Obstructive Sleep Apnea Categories Research Articles

Obstructive Sleep Apnea and Oxygenation in Very Old Adults: A Propensity-Score Match Study

ObjectivesThe prevalence of obstructive sleep apnea (OSA) escalates with advancing age. Although the apnea-hypopnea index (AHI) is the standard measure for assessing OSA severity, it does not account for additional oximetric parameters that may influence disease progression in older adults. This study aimed to evaluate disparities in respiratory polygraphy/polysomnography parameters among patients with OSA, stratified by age and sex. DesignRetrospective propensity score-matched study. Setting and ParticipantsSleep unit of a university hospital; 11,747 participants, 210 aged 80 years or older. MethodsPropensity score matching was used to establish 4 age cohorts, with the 210 oldest adults serving as the reference group. Primary outcome variables included the total sleep time with oxygen saturation (SaO2) below 90% (T90), average SaO2, minimum SaO2, and AHI. The association between T90 and AHI, as well as the severity of OSA, was assessed across the 4 age categories. ResultsDespite comparable AHI scores, the oldest patients with OSA exhibited the highest T90 and the lowest SaO2 levels compared to younger counterparts. The proportion of patients with severe OSA and T90 in the highest quartile increased with age: 12.5% in young adults, 14.8% in adults, 21.7% in the old, and 34% in the very old participants (P < .001). old and very old patients had a greater likelihood of being in the most severe OSA category compared to the younger ones, with odds ratios (OR) 2.57 (95% CI 1.42–4.65) and 5.52 (95% CI 3.06–9.97), respectively. These patterns were more pronounced in women of advanced age, indicating a sex-specific variation in disease severity with increasing age. Conclusions and ImplicationsOld patients with OSA, particularly women, demonstrate elevated T90 and reduced SaO2 levels, irrespective of AHI, indicating a hypoxemia increased risk. The diagnostic criteria, management, and outcomes for OSA may require adaptations to address the unique needs of very old populations.

Influence of excessive daytime sleepiness on the treatment adherence of obstructive sleep apnea

ObjectivesTo compare positive airway pressure (PAP) adherence between patients with or without excessive daytime sleepiness (EDS) in mild, moderate and severe obstructive sleep apnea (OSA). MethodsPatients ≥18 years diagnosed with OSA in 2018 and 2019, without previous history of PAP usage and with adherence registration in the first medical consultation after treatment initiation, were included. EDS was defined as a score of ≥10 on the Epworth Scale. Patients were divided into two groups according to the adherence to PAP: “Adherent” if using the device for ≥4 h for ≥70% of the nights and “Nonadherent” otherwise. Simple and multiple logistic regression models for adherence were determined. Results321 patients were included, most male (64.2%), with mean age 56.56 years. Most patients had severe OSA (n = 159; 49.5%), and median AHI was 29.3/h [16.8; 47.5]. Being older or having a severe OSA resulted in an increased adherence (OR = 1.020, CI95% = [1.002; 1.039] and OR = 2.299, CI95% = [1.273; 4.191], respectively). In patients without EDS a statistically significant difference was found in adherence between those with severe OSA and both mild and moderate OSA categories (OR = 0.285, p = 0.023 and OR = 0.387, p = 0.026, respectively), with patients with severe OSA being adherent. There was no statistical difference in adherence between patients with or without EDS (OR 1.083; p = 0.876), nor in the different degrees of severity in those with EDS. ConclusionIn our study there were no differences in PAP therapy adherence between patients with or without excessive daytime sleepiness. Older age and higher OSA severity resulted in higher adherence rates.

Lighter sleep and obstructive sleep apnea associate with higher enlarged perivascular spaces 15 years later

