within 26 days of their PSG, no exogenous hormone use, no history of polycystic ovarian syndrome, and who were scheduled for diagnostic PSG at Boston Medical satisfied inclusion criteria for the study. These subjects were divided into a Follicular Cohort (days 0-13 of the cycle) or Luteal Cohort (days 14-26 of the cycle), and a one-way analysis using a t-test was performed to test the hypothesis that the follicular phase confers protection against obstructive sleep apnea (OSA). A likelihood-ratio chi-square test was also applied to assess for a statistically significant association between menstrual stage and the presence of moderate-to-severe sleep apnea (apnea-hypopnea index (AHI) > 15/h). Thus, the statistical analysis was performed using AHI as both a continuous and a categorical outcome.Results: The mean AHI for patients in the Follicular Cohort (6.1/h) was significantly lower than the Luteal Cohort (14.3/h, p = 0.033). In the Follicular Cohort, 12% of patients had moderate to severe OSA. In the Luteal Cohort, 46% of patients had moderate to severe OSA (p = 0.045).Conclusions: Subjects undergoing PSG during the follicular phase have significantly lower AHIs than those in the luteal phase. Thus, the timing of PSG acquisition for regularly menstruating women should be considered when interpreting results.

Effect of Sleep-disordered Breathing Severity on Cognitive Performance Measures in a Large Community Cohort of Young School-aged Children.

Sleep-disordered breathing (SDB) in children is associated with cognitive challenges. However, potential associations between SDB severity and neurocognitive function, as well as the presence of an SDB cutoff, have not been fully explored. To determine whether SDB-associated adverse changes in neurocognitive functioning are severity dependent. A total of 1,010 snoring and nonsnoring children ages 5-7 years were prospectively recruited from public schools and underwent polysomnography and neurocognitive assessments of intellectual, attention, memory, language, and executive function development. The children were subdivided into four severity groups on the basis of apnea-hypopnea index (AHI), followed by comparisons of cognitive function, with a particular focus on standardized subtests of intellectual, language, attention, memory, and executive function. Differential Ability Scales Verbal (P < 0.001) and Nonverbal (P = 0.002) performance, as well as global conceptual ability (IQ) (P < 0.001) scores, differed significantly across the groups, with individuals with higher AHI showing worse performance. Additionally, specific NEPSY (a Developmental Neuropsychological Assessment) subscores focused on attention and executive skills differed across the groups, indicating differences in levels of engagement and problem solving. Children with higher AHI (>5 per hour of total sleep time) were significantly more impaired than all three lower AHI groups, indicating a dose-response impact of SDB. This large community-based sample of children highlights the significant deleterious impact of SDB, particularly in children with moderate to severe obstructive sleep apnea, and also that even snoring alone affects neurocognitive function. By affecting developing capabilities, as illustrated by cognitive measures in a severity-graded manner, SDB could adversely impact children's capacity to attain academic and adaptive goals, ultimately hampering their ability to reach independence. Our findings support the need for increased awareness of SDB, with particular emphasis on children with more severe obstructive sleep apnea.

Polysomnographic indicators of mortality in stroke patients.

The purpose of the study was to assess polysomnographic indicators of increased mortality risk in patients with stroke or a transient ischemic attack (TIA). We performed polysomnographies in 63 acute stroke/TIA patients. Mortality data were collected from a national database after a 19-37-month follow-up period. Of the 57 stroke and 6 TIA patients, 9 stroke patients died during follow-up. All nine had moderate or severe sleep-related breathing disorders (SRBDs). Binarily divided, the group with the highest apnea hypopnea index (AHI) had an almost 10-fold higher mortality risk (hazard ratio (HR) 9.71; 95% confidence interval (CI) 1.20-78.29; p=0.033) compared to the patients with the lowest AHI. The patients with the longest versus shortest nocturnal wake time had a higher mortality (HR 8.78; 95% CI 1.1-71.8; p=0.0428). Lung disease increased mortality (HR 9.92; 95% CI 2.00-49.23; p=0.005), and there was a trend toward a higher mortality risk with atrial fibrillation/flutter (HR 3.63; 95% CI 0.97-13.51; p=0.055). In stroke patients, the AHI and nocturnal wake time are indicators of increased mortality risk. SRBDs in stroke patients should receive increased attention.

