Treatment Of OSA Research Articles

0630 Comparison Between the Use of APAP and Manual Titration During Split Night Polysomnography for Diagnosis and Treatment of OSA

Abstract Introduction CPAP remains the gold standard treatment for OSA, CPAP titration can be done using manual titration or using APAP devices, CPAP titration can be done using full night or split night protocol. The aim of the study Is to compare between the use of APAP and manual titration to determine the needed CPAP pressure during split night polysomnography for diagnosis and treatment of OSA. Methods 100 patients with severe OSA were enrolled after exclusion of patients with heart failure or respiratory failure. After diagnostic polysomnography, patients were divided into 2 groups: group1 offered manual CPAP titration and Group2 offered APAP titration, the time for CPAP titration was at least 4 hours in both groups. Results both groups were matched as regard age, gender, BMI, sleep parameters and AHI (44.52 ± 7.81/hour in group1 and 42.66 ± 9.68/hour in group2 with no statistical significance, after CPAP titration AHI was significantly improved in both groups, the time needed to reach the therapeutic pressure was significantly lower in group2 than in group1, attended technician was needed only in group1. Conclusion Use of APAP was equal to manual titration in this group of patients with severe OSA, with decreased cost and lesser time to reach the therapeutic pressure, large multicenter trials are needed to modify the guidelines in view of using APAP in split night protocol for diagnosis and treatment of OSA. Support no conflict of interest

0582 Examining OSA Screening and Treatment for Individuals on a PTSD and Alcohol Disorder Residential Treatment Unit

Abstract Introduction Obstructive sleep apnea (OSA) is highly co-occurring with both alcohol use disorder (AUD) and posttraumatic stress disorder (PTSD) and has been shown to interfere with both PTSD and AUD outcomes. However, OSA often goes undiagnosed and untreated in residential treatment facilities. Our study aimed to assess the feasibility of incorporating OSA screening and treatment onto a substance abuse residential rehabilitation treatment program (SARRTP). Further, we examine the relationship between adherence rates of CPAP on PTSD outcomes. Methods Participants were 35 consecutive veterans admitted to the SARRTP PTSD track who consented to screening. Veterans were on the unit for 4-6 weeks. OSA was diagnosed using Nox T3 recorders, a Type-3 portable OSA screener (using Apnea Hypopnea Index >= 5). Insomnia Severity Index and PTSD checklist were given at pre- and post-treatment. Results 64.7% of Veterans screened positive for OSA. 11.8% were previously diagnosed with OSA, but did not use a CPAP machine; 17.6% were previously diagnosed and were using a CPAP machine; and 35.3% were newly diagnosed with OSA. Individuals with untreated OSA had significantly more days drinking in the last 30 days (M = 21.17 days, SD = 11.41) compared to no OSA/Treated OSA group (M = 8.82 days, SD = 10.92). There was no difference in change in PCL scores from baseline to post-treatment by the no-OSA/high compliance group and the low compliance group. Conclusion Taken together, OSA screening on the unit was accepted by the participants, feasible, and effective in diagnosing OSA. OSA screening and treatment should be considered as necessary on SUD and PTSD units. We did not find that OSA adherence predicted change in PTSD score, this is most likely due to veterans receiving their CPAP late into their stay on the unit. Future studies will need to examine OSA treatment on long term treatment outcomes. Support: Support This work is supported by UCSD Academic Senate Grant and a Veterans Affairs RR&D CDA (1lK2Rx002120-01) to Peter Colvonen.

1189 Recruiting, Training, And Implementing Sleep Health Educators In Community-based Research To Improve Sleep Health

Abstract Introduction Adherence to OSA assessment and treatment is low among racial/ethnic minorities, particularly among blacks. Navigating patients along the continuum of care from assessment to treatment adherence requires motivation, social support, and self-efficacy. Previous studies indicate that community health educators can provide motivation, social support, and skills to patients to better navigate the complex OSA care continuum. However, recruiting, training, and implementing sleep health educators in clinical or research settings is complex. For the current study, we describe how we recruit, train, and implement sleep health educators in research and clinical settings and assess what makes a sleep health educator successful. Methods We recruited and trained twenty-five self-identified black sleep health educators for a randomized clinical trial (R01MD007716) focused on increasing OSA assessment and treatment adherence among blacks. During recruitment, we assessed key personality attributes that translate to being an effective sleep health educator, via behavioral and personality surveys, focused groups, and process forms filled out by educators. Sleep health educators underwent an 8-week training program on sleep health and motivational interviewing. In order to be certified, sleep health educators had to pass a written and scenario-based assessment. During the implementation phase of the trial, we assessed how many interviews each health educator conducted and whether individual characteristics were related to how many interviews. Results Of the trained educators, 80% were female, ranging from 25 to 58 years old. They all completed at least high school. All educators rated the program highly and were very satisfied with dispensing tailored sleep health education. Educators who displayed the highest knowledge about sleep health, provided frequent emotional and strategic support, committed to helping their assigned participants, and who rated their rapport highly with their assigned participants were most effective in getting their participant to adhere to OSA assessment and treatment. Conclusion Sleep health educators can be vital to increasing OSA assessment and treatment adherence among blacks. In order to ensure success, sleep health educators must undergo a thorough recruitment, training, and implementation and dissemination process. Support K01HL135452, R01MD007716, R01HL142066, K01HL135452,and K07AG052685