AbstractBackgroundEnlarged perivascular spaces (ePVS) and sleep disturbances have been associated with incident dementia. While healthy sleep is suggested to promote glymphatic clearance in the brain, poorer sleep may be associated with higher ePVS burden (representing impaired perivascular drainage), which may contribute to sleep’s role in dementia risk. We assessed the association between sleep characteristics measured with polysomnography and subsequent ePVS burden.MethodWithin the Framingham Heart Study, 522 participants (age: 46.1±9.0 years; 50.4%M) underwent a full‐night in‐home polysomnography. Sleep variables measuring sleep architecture (total sleep time, wake after sleep onset, sleep efficiency), sleep stages (N1, N2, N3 and REM sleep in absolute minutes and percent of total sleep time), and obstructive sleep apnea severity (apnea‐hypopnea index, obstructive sleep apnea categories [mild, moderate, severe], sleep time &lt;90% SaO2) were extracted. On average 16.7 ± 2.6 years later, participants underwent magnetic resonance imaging. ePVS were rated in the basal ganglia and centrum semiovale, and dichotomized for analyses: low burden (&lt;20 counts, grade 1 and 2) or high burden (&gt;20 counts, grade 3 and 4). Logistic regressions analyses relating sleep characteristics to ePVS burden were used, adjusted for age, sex, time interval between polysomnography and magnetic resonance imaging, APOE4 allele carrier status, hypertension, and smoking.Results21 participants had high ePVS burden in basal ganglia, and 68 participants in the centrum semiovale. Longer time spent in N1 (minutes and % of total sleep time; OR[95%]: 1.02[1.00‐1.04], p = 0.026; 1.11[1.03‐1.19], p = 0.008 respectively), shorter time spent in N3 (minutes; OR[95%]: 0.99[0.98‐0.99], p = 0.029), and longer time spent &lt;90% SaO2 (OR[95%]: 1.03[1.00‐1.05], p = 0.025) were associated with higher ePVS burden in the centrum semiovale. No other associations between sleep characteristics and ePVS ratings were observed.ConclusionLighter sleep, as characterized by longer N1 sleep and shorter N3 sleep, as well as the hypoxemia component of obstructive sleep apnea are associated with higher ePVS burden in subsequent brain magnetic resonance imaging. If replicated, these findings suggest a role for sleep disturbances in glymphatic clearance and cerebral small vessel disease, which may be implicated in the association between sleep and dementia risk.

Atherosclerotic plaque in individuals without known cardiovascular disease but with established obstructive sleep apnea and at high risk of obstructive sleep apnea

ObjectivesIn a large U.S. cohort free of CVD evaluated by coronary computed CT angiography, we aimed to assess the association between established / high risk of Obstructive Sleep Apnea (OSA) and coronary plaque. BackgroundThere are limited data available depicting the association between established / high risk of OSA and the presence of coronary plaque in a population-based sample free from CVD. MethodsCross-sectional data from 2359 participants enrolled in the Miami Heart Study (MiHeart) who underwent coronary CT angiography was used for this study. The Berlin questionnaire was used to stratify patients as having high or low risk of OSA. Multiple multivariable logistic regression analyses were conducted to investigate the association between the risk of developing OSA with the presence, volume, and composition of plaque. ResultsAccording to the Berlin questionnaire, 1559 participants were (66.1%) at low risk of OSA and 800 patients (33.9%) with established / high risk of OSA. Plaque characterization on CCTA revealed a greater incidence of any possible plaque composition in the established / high risk of OSA category (59.6% vs. 43.5%) compared to the low risk of OSA cohort. In logistic regression models, after adjusting for demographics and cardiovascular risk factors, a significant association could still be noted between established / high risk of OSA and any coronary plaque on CCTA (OR=1.31, CI 1.05, 1.63, p = 0.016). Subgroup analysis in the Hispanic population also portrayed a significant association between established / high risk of OSA and the presence of coronary plaque on CCTA (OR = 1.55 CI 1.13, 2.12, p = 0.007). ConclusionAfter accounting for CVD risk factors, individuals at established / high risk of OSA have a higher likelihood of the presence of coronary plaque. Future studies should focus on OSA presence or risk, OSA severity, and the longitudinal consequences of coronary atherosclerosis.

Abstract MP45: Nocturnal Hypoxemia, Obstructive Sleep Apnea and the Risk of Cardiovascular Diseases and Mortality: Insights From the Atherosclerosis Risk in Communities Participants of the Sleep Heart Health Study

Background: Nocturnal hypoxemia may better capture disease burden than obstructive sleep apnea (OSA). Using a subset of participants from the Atherosclerosis Risk in Communities (ARIC) study who participated in the Sleep Heart Health Study (SHHS), we examined the association of nocturnal hypoxemia and OSA with cardiovascular diseases (CVD) and mortality in a white, older cohort in the US. Methods: A total of 1,455 participants free of CVD had an in-home, overnight polysomnogram; nocturnal hypoxemia (% of total sleep time with oxygen saturation &lt;90%) and OSA (apnea-hypopnea index - # of apneas/hypopneas per hour of sleep) were derived from these readings. Incident CVD events and mortality were identified through the end of 2019 using annual telephone calls, hospital discharge lists and death certificates and were adjudicated by physician review. Included in this analysis were coronary heart disease (CHD), heart failure (HF), stroke, any CVD event (CHD, HF, or stroke), atrial fibrillation (AF), and all-cause mortality. We used Cox proportional hazards models to assess the association of nocturnal hypoxemia (categories: &lt;1%, 1-&lt;5%, ≥5%) and OSA (categories: &lt;5, 5-&lt;15, 15-&lt;30, ≥30) with each outcome. Results: At the sleep assessment, participants had a mean (SD) age of 62 (6) years, 53% were female, and 14% had a nocturnal hypoxemia ≥5%. Over a mean follow-up of 17.8 years, a total of 408 participants had any CVD event, and 602 died. Nocturnal hypoxemia ≥5% was associated with incident HF and all-cause mortality in the fully adjusted model (Table). Nocturnal hypoxemia ≥5% was also associated with incident CVD and AF in Model 1; however, adjustment for body mass index attenuated these associations (Table, Model 2). OSA was not associated with the outcomes in any model (data not shown). Conclusion: Further research is needed to understand the distinction between nocturnal hypoxemia and OSA and how they relate to the risk of CVD and mortality. It is possible that reducing nocturnal hypoxemia should be targeted over OSA for CVD prevention.