The Relationship Between Obstructive Sleep Apnea Hypopnea Syndrome and Inflammatory Markers and Quality of Life in Subjects With Acute Coronary Syndrome

The objective of this work was to examine the relationship between obstructive sleep apnea (OSA) and inflammatory markers and quality of life in patients with acute coronary syndrome, especially undergoing percutaneous coronary intervention. One hundred eighteen subjects were admitted with acute coronary syndrome over 1 y who had symptoms of OSA and positive polysomnography on admission. Of these subjects, 53 underwent primary percutaneous coronary intervention during their admission, and 65 had medical management. We then compared inflammatory markers by OSA status. We also assessed cardiac symptoms using the Seattle Angina Questionnaire and sleep symptoms using the Epworth Sleepiness Scale. Subjects in the percutaneous coronary intervention group had a higher oxygen desaturation index (ODI) (P = .02) and apnea-hypopnea index (AHI) (P = .048) compared with those in the medical management group. In percutaneous coronary intervention subjects, the moderate-severe OSA group (AHI ≥ 15/h) had a higher hematocrit (P = .047), homocysteine (P = .01), and high-sensitivity C-reactive protein (P = .045) compared with those with no or mild OSA (AHI < 15/h). There was a significant correlation between high-sensitivity C-reactive protein and both AHI (r = 0.46, P = .001) and ODI (r = 0.47, P < .001). Those with moderate-severe OSA had higher Epworth Sleepiness Scale (P = .002), greater physical limitation (P = .01), and lower treatment satisfaction and disease perception (P = .007), as judged by subscales of the Seattle Angina Questionnaire, compared with those with no or mild OSA. Finally, subjects undergoing percutaneous coronary intervention with lower AHI (r = 0.48, P < .001) and ODI (r = 0.49, P < .001) reported higher treatment satisfaction. Subjects with acute coronary syndrome undergoing percutaneous coronary intervention who had moderate-severe OSA showed higher levels of inflammatory mediators and lower treatment satisfaction and disease perception. These factors may increase the risk of adverse sequelae by increasing the systemic inflammatory response.

The Effect of Changes in Cardiorespiratory Fitness and Weight on Obstructive Sleep Apnea Severity in Overweight Adults with Type 2 Diabetes

To examine the effect of changes in cardiorespiratory fitness on obstructive sleep apnea (OSA) severity prior to and following adjustment for changes in weight over the course of a 4-y weight loss intervention. As secondary analyses of a randomized controlled trial, 263 overweight/obese adults with type 2 diabetes and OSA participated in an intensive lifestyle intervention or education control condition. Measures of OSA severity, cardiorespiratory fitness, and body weight were obtained at baseline, year 1, and year 4. Change in the apnea-hypopnea index (AHI) served as the primary outcome. The percentage change in fitness (submaximal metabolic equivalents [METs]) and change in weight (kg) were the primary independent variables. Primary analyses collapsed intervention conditions with statistical adjustment for treatment group and baseline METs, weight, and AHI among other relevant covariates. At baseline, greater METs were associated with lower AHI (B [SE] = -1.48 [0.71], P = 0.038), but this relationship no longer existed (B [SE] = -0.24 [0.73], P = 0.75) after adjustment for weight (B [SE] = 0.31 [0.07], P < 0.0001). Fitness significantly increased at year 1 (+16.53 ± 28.71% relative to baseline), but returned to near-baseline levels by year 4 (+1.81 ± 24.48%). In mixed-model analyses of AHI change over time without consideration of weight change, increased fitness at year 1 (B [SE] = -0.15 [0.04], P < 0.0001), but not at year 4 (B [SE] = 0.04 [0.05], P = 0.48), was associated with AHI reduction. However, with weight change in the model, greater weight loss was associated with AHI reduction at years 1 and 4 (B [SE] = 0.81 [0.16] and 0.60 [0.16], both P < 0.0001), rendering the association between fitness and AHI change at year 1 nonsignificant (B [SE] = -0.04 [0.04], P = 0.31). Among overweight/obese adults with type 2 diabetes, fitness change did not influence OSA severity change when weight change was taken into account. ClinicalTrials.gov identification number NCT00194259.

Obstructive Sleep Apnea in Women: Specific Issues and Interventions.