1131 Obstructive Sleep Apnea Treatment and Dementia Risk in Older Adults

Abstract Introduction Obstructive Sleep Apnea (OSA) has been linked to dementia and Alzheimer’s Disease (AD), as well as pre-dementia. The potential benefits of OSA treatment on cognitive performance are inconclusive. Further, the impact of OSA treatment on the development of neurodegenerative disorders has not been sufficiently studied. This study examined associations between Positive Airway Pressure (PAP) therapy and incident diagnosis of pre-dementia (MCI), dementia (DNOS), or AD in a population-level sample of older adults. Methods Using a random 5% sample from Medicare claims data (persons age 65 and older), individuals with an ICD-9 diagnosis code for OSA prior to 2011 (n=53,321) were selected for analyses. Over the survey period (2011-2013), we further identified persons newly diagnosed with MCI (n=443), DNOS (n=378), or AD (n=1,057). We also identified individual HCPCS claims for PAP equipment as evidence of prescription, and repeated HCPCS claims for supplies as evidence of adherence to PAP treatment. Logistic regression models were used to adjust for potential confounders including age, gender, hypertension, and Parkinson’s Disease that might increase risk for dementia. Results Seventy-eight percent of beneficiaries with OSA were prescribed PAP, and 74% showed evidence of adherent use. After adjustment for potential confounders, prescription of PAP was associated with significantly lower odds of incident AD and DNOS (OR=0.78, 95% CI: 0.69, 0.89; and OR=0.69, 95% CI: 0.55, 0.85). Lower odds of MCI, approaching statistical significance, were also observed among beneficiaries who were prescribed PAP (OR=0.82, (95% CI: 0.66, 1.02). Evidence of adherence to PAP was significantly associated with lower odds of incident AD (OR=0.65, 95% CI: 0.56, 0.76). Conclusion Among older individuals with OSA, PAP prescription and adherence are each associated with a significantly lower risk of incident AD or DNOS, though not MCI. Although a prospective cohort design cannot prove causality, results suggest that treatment of OSA could reduce risk of subsequent dementia. Support This study was supported by The American Academy of Sleep Medicine Foundation Strategic Research Award 115-SR-15 (PI Braley).

0620 Characteristics Distinguishing Special Operational Forces (SOF) Personnel from Non-SOF Peers with TBI: Retrospective Analysis From the VA TBI Model Systems

Abstract Introduction Special Operations Forces (SOF) is an umbrella term which encompasses over a dozen specialized communities across all military branches. Little is known about potential differences in demographic and health characteristics, including sleep, between SOF vs. non-SOF service members. We leveraged existing longitudinal studies of those with history of TBI to examine differences between SOF and non-SOF in the dataset. Methods We conducted a retrospective analysis of data from the VA TBI Model Systems, a multi-center longitudinal study of outcomes following TBI rehabilitation. Participants were included if SOF status was known (N = 261). Differences between groups on variables of interest were then classified as “Immaterial”, “Minor,” and “Important” based on either prevalence (categorical data) or degree of difference (continuous data). Results Of included participants, 68 (26%) were identified as SOF and 193 (74%) as non-SOF. SOF were more highly educated and more likely to have history of mild TBI. There were multiple “important” differences in co-morbidity prevalence. SOF participants were more likely to be diagnosed with sleep apnea (36% SOF vs 12% non-SOF). They were also more likely to have been diagnosed with chronic pain, a cardiac condition, high blood cholesterol, and/or osteoarthritis. Conclusion SOF participants differed from non-SOF in a multiple important ways, suggesting this is a different and medically complex population. The most striking finding was that SOF personnel had a significantly greater rate of sleep apnea, relative to non-SOF. The mechanism underlying this difference is not known but may relate to training, blast exposure, weapons use, and mission demands. Further investigation regarding mechanisms, prevalence, and treatment of OSA in the SOF community is needed. Support This research was sponsored by VHA Central Office VA TBI Model Systems Program of Research; Subcontract from General Dynamics Information