The effects of an exercise intervention on executive function among overweight adults with obstructive sleep apnea.

Obstructive sleep apnea (OSA) is associated with poorer executive function. This study examined the effects of a comprehensive exercise intervention on executive function in overweight adults with mild and moderate-to-severe OSA. Participants aged between 30 and 65 years, with a body mass index (BMI) ranging from 27 to 42 kg/m2, participated in a 6-week exercise program. Standardized polysomnographic recording methods provided total Apnea-Hypopnea Index (AHI) and level of hypoxemia. Executive function was assessed using the NIH Toolbox Flanker Inhibitory Control Test. A submaximal treadmill exercise test evaluated cardiorespiratory fitness. Participants with baseline total AHI between 5 and 14.9 events/h were classified as mild OSA and participants with baseline total AHI 15 ≥ events/h were classified as moderate-to-severe OSA. Fifteen participants completed 18 exercise sessions. Significant differences between OSA categories at baseline were observed for sleep characteristics, but not for fitness or executive function. Wilcoxon Signed Rank Tests showed significant increases in median values for the Flanker Test in the moderate-to-severe category only, z = 2.429, p < .015, η2 = .737. Six weeks of exercise improved executive function in overweight individuals with moderate-to-severe OSA, but not in those with mild OSA.

Night-to-night variability in obstructive sleep apnea using peripheral arterial tonometry: a case for multiple night testing.

Night-to-night variability of obstructive sleep apnea severity is considerable and may depend on the diagnostic modality used. We investigated the night-to-night variability using peripheral arterial tonometry (PAT). Home sleep apnea testing was performed in 51 patients during 3 consecutive nights using PAT. Patients referred to our sleep clinic were screened and prospectively recruited for this study. All recordings were automatically and manually scored according to the PAT scoring guidelines. No systematic differences in PAT-derived apnea-hypopnea index (pAHI) were found between the nights. The night-to-night variability was comparable between manually and automatically scored data. pAHI varied in 35% of patients more than 10 events/h between the nights. The obstructive sleep apnea severity of 24% of patients was misclassified when using 1 night compared to the average of all nights. On average, pAHI varied by 57% from night to night. The variability of pAHI could partially be explained by the variability of time spent in the supine position with more time supine leading to a higher pAHI. On measuring a subsequent night, 12-14% of patients spontaneously fulfilled the commonly accepted criteria for treatment success without any intervention. With repeated recordings of PAT, we found no first night effect. However, there is considerable night-to-night variability similar to values found for polysomnography, which can partially be explained by the variability of time spent in the supine position. Obstructive sleep apnea severity was frequently misclassified due to the night-to-night variability. Our findings make a strong case for multiple testing in the diagnostic work-up of obstructive sleep apnea patients. Tschopp S, Wimmer W, Caversaccio M, Borner U, Tschopp K. Night-to-night variability in obstructive sleep apnea using peripheral arterial tonometry: a case for multiple night testing. J Clin Sleep Med. 2021;17(9):1751-1758.

Can the negative pressures found in obstructive sleep apnea and Eustachian tube dysfunction be related?

ObjectiveThe association between obstructive sleep apnea (OSA) and Eustachian tube dysfunction (ETD) is well known. When both exist in a single pediatric patient, one of the expected culprits is adenoid enlargement. We hypothesize, in contrast, that the negative pharyngeal pressure found in OSA may be transmitted to the middle ear as negative middle ear pressure (MEP), which subsequently results in pathology. The objective of this study was to determine whether the degree of OSA and MEP are associated while using MEP as a quantifiable measurement of ETD. Study designRetrospective chart review. SettingTertiary academic center (Jan 2000–Jan 2018). Subjects and methodsThe relationship between apnea-hypopnea index (AHI) and MEP was examined. A non-anatomic model was utilized to support causality. ResultsThirty-four pediatric patients and twenty-three adult patients were included in the analysis. REM AHI showed a moderate negative correlation with MEP in children (r = -0.265), and a weak positive correlation with MEP in adults (r = 0.171). Children with an AHI in the severe OSA category had a more negative mean MEP than those in the mild category (p = 0.36). Adults with an AHI in the severe OSA category had a more positive mean MEP than those in the mild category (p = 0.11). ConclusionIn children, increasing severity of OSA is associated with a negative MEP, suggesting that negative pressure associated with OSA may be transmitted to the middle ear. In adults, increasing severity of OSA is associated with a more positive MEP.