Obstructive sleep apnea (OSA) has traditionally been seen as a male disease. However, the importance of OSA in women is increasingly being recognized, along with a number of significant gender-related differences in the symptoms, diagnosis, consequences, and treatment of OSA. Women tend to have less severe OSA than males, with a lower apnea-hypopnea index (AHI) and shorter apneas and hypopneas. Episodes of upper airway resistance that do not meet the criteria for apneas are more common in women. Prevalence rates are lower in women, and proportionally fewer women receive a correct diagnosis. Research has also documented sex differences in the upper airway, fat distribution, and respiratory stability in OSA. Hormones are implicated in some gender-related variations, with differences between men and women in the prevalence of OSA decreasing as age increases. The limited data available suggest that although the prevalence and severity of OSA may be lower in women than in men, the consequences of the disease are at least the same, if not worse for comparable degrees of severity. Few studies have investigated gender differences in the effects of OSA treatment. However, given the differences in physiology and presentation, it is possible that personalized therapy may provide more optimal care.

Possible effect of periodic limb movements during sleep on the sleepiness of patients with sleep disordered breathing

We aimed to conduct a cross-sectional study in order to investigate the effect of periodic limb movements during sleep (PLMS) on daytime sleepiness in patients with sleep disordered breathing especially those with obstructive sleep apnea syndrome (OSAS), diagnosed by polysomnography (PSG). Our subjects included 233 male patients who visited our institute during the 25-month period between June 2012 and June 2013. We scored the number of Periodic Limb Movements per hour as the Periodic Limb Movements Index (PLMI) on standard PSG, and considered that periodic limb movements during sleep was present in the patients with PLMI >15/h. Non-PLMS group included those patients with PLMI ≤15/h. To assess the sleepiness of participants, we used Japanese version of the Epworth Sleepiness Scale (JESS) and Japanese version of the Pittsburgh Sleep Quality Index. We compared the sleep parameters and sleepiness indicators between patients with PLMS and age, apnea–hypopnea index (AHI), and body mass index-matched non-PLMS control groups. JESS scores were higher in patients with PLMS than in non-PLMS in both low AHI (<15/h) and high AHI (≥15/h) strata. However, the difference was statistically significant only in high AHI stratum (P = 0.399 and 0.001, respectively). In conclusion, PLMS was associated with increased JESS especially in patients with moderate-to-severe OSAS. Although the magnitude of the difference in those with AHI <15/h was smaller and statistically insignificant in the present study, this issue warrants further investigation by enrolling more patients with AHI <15/h.

Sleep Apnea in Patients with and without a Right-to-Left Shunt.

To assess the presence of right-to-left shunting (RLS) in patients with obstructive sleep apnea (OSA), and compare clinical characteristics and parameters of the sleep studies of patients with and without RLS. The most common cause of RLS is due to intermittent flow through a patent foramen ovale (PFO). PFO occurs more frequently in patients with OSA and may be involved in the exacerbation of OSA. Patients with an abnormal polysomnogram seen at UCLA-Santa Monica Sleep Medicine Clinic were enrolled. A diagnosis of RLS was made using a transcranial Doppler (TCD) bubble study. Gender and age-matched controls were drawn from patients referred for cardiac catheterization who underwent a TCD. The frequency of RLS in OSA patients and the controls was evaluated. Clinical characteristics and polysomnogram parameters were compared between OSA patients with and without a RLS. A total of 100 OSA patients and 200 controls participated in the study. The prevalence of RLS was higher in patients with OSA compared to the control group (42% versus 19%; p < 0.0001). Patients with OSA and a RLS had a lower apnea-hypopnea index (AHI), less obstructive apnea, and fewer hypopnea episodes than patients with OSA without a RLS. The baseline and nadir SpO2 were similar in both groups and did not correlate with the level of RLS assessed by TCD. The degree of desaturation for a given respiratory disturbance, as measured by oxygen desaturation index (ODI)/AHI ratio, was higher in OSA patients with RLS versus OSA patients without RLS (0.85 ± 0.07 versus 0.68 ± 0.04; p < 0.0001). RLS, most commonly due to a PFO, occurs 2.2 times more frequently in OSA patients compared to a control population that was matched for age and gender. The severity of sleep apnea is not greater in OSA patients who have a PFO. However, patients with OSA and a PFO are more likely to become symptomatic at a younger age with an equivalent decrease in nocturnal SpO2, and have greater arterial desaturation in proportion to the frequency of respiratory disturbances.