The Relationship of Serum 25-Hydroxyvitamin-D Level with Severity of Obstructive Sleep Apnea in Patients with Type 2 Diabetes Mellitus.

ObjectiveTo explore the association of serum vitamin-D levels with the severity of obstructive sleep apnea (OSA) in patients with type 2 diabetes mellitus (T2DM).MethodsA cross-sectional study of 136 patients with T2DM who underwent overnight polysomnography (PSG) tests and serum 25‐hydroxyvitamin‐D3 (25(OH)D3) level detections was conducted. Multivariable linear regression and logistic regression analyses were performed to determine the associations of serum 25(OH)D3 levels with apnea–hypopnea index (AHI) and obstructive sleep apnea (OSA).ResultsThe prevalence rates of OSA were 84.4% for male and 65.2% for female patients, respectively (p = 0.011). With increasing severities of OSA categories (none, mild, moderate and severe), patients were more likely to be male and obese, but there was no significant difference in serum 25(OH)D3 level ((mean ± standard deviation) 21.8 ± 8.8, 27.7 ± 14.6, 24.2 ± 9.8 and 26.8 ± 6.2 ng/mL, respectively, p=0.086). Serum 25(OH)D3 level was not significantly correlated with AHI (log-transformed), with the correlation coefficient of 0.133 (p=0.124). With adjustment for potential confounding factors, multivariable linear regression and logistic regression analyses showed that serum 25(OH)D3 level was not significantly associated with either AHI (log-transformed) or the risk of OSA, with the standardized regression coefficient (95% confidence interval (CI)) of 0.098 (−0.004–0.014, p=0.252) and the adjusted odds ratio (95% CI) of 1.055 (0.991–1.124, p=0.095), respectively.ConclusionSerum 25(OH)D3 level was not significantly associated with either AHI or the risk of OSA in patients with T2DM.

Effects on obstructive sleep apnea severity following a tailored behavioral sleep medicine intervention aimed at increased physical activity and sound eating: an 18-month follow-up of a randomized controlled trial.

Positive effects have been reported following a behavioral sleep medicine (BSM) intervention targeting physical activity and eating behavior in addition to continuous positive airway pressure (CPAP) treatment in patients with obstructive sleep apnea (OSA). Long-term follow-up remains to be explored. The aim was to examine the long-term effects of a tailored BSM intervention addressing physical activity and eating behavior in addition to CPAP treatment in patients with moderate to severe OSA combined with overweight and physical inactivity. Further, the aim was to identify variables at baseline, associated with treatment success regarding OSA severity. Sixty participants (body mass index: 34.5 ± 5.0 kg/m²; apnea-hypopnea index [AHI]: 43.7 ± 21.2 events/h) completed the randomized controlled trial with a follow-up at 18 months. The participants were randomized to either a control group treated with CPAP or an experimental group treated with CPAP and a BSM intervention targeting physical activity and eating behavior changes. OSA was categorized as mild (AHI: 5 to <14.9 events/h), moderate (AHI: 15 to <29.9 events/h), or severe (AHI ≥30 events/h). Being in the experimental group was associated with a larger improvement (B = -9.353, P = .029) in AHI at the 18-month follow-up compared with being in the control group when adjusting for baseline AHI and body mass index. Improvement in OSA category occurred more frequently in the experimental group participants (n = 11; 36.7%) compared with the control group (n = 2; 6.7%). Deterioration in OSA category was found in 1 (3.3%) participant in the experimental group and 3 (10%) in the control group. The importance of a BSM intervention as an adjunct treatment in patients with OSA is emphasized due to its long-term benefits. Registry: ClinicalTrials.gov; Name: Lifestyle changes in obstructive sleep apnea; Identifier: NCT01102920.

Exploring the STOP-BANG questionnaire for obstructive sleep apnea screening in seniors.

The accuracy of obstructive sleep apnea (OSA) screening instruments in seniors may change as the predictive role of sex, age, and body mass index (BMI) changes with aging. We investigated the diagnostic performance of the STOP-BANG questionnaire in older individuals with aging-adapted scores and thresholds. Independent community-dwelling adults aged 65 years or older were screened for OSA. The STOP-BANG questionnaire was tested with different configurations and compared to the apnea-hypopnea index (AHI) obtained from home sleep apnea testing (HSAT). Epworth Sleepiness Scale (ESS) and Athens Insomnia Scale (AIS) were tested as possible supplementary screening criteria. We recruited 458 individuals with a mean age of 71 ± 5 years, 41% men, BMI of 28.5 ± 4.6 kg/m². Mild, moderate, and severe OSA were present in, respectively, 34%, 30%, and 19% of the sample. The STOP questions had an area under the curve (AUC) of the receiver operating characteristic curve significantly lower than the STOP-BANG and the STOP+BMI > 28 kg/m² (STOP-B28). Both STOP-BANG and STOP-B28 had high sensitivity and low specificity in all OSA levels with similar AUC to predict AHI ≥ 5 events/h, 0.64. ESS and AIS were nonsignificant as adjunctive instruments. Novel modifications of a standard instrument created the STOP-B28, a simpler-to-obtain and similarly performing variation of the STOP-BANG using fewer inputs, and useful to exclude OSA. Screening seniors via questionnaires to detect OSA is problematic. Considering the 83% OSA prevalence in this age group, it may be a sensible option to indicate objective tests, oximetry, HSAT, or even polysomnography, as a first step in OSA investigation.

1042 Assessment of left ventricular systolic function in obstructive sleep apnea with automatic function imaging and its relation relation with hypoxia

Abstract Funding Acknowledgements OSA &amp; Subclinical myocardial impairment Background Early detection of left ventricular (LV) systolic dysfunction is crucial for patients with obstructive sleep apnea (OSA) . LV longitudinal strain (GLS), derived from automated function imaging (AFI) based on 2D echocardiography, provides a new tool to detect subclinical impairment of both global and regional myocardium. Its value in OSA remains unclear compared to traditional parameters since obesity is not uncommon in OSA, which may compromise the accuracy of AFI. We aimed to investigate the feasibility of AFI in OSA and further to explore the impact of OSA severity and degree of hypoxia on LV function. Methods Comprehensive transthoracic echocardiography was done in those receiving polysomnography (PSG) suspected as OSA consecutively (n = 322). All subjects were divided into 3 groups by apnea-hyponea index (AHI) by PSG (Control: AHI＜5; mild-to-moderate AHI 5-30; severe: AHI≥30) and GLS and mitral annular plane systolic excursion (MAPSE) were compared among the 3 groups. Results 322 patients with normal LVEF (≥50%) were finally analyzed. Though more segments were measured, inter- and intra- observer variability of GLS were comparable with MAPSE in a Bland-Altman analysis. For group comparison, GLS was reduced compared to the other 2 groups in the severe OSA category (p ≤ 0.001) while MAPSE showed no differences. Further analysis showed the feasibility of AFI was acceptable even in obese patients. In multivariable analysis of GLS, only maximum desaturation was an independent associated factor (p = 0.027). Conclusions Even in OSA patients with obesity, AFI-derived GLS is feasible. GLS is more sensitive than MAPSE or TDI for detection of reduced LV systolic function in OSA. Control(n = 27) Mild-Mod OSA(n = 145) Severe OSA(n = 160) P-value Age(years) 43 ± 13 47 ± 12 46 ± 11 0.218 Males, n(%) 17(63.0%) 118(81.4%) 154(96.3%) ＜0.001 BSA(m2) 1.82 ± 0.18 1.88 ± 0.18 1.97 ± 0.17*† ＜0.001 BMI(kg/ m2) 24.7 ± 4.4 26.8 ± 3.7* 28.6 ± 4.2*† ＜0.001 LVEF(%) 66.5 ± 6.4 67.0 ± 5.0 66.7 ± 4.6 0.813 Sep S’(cm/s) 8.3 ± 1.7 8.4 ± 1.5 8.7 ± 1.9 0.256 Sep E’(cm/s) 9.5 ± 3.0 9.0 ± 2.4 8.2 ± 2.0*† 0.003 E/ E’ 9.2 ± 2.9 9.1 ± 2.9 9.8 ± 2.9 0.145 GLS(%) 19.1 ± 2.7 19.0 ± 2.5 17.9 ± 2.4*† ＜0.001 MAPSE(mm) 15.1 ± 2.5 14.7 ± 2.3 14.3 ± 2.2 0.302 *p＜0.05 compared with mild OSA patients, †p＜0.05 compared with moderate OSA patients Echo Comparison between 3 OSA Groups

Association between REM sleep and obstructive sleep apnea in obese and overweight adolescents.