Prognosis for Spontaneous Resolution of OSA in Children

Adenotonsillectomy (AT) is commonly performed for childhood OSA syndrome (OSAS), but little is known about prognosis without treatment. The Childhood Adenotonsillectomy Trial (CHAT) randomized 50% of eligible children with OSAS to a control arm (watchful waiting), with 7-month follow-up symptom inventories, physical examinations, and polysomnography. Polysomnographic and symptomatic resolution were defined respectively by an apnea/hypopnea index (AHI) <2 and obstructive apnea index (OAI) <1 and by an OSAS symptom score (Pediatric Sleep Questionnaire [PSQ]) < 0.33 with ≥ 25% improvement from baseline. After 194 children aged 5 to 9 years underwent 7 months of watchful waiting, 82 (42%) no longer met polysomnographic criteria for OSAS. Baseline predictors of resolution included lower AHI, better oxygen saturation, smaller waist circumference or percentile, higher-positioned soft palate, smaller neck circumference, and non-black race (each P < .05). Among these, the independent predictors were lower AHI and waist circumference percentile < 90%. Among 167 children with baseline PSQ scores ≥ 0.33, only 25 (15%) experienced symptomatic resolution. Baseline predictors were low PSQ and PSQ snoring subscale scores; absence of habitual snoring, loud snoring, observed apneas, or a household smoker; higher quality of life; fewer attention-deficit/hyperactivity disorder symptoms; and female sex. Only lower PSQ and snoring scores were independent predictors. Many candidates for AT no longer have OSAS on polysomnography after 7 months of watchful waiting, whereas meaningful improvement in symptoms is not common. In practice, a baseline low AHI and normal waist circumference, or low PSQ and snoring score, may help identify an opportunity to avoid AT. ClinicalTrials.gov; No.: NCT00560859; URL: www.clinicaltrials.gov.

Comparison of improvement in quality of life between continuous positive airway pressure and autotitrating positive airway pressure treatment for obstructive sleep apnea: A randomized crossover study

ObjectivesObstructive sleep apnea (OSA) is a sleep disorder with repeated nocturnal desaturation and sleep fragmentation. It can lead to poor quality of life. Our goal was to compare improvement in the quality of life of patients with OSA between those treated with continuous positive airway pressure (CPAP) and autotitrating positive airway pressure (APAP) for 3 months. Materials and MethodsThis was a prospective, randomized, crossover study. Study participants were patients with OSA randomized into the APAP or CPAP group, with crossover to the other group 3 months later. All patients received CPAP or APAP treatment for > 4 h/d. Each patient completed the Short Form 36 Health Survey (SF-36) before and after the 3-month CPAP and APAP treatment. ResultsThe 19 patients had severe OSA [mean apnea–hypopnea index (AHI) 59.7 ± 23.9/h] and the mean optimal pressure of CPAP titration was 8.7 ± 1.5 mmHg. The CPAP group had a higher mean pressure 8.7 ± 1.4 mmHg as well as a lower AHI 0.6 ± 1.4/h than the APAP group. There was no difference in compliance between groups. Both groups had significant improvement in general health and vitality after treatment compared with before treatment. However, there were no significant differences in improvement in any component of the SF-36 between groups. ConclusionIn our study, the CPAP patients had a higher pressure and lower AHI than the APAP patients. OSA patients preferred APAP. Both CPAP and APAP can improve general health and vitality in OSA patients.

19 Sleep-disordered breathing in heart failure patients requiring cardiac resynchronisation therapy: is there a link to poorer outcomes after device insertion

Rationale We sought to ascertain the burden of undiagnosed sleep-disordered breathing (SDB) in high-risk heart failure patients, namely patients requiring cardiac resynchronisation therapy (CRT). Additionally, we looked for correlation between presence of SDB and change in cardiac function pre- and post-device. Methods From a population of 40 patients with CRT devices implanted, a stable group of 18 were selected. Polysomnography was undertaken in each case. Apnoea-hypopnoea index (AHI), oxygen desaturation index (ODI), sleep efficiency, minimum oxygen saturation and snore index were calculated. Comparison was made to left ventricular function, left atrial dimension and mitral regurgitation severity pre- and post-implantation of CRT device. We also measured functional capacity of each patient using the International Physical Activity Questionnaire (IPAQ) tool and compared sleep profiled of those with a good functional capacity (>1000 MET minutes/week) against those with poor functional capacity. Data were analysed with simple descriptive statistics for baseline characteristics and comparisons made using Student t-test. Results Our population had a high AHI (mean 14.2) and ODI (15.2) with poor sleep efficiency (mean 62%). 2 patients (11%) were classified as severe OSA (AHI > 30), and 11 (61%) had mild to moderate OSA. Patients were subdivided into those with improved cardiac function post-implant (n = 8) and those with unchanged or disimproved function (n = 10). Those patients who had an objective improvement in cardiac function by echocardiographic parameters were found to have a better overall sleep profile with a lower AHI (6.8 vs 16.05), snore index (32.6 vs 49.95) and higher sleep efficiency (63% vs 61%) and minimum nocturnal oxygen saturation (88% vs 83%). Patients with poor functional capacity as identified by were additionally found to have a higher snore index (48.7 vs 26.9) and poorer sleep efficiency (48.7 vs 71.8). Conclusions There is a high prevalence of SDB in our cohort with a trend towards more severe sleep apnoea in non-responders to CRT. Failure to respond to appropriate device therapy in severe heart failure may be a red flag for clinicians, with identification and treatment of co-morbid sleep apnoea potentially having a role in optimising patient outcomes.

The diagnostic method has a strong influence on classification of obstructive sleep apnea.

Polygraphy (PG) and polysomnography (PSG) are used in clinical settings in Europe for diagnosing obstructive sleep apnea (OSA), but their equivalence in unselected clinical cohorts is unknown. We hypothesized that the method would affect both diagnostic outcomes and disease severity stratification. Data from 11 049 patients in the multi-centre European Sleep Apnea Cohort (ESADA) with suspected OSA (male and female, aged 18-80 years) were used in two groups of patients to compare PG (n = 5745) and PSG (n = 5304). Respiratory events were scored using the 2007 American Association of Sleep Medicine (AASM) criteria. In subjects who underwent PSG, mean apnea-hypopnea index (AHI) using sleep time (AHIPSG 31.0 ± 26.1 h(-1) ) and total analysed time (TAT) (AHITAT 24.7 ± 22.0 h(-1) ) were higher than in subjects who underwent PG (AHIPG 22.0 ± 23.5 h(-1) ) (P < 0.0001). The oxygen desaturation index (ODI) was lower in subjects investigated with PG (ODIPG 18.4 ± 21.7 h(-1) ) compared to subjects investigated with PSG (ODIPSG 23.0 ± 25.3 h(-1) ) but not different when the PSG was indexed by TAT (ODITAT 18.6 ± 21.4 h(-1) , P < 0.65). The proportion of patients with an AHI ≥ 15 was 64% in the subjects who underwent PSG and 47% in the subjects who underwent PG (P < 0.001). Overall, patients investigated using PG are likely to have a 30% lower AHI on average, compared to patients investigated by PSG. This study suggests that PG interpreted using standard guidelines results in underdiagnosis and misclassification of OSA. We advocate the development of PG-specific guidelines for the management of OSA patients.

Sleep apnea diagnosis varies with the hypopnea criteria applied.

We aimed to evaluate the three hypopnea criteria, A and B from 2007 and the revised from 2012, proposed by the American Academy of Sleep Medicine (AASM) for scoring sleep-related breathing disorders (SRBDs) in patients with acute stroke or transient ischemic attack (TIA). Polysomnographies (PSGs) in patients with TIA or stroke were scored according to the A-, B-, and 2012-hypopnea criteria. Sixty-three PSGs were eligible for hypopnea scoring. There was no difference in the number of patients diagnosed with the B- and 2012-criteria. Therefore, they are mentioned as one. Forty-seven patients (75 %) were diagnosed with SRBD using the A-criteria versus 57 patients (90 %) using the B/2012-criteria (p < 0.0016). In 30 cases, a change from A- to B/2012-criteria resulted in a change in diagnosis. Ten cases of "no SRBD" changed to mild/moderate/severe SRBD. An apnea hypopnea index (AHI) >15 is a typical indication of treatment. With the B/2012-criteria, we found an additional indication of treatment in 18 patients, compared to when the A-criteria were applied (p < 0.0001). Two of these patients were labeled as no SRBD with the A-criteria. The difference is significant between the AHIs achieved by the A- and the B-/2012-hypopnea criteria, with much lower AHIs achieved with the A-criteria. As SRBD treatment lessens the risk of complications, correct identification of SRBD patients is of the utmost importance.