Overweight and obese children have demonstrated reduced rapid eye movement (REM) sleep, affecting energy balance regulation and predisposition to weight gain. Obstructive sleep apnea (OSA) is a known cause of decreased REM sleep. The purpose of this study is to examine the association between the percentage of REM sleep, BMI z-score, and OSA severity in overweight and obese adolescents. We performed a cross-sectional study of 92 (43% female) overweight and obese adolescents (13-17years old) who underwent overnight polysomnography (PSG) at Children's Hospital Los Angeles between 2010 and 2017. The average Body Mass Index (BMI) z-score was 2.27 ± 0.47, with 71% having BMI z-score ≥ 2. REM% during PSG was 15.6 ± 6.8, and obstructive apnea-hypopnea index was 17.1 ± 24.3. The distribution across categories of OSA severity was 27% none (≤ 1.5events/h), 24% mild (> 1.5-5events/h), 8% moderate (> 5-10events/h), and 41% severe (> 10events/h). REM% was not associated with BMI z-score, either on univariate or multivariate regression with adjustment for age, gender, and apnea-hypopnea index (AHI). When subdivided into OSA categories, a 1-unit increase in BMI z-score was associated with a 5.96 (p = 0.03) increase in REM% in mild OSA and an 8.86 (p = 0.02) decrease in REM% in severe OSA. There was no association between BMI z-score and REM% in none and moderate OSA. Among overweight and obese adolescents, BMI z-score was associated with decreased REM% in severe OSA and unexpectedly increased REM% in mild OSA, but there was no association in none or moderate OSA.

Flow limitation/obstruction with recovery breath (FLOW) event for improved scoring of mild obstructive sleep apnea without electroencephalography

ObjectiveApnea/hypopnea index (AHI), especially without arousal criteria, does not adequately risk stratify patients with mild obstructive sleep apnea (OSA). We describe and test scoring reliability of an event, Flow Limitation/Obstruction With recovery breath (FLOW), representing obstructive airflow disruptions using only pressure transducer and snore signals available without electroencephalography. MethodsThe following process was used (i) Development of FLOW event definition, (ii) Training period and definition refinement, and (iii) Reliability testing on 10 100-epoch polysomnography (PSG) samples and two 100-sample tests. Twenty full-night in-laboratory baseline PSGs in OSA patients with AHI with ≥4% desaturations <15 were rescored for FLOW events, traditional hypopneas with desaturations, respiratory-related arousal (RRA) events (hypopneas with arousals and respiratory-effort related arousals) and non-respiratory arousals (NRA). ResultsScoring of FLOW events in 100-epoch samples had good reliability with intraclass correlation (ICC) of 0.91. The overall kappa for presence of events on two sets of 100 sample events was 0.84 and 0.87 demonstrating good agreement. Moreover, 80% of RRA and 8% of NRA were concurrent with FLOW events. Furthermore, 56% of FLOW events were independent of RRA events. FLOW stratifies patients in traditional AHI categories with 50%/8% of AHI with ≥3% desaturations (AHI3) <5 and 12%/63% of AHI3 >5 in lowest/highest tertiles of AHI3 plus FLOW index. ConclusionsScoring of FLOW after training is reliable. FLOW scores a high proportion of RRA and many currently unrepresented obstructive airflow disruptions. FLOW allows for stratification within the current normal-mild OSA category, which may better identify patients who will benefit from treatment.

The relationship between obstructive sleep apnea and insomnia: a population-based cross-sectional polysomnographic study

BackgroundThe relationship between insomnia and objectively measured obstructive sleep apnea (OSA) severity has not previously been investigated in both genders in the general population. The main aim of this population-based polysomnography (PSG) study was to evaluate the cross-sectional association between severity of OSA and DSM-V insomnia and insomnia severity. MethodsA random sample of 1200 participants in the third Nord-Trøndelag Health Study (HUNT3) was invited and 213 (18%) aged between 21 and 82 years underwent an ambulatory PSG, a semi-structured interview, and a sleep-specific questionnaire. A proxy DSM-V insomnia diagnosis as well as an Insomnia Symptom Score (ISS, range 0–12) were calculated from three insomnia questions and one daytime sleepiness symptom question. Participants were then divided into three groups according to their apnea-hypopnea index (AHI): AHI < 5 (without OSA), AHI 5–14.9 (mild OSA), and AHI ≥ 15 (moderate-to-severe OSA). Associations between prevalence of insomnia and OSA groups were assessed by logistic regression models adjusted for age and gender. Associations between ISS and OSA were assessed in a general linear model with contrasts. ResultsA total of 25.2% (29.1% women, 12.5% men) had insomnia. Insomnia prevalence did not differ between subjects with and without OSA, but ISS differed significantly between OSA categories (ANCOVA df 2, F = 6.73, p = 0.001). ISS was lower in the moderate-to-severe OSA-group compared to those without OSA (mean difference −2.68; 95% [CI −4.33, −1.04]; p = 0.002). In subjects with moderate-to-severe OSA, ISS correlated negatively with age (Pearson r = −0.66, p = 0.015). ConclusionIn this population-based PSG study, no overall statistical association between OSA and insomnia prevalence was found. However, participants with moderate-to-severe OSA reported less insomnia symptoms than subjects without OSA, in particular in older individuals.

Snore Sound Analysis Can Detect the Presence of Obstructive Sleep Apnea Specific to NREM or REM Sleep.

Severities of obstructive sleep apnea (OSA) estimated both for the overall sleep duration and for the time spent in rapid eye movement (REM) and non-rapid eye movement (NREM) sleep are important in managing the disease. The objective of this study is to investigate a method by which snore sounds can be analyzed to detect the presence of OSA in NREM and REM sleep. Using bedside microphones, snoring and breathing-related sounds were acquired from 91 patients with OSA (35 females and 56 males) undergoing routine diagnostic polysomnography studies. A previously developed automated mathematical algorithm was applied to label each snore sound as belonging to either NREM or REM sleep. The snore sounds were then used to compute a set of mathematical features characteristic to OSA and to train a logistic regression model (LRM) to classify patients into an OSA or non-OSA category in each sleep state. The performance of the LRM was estimated using a leave-one-patient-out cross-validation technique within the entire dataset. We used the polysomnography-based diagnosis as our reference method. The models achieved 80% to 86% accuracy for detecting OSA in NREM sleep and 82% to 85% in REM sleep. When separate models were developed for females and males, the accuracy for detecting OSA in NREM sleep was 91% in females and 88% to 89% in males. Accuracy for detecting OSA in REM sleep was 88% to 91% in females and 89% to 91% in males. Snore sounds carry sufficient information to detect the presence of OSA during NREM and REM sleep. Because the methods used include technology that is fully automated and sensors that do not have a physical connection to the patient, it has potential for OSA screening in the home environment. The accuracy of the method can be improved by developing sex-specific models.

F25. Intranight variability of AHI can affect the efficiency of CPAP treatment

Introduction Obstructive sleep apnea (OSA) is a common disease with severe health consequences most commonly treated with continuous positive airway pressure (CPAP) device. However, the adherence to CPAP treatment is often limited and the usage of the CPAP device can be only around 4 h per night after 1 month usage ( Chai-Coetzer et al., 2013 ). Possibly for this reason the benefits of the CPAP usage in terms of cardiovascular outcomes are not always obvious ( McEvoy et al., 2016 ). The severity of OSA is estimated with apnea-hypopnea-index (AHI) together with daytime symptoms. AHI may vary hour by hour during the night. In the current study, the aim was to investigate whether there is a difference in AHI during the first 4 h of sleep (possible CPAP adherence) and during the worst 4 h during the night. Methods 2002 ambulatory polygraphic recordings of suspected OSA patients were evaluated. The patients were divided into normal, mild, moderate and severe OSA categories based on their total AHI. Total AHI, AHI during the first 4 h and AHI during the worst 4 h during the recording were analyzed. AHI during the first and the worst 4 h were then compared. Wilcoxon signed ranks test was used to estimate the statistical significance of the differences. p Results There were 972, 508, 260 and 262 patients in normal, mild, moderate and severe OSA categories, respectively. We found a trend of increasing AHI towards the end of the night. The median total AHI in these categories were 1.5, 8.7, 20.7 and 47.6 events/h, respectively. The median differences between the AHI during the worst 4 h and the first 4 h of the recording were 0.8, 4.8, 10.4 and 9.8 events/h ( p Conclusion There were statistically and clinically significant differences between the median AHI values of the worst 4 h and the first 4 h of the night in all OSA severity categories. CPAP adherence has been reported to be around 4 h per night ( Chai-Coetzer et al., 2013 ) and the CPAP usage is probably typically focused on the first hours from the beginning of the night. For these reasons the benefits of the CPAP usage are probably not as linear as the simple time of adherence indicates. With limited adherence time, CPAP treatment is not always able to prevent severe cardiovascular outcomes ( McEvoy et al., 2016 ). If the CPAP usage could be directed to the worst hours of the night at the same adherence level it might provide better treatment results. The total AHI would decrease more when CPAP would be used during the worst hours instead the first hours of the night.