Effects of Mandibular Advancement Devices on Sleep, Blood Pressure and Jaw Functions in Patients with or without Diabetes

Severity of obstructive sleep apnea (OSA) has two main components: severity of daytime sleepiness and apnea hypopnea index (AHI) in addition to adjacent health complications. We investigated the effect of custom-made Mandibular Advancement Devices (MADs) on breathing pattern parameters (including apneahypopnea index), blood pressure, daytime sleepiness (Epworth score) and temporomandibular disorders (TMD) in a randomized crossover trial at the Department of Oral and Maxillofacial Surgery, Odense University Hospital, on consecutively treated patients diagnosed with snoring or sleep apnea. Continuous registrations of outcome variables were performed; patients underwent diagnostic cardio-respiratory monitoring before and after 3 months’ MAD therapy, and results obtained in patients before MAD therapy were compared with those obtained after MAD therapy. Measurements with and without MAD were compared using Student’s t-test or Wilcoxon signed rank test, and mixed-model analyses was performed to analyze repeated measurements and adjusting for sleep apnea severity, type 2 diabetes, body-mass-index, sex and age. A total of 44 patients (31 men; 13 women, aged 50 ± 13 years, BMI 31 ± 5.6, diabetic n=18; non-diabetic n=26) completed the trial. The apnea-hypopnea index (AHI) reduced from 15.8 ± 17.4 without MAD to 6.2 ± 9.8 events/h with MAD (P<0.001). After 6 months without therapy compared with 6 months’ MAD therapy, mean systolic blood pressure decreased from 135 ± 15 to 132 ± 15 mm/Hg (P=0.02) and Epworth score decreased from 10 ± 5 to 6 ± 3 (P<0.001). The occurrence of TMD diagnoses did not increase, no patients discontinued therapy due to TMD, and there were no interactions between diabetes status or obstructive sleep apnea severity evident for any outcome parameter. Conclusions: The present study confirmed MAD therapy to be a relevant treatment option without significant side effects on jaw function in patients with high as well as low AHI, and in diabetic as well as non-diabetic patients.

Severity of the Apnea-Hypopnea Sleep Syndrome in Patients with Rheumatoid Arthritis and Spondyloarthropathies. Modulation of the Sleep Apnea Index with Anti-TNF-? Inhibitors

Objective: To evaluate severity of the sleep apnea-hypopnea syndrome (SAHS) in patients with rheumatoid arthritis (RA) and spondyloarthropathies (SpA). To study the behavior of the apnea-hypopnea index (AHI) in patients treated with anti-TNF-α. Materials and methods: An observational, retrospective study was conducted in patients with RA and SpA (study group) and with osteoarthritis (control group) who have SAHS symptoms. AHI (expressed in median and 25- 75 percentiles), mean oxygen saturation (SaO2 ) and information on associated cardiovascular risk factors (CVRF) were collected. This information was also collected in the anti-TNF-α treated study group. Results: The study group (75 patients [48 with RA and 27 with SpA], 36 men) were younger (53.1 ± 10.6 vs. 57.2 ± 9.6 years, p=0.022) compared to the control group (58 patients, 23 men). The study group had a higher incidence of hypercholesterolemia (62.7% vs. 17.2%, p<0.001) and ischemic heart disease (17.3% vs. 3.4%, p=0.013). Sixteen patients of the study group were treated with anti-TNF-α. Patients in the study group had higher AHI than the control group (median 37.4 vs. 27.8, p=0.025). Those treated had a similar value to the control group (29.1 vs. 27.8, NS) and a lower value compared to the non-treated (29.1 vs. 36.8, p=0.052). No differences in the SaO2 were observed. Conclusions: Patients with SAHS and inflammatory arthritis are younger and have more CV risk factors than those who have non-inflammatory arthropathy. Patients with SAHS and inflammatory arthritis treated with TNF-α inhibitors have a lower AHI than those treated only with disease modifying drugs and one that is similar to patients with non-inflammatory arthropathy. This suggests improvement of the SAHS.

Effectiveness of home single-channel nasal pressure for sleep apnea diagnosis.