Severity of individual obstruction events increases with age in patients with obstructive sleep apnea

BackgroundAge is a risk factor of obstructive sleep apnea (OSA). It has been shown that OSA progresses over time, although conflicting results have been reported. However, the effect of age on the severity of OSA and individual obstruction events has not been investigated within different OSA severity categories by taking the most prominent confounding factors (i.e., body mass index, gender, smoking, daytime sleepiness, snoring, hypertension, heart failure, and proportion of supine sleep) into account. MethodsPolygraphic data of 1090 patients with apnea–hypopnea index (AHI) ≥5 were retrospectively reanalyzed. The effect of age on the severity of OSA and obstruction events was investigated in general, within different OSA severity categories, and in different age groups (age <40, 40≤ age <50, 50≤ age <60, and age ≥60 years). ResultsIn the whole population, AHI and durations of apneas, hypopneas, and desaturations increased with increasing age (B ≥ 0.108, p ≤ 0.010). In more detailed analysis, AHI increased with age only in the moderate OSA category (B = 0.075, p = 0.022), although durations of apneas increased in mild and severe OSA categories (B ≥ 0.076, p ≤ 0.038). Furthermore, durations of hypopneas increased with age in mild and moderate OSA categories (B ≥ 0.105, p ≤ 0.038), and durations of desaturations (B ≥ 0.120, p ≤ 0.013) in all OSA severity categories. AHI was not statistically significantly different between the age groups, although durations of obstruction events tended to increase towards older age groups. ConclusionAs obstruction event severity was more strongly dependent on the age than it was dependent on AHI, considering the severity of obstruction events could be beneficial while estimating the long-term effects of the treatments and prognosticating the disease progression.

Erectile dysfunction is independently associated with apnea-hypopnea index and oxygen desaturation index in elderly, but not younger, community-dwelling men

Objective(s)To examine the association between obstructive sleep apnea (OSA) and other sleep indices using polysomnography (PSG) data and erectile dysfunction (ED) in a representative cohort of men. DesignCross-sectional. SettingCommunity-based. ParticipantsAged 40+ years (n=734; mean age [SD], 60.8 [10.9]). MeasurementsMen with no prior OSA diagnosis who underwent in-home PSG (Embletta X100; 2010-11) and ED assessment (Global Impotence Rating) were selected. Un-adjusted and multi-adjusted regression models of ED were fitted against PSG measures, along with qualifying sociodemographic, lifestyle, and health-related covariates. Mediation effects were examined using the Baron-Kenny method. ResultsOf the men examined, 24.7% (n=181) had ED, most notably in men older than 65years (cf. men 35-49 and 50-64years; P<.001). There was no significant association between ED and any of the PSG measures for allaged men. Given an observed ageinteraction within OSA categories (P=.005), analyses were repeated in age-stratified samples (<65 years; 65+ years). In men younger than 65years, only severe OSA was found to have an association with ED (2.01; 1.13-4.69) in unadjusted models. For men aged 65+ years, an independent association with ED was found for apnea-hyponea index (AHI; 1.55;1.02-2.36), moderate (AHI:10.0-19.9; 1.79;1.18-2.43), and severe (AHI:20.0+; 4.84;2.56-9.93) OSA, and oxygen desaturation index (ODI; both continuous [1.48;1.03-1.99] and >16 seconds [2.79;1.23-6.32]). The effect of AHI on ED was shown to be primarily mediated through ODI (63.4%, Sobel P value=.29). ConclusionsIn younger, community-based men, there appeared no independent relationship between objective measures of sleep and ED. However, there appears a strong, independent relationship between OSA, ODI, and ED in men 65 years and older.

Relation of Obstructive Sleep Apnea and a Common Variant at Chromosome 4q25 to Atrial Fibrillation

Obstructive sleep apnea (OSA) and single nucleotide polymorphisms (SNPs) at the 4q25 locus are associated with increased risk of atrial fibrillation (AF). Whether these associations are independent of traditional risk factors for AF remains unknown. Using billing code queries and manual chart review, we assembled a cohort of adults that underwent overnight polysomnography and at least 1 12-lead electrocardiogram. Case status was defined by electrocardiographic data in support of AF or documentation of AF by a staff cardiologist. Controls were defined by a lack of primary evidence of AF and absence of a diagnosis of AF in the medical record. OSA severity was categorized based on Apnea-Hypopnea Index. Genotyping for a key 4q25 SNP (rs2200733) was performed using the Sequenom platform. Logistic regression was used to test for associations of AF with OSA category and 4q25 SNP genotype while adjusting for age, gender, body mass index, ancestry, hypertension status, and heart failure status. The cohort consisted of 674 subjects (62 ± 13years; 44% women), including 132 patients with AF. After adjustment for established risk factors, the association between AF and OSA severity was borderline significant (odds ratio 1.2, 95% CI 1.0 to 1.5). The association between AF and 4q25 SNP status remained significant in a fully adjusted model that included OSA severity (odds ratio 1.5, 95% CI 1.3 to 5.7). In conclusion, OSA severity and the chromosome 4q25 SNP genotype were associated with AF status independent of clinical risk factors. Knowledge of AF-related SNPs may enhance AF risk stratification for those undergoing polysomnography.