Home single-channel nasal pressure (HNP) may be an alternative to polysomnography (PSG) for obstructive sleep apnea (OSA) diagnosis, but no cost studies have yet been carried out. Automatic scoring is simpler but generally less effective than manual scoring. To determine the diagnostic efficacy and cost of both scorings (automatic and manual) compared with PSG, taking as a polysomnographic OSA diagnosis several apnea-hypopnea index (AHI) cutoff points. We included suspected OSA patients in a multicenter study. They were randomized to home and hospital protocols. We constructed receiver operating characteristic (ROC) curves for both scorings. Diagnostic efficacy was explored for several HNP AHI cutoff points, and costs were calculated for equally effective alternatives. Of 787 randomized patients, 752 underwent HNP. Manual scoring produced better ROC curves than automatic for AHI < 15; similar curves were obtained for AHI ≥ 15. A valid HNP with manual scoring would determine the presence of OSA (or otherwise) in 90% of patients with a polysomnographic AHI ≥ 5 cutoff point, in 74% of patients with a polysomnographic AHI ≥ 10 cutoff point, and in 61% of patients with a polysomnographic AHI ≥ 15 cutoff point. In the same way, a valid HNP with automatic scoring would determine the presence of OSA (or otherwise) in 73% of patients with a polysomnographic AHI ≥ 5 cutoff point, in 64% of patients with a polysomnographic AHI ≥ 10 cutoff point, and in 57% of patients with a polysomnographic AHI ≥ 15 cutoff point. The costs of either HNP approaches were 40% to 70% lower than those of PSG at the same level of diagnostic efficacy. Manual HNP had the lowest cost for low polysomnographic AHI levels (≥ 5 and ≥ 10), and manual and automatic scorings had similar costs for higher polysomnographic cutoff points (AHI ≥ 15) of diagnosis. Home single-channel nasal pressure (HNP) is a cheaper alternative than polysomnography for obstructive sleep apnea diagnosis. HNP with manual scoring seems to have better diagnostic accuracy and a lower cost than automatic scoring for patients with low apnea-hypopnea index (AHI) levels, although automatic scoring has similar diagnostic accuracy and cost as manual scoring for intermediate and high AHI levels. Therefore, automatic scoring can be appropriately used, although diagnostic efficacy could improve if we carried out manual scoring on patients with AHI < 15. Clinicaltrials.gov identifier: NCT01347398.

Efficacy of auto-trilevel positive airway ventilation in hypercapnic patients with overlap syndrome

To observe the efficacy of auto-trilevel positive airway pressure (Auto-trilevel PAP) ventilation in overlap syndrome (OS) patients with hypercapnia. From October 2012 to May 2014, 21 OS patients with a PaCO2> 45 mmHg (1 mmHg = 0.133 kPa) and coexisting stable chronic obstructive pulmonary diseases (COPD) and moderate-to-severe OSAS were recruited. Three different positive airway pressure (PAP) modes of ventilators (SOMNOvent auto-S, Weinmann Inc, Germany) were employed for 8 hours per night with each mode at each night and two nights' interval without any treatment among different modes. Under mode one, the expiratory positive airway pressure (EPAP) issued by bilevel positive airway pressure (BiPAP) was titrated as the minimal positive pressure for a disappearance of snoring. The same inspiratory positive airway pressure (IPAP) titrated by end tidal CO2 levels under mode 1 was used under modes 2 and 3 as well. However, the EPAP issued by BiPAP under mode 2 was 3 cmH2O (1 cmH2O = 0.098 kPa) higher than that under mode 1. Under mode 3 with autotrilevel PAP, the beginning of EPAP was set the same as that under mode 1 while the end of EPAP (EEPAP) was automatically adjusted based on upper airway patency condition. Comparisons were made for parameters before and after treatment as well as among different ventilation modes. The following parameters were compared such as nocturnal apnea hypopnea index (AHI), minimal SpO2 (miniSpO2), arousal index, sleep efficiency, morning PaCO2 and Epworth sleepiness score (ESS). Compared with the parameters pre-therapy, modes 1-3 showed a significant decrease in nocturnal AHI (6.3 ± 1.3), (3.1 ± 1.0), (3.6 ± 0.6) vs (38.6 ± 11.3) events/h), arousal index ((7.0 ± 1.1), (5.1 ± 0.9), (4.2 ± 1.7) vs (27.5 ± 5.4) events/h), morning PaCO2 (42.4 ± 3.8), (47.9 ± 2.6) and (43.2 ± 3.3) vs (57.3 ± 4.3) mmHg and daytime ESS (7.2 ± 1.3, 7.4 ± 1.3 and 5.3 ± 1.5 vs 11.4 ± 2.7), but a significant increase in nocturnal miniSpO2 (82.3 ± 5.4), (89.6 ± 3.9) and (90.3 ± 3.2) vs (62.4 ± 11.3) mmHg and sleep efficiency caused (71.3 ± 5.2)%, (79.4 ± 4.3)% and (83.2 ± 4.4)% vs (59.8 ± 6.3)% (all P < 0.01). Comparison of 3 modes demonstrated that, with the same IPAP, mode 3 resulted in the lowest arousal index, daytime ESS and the highest sleep efficiency. Comparison of modes 1 and 2 revealed a statistically lower AHI but higher miniSpO2 and morning PaCO2 under mode 2 (all P < 0.01). Compared with mode 1, mode 3 showed a lower AHI, higher miniSpO2 (all P < 0.01), but there was no significant difference in PaCO2 at the end of therapy. Compared with mode 2, mode 3 showed a significant lower PaCO2 (P < 0.01), but there was no significant difference in AHI and miniSpO2. Auto-trilevel PAP ventilation is superior to fixed BiPAP ventilation in the treatment of hypercapnic OS since this novel PAP mode can achieve a higher efficacy in simultaneous removal of residual apnea hypopnea events and correction of hypercapnia and yield a higher sleep quality and lower daytime sleepiness.

Clinical verification of patients with obstructive sleep apnea provided with a customized cushion for continuous positive airway pressure

Statement of problemPatients with obstructive sleep apnea may stop breathing momentarily during sleep because of a narrow upper respiratory tract. One of the main treatments for obstructive sleep apnea is continuous positive airway pressure. However, after long-term treatment, patients tend to complain about the leakage, inconvenience, and discomfort of the nasal mask. PurposeThe purpose of the study was to develop customized cushions and compare the clinical performance of the customized cushion with the conventional one. Material and methodsEach participant's face was replicated by using a 3-dimensional scanner and reverse-engineering technology, and computer numerical control techniques were used to design and manufacture customized cushions. Forty participants were randomly divided into 2 groups, a control group with conventional cushions and an experimental group with customized cushions. The saturation level of peripheral oxygen, apnea-hypopnea index, leakage data, and answers to a comfort questionnaire were examined. ResultsCustomized and conventional cushions were compared with independent sampling t tests and relational analyses. A significant difference was found in the apnea-hypopnea index (P=.001) of participants with the customized cushion and those with the conventional cushion. Participants with the conventional cushion had a lower apnea-hypopnea index. The customized cushion applied less headgear force and fit better than the conventional cushion. The leakage volume, saturation of peripheral oxygen (SpO2), treatment compliance, and degree of comfort were not significantly different between the groups. ConclusionsCustomized nasal mask cushions fit better and reduce the force applied by the headgear. Participants using a customized cushion showed an improved apnea-hypopnea index.

Preliminary research on clinical value of localization of upper airway obstruction with nasopharyngeal airway combined with polysomnography

To investigate the clinical value of localization of upper airway obstructive site with the method of combination of nasopharyngeal airway and polysomnography (PSG). Forty-seven patients diagnosed as obstructive sleep apnea hypopnea syndrome (OSAHS) by PSG were enrolled. Each patient was examined by Somte PSG for the first night, underwent repeated PSG examination with the nasopharyngeal airway in place for the second night and received airway continuous pressure measurements (ApneaGraph) examination for the third night. The standard of treatment success was defined as apnea-hypopnea index (AHI) less than 20/h and a reduction of 50% or more. The patients were divided into success group and failure group. The PSG indices and ApneaGraph data of the two groups were compared. Correlations between AHI with nasopharyngeal airway in place by PSG and lower AHI and constituent ratio of lower obstruction by ApneaGraph were calculated. SPSS 17.0 software was used to analyze the data. Forty-two patients completal three-night examination. With the nasopharyngeal airway in place, AHI, the lowest oxyhemoglobin saturation (LSaO2), average oxyhemoglobin saturation, percent of sleep time with oxyhemoglobin saturation <0.90 (SaO2 < 0.90T%) were improved obviously (P < 0.001). Twenty-nine patients (69.0%) achieved treatment success. There were statistical differences (t = 2.670, P = 0.011; Z = -3.252, P = 0.001 and t = -4.556, P < 0.001) of LSaO2 by PSG, lower AHI and constituent ratio of lower obstruction by ApneaGraph compared success group with failure group. The correlations between AHI with nasopharyngeal airway in place by PSG and lower AHI and constituent ratio of lower obstruction by ApneaGraph were 0.616 (P < 0.001) and 0.526 (P < 0.001). The method of combination of nasopharyngeal airway with PSG is a reliable method of localization of upper airway obstructive site and can be used as a simple means to find out if there's any retroglossal obstruction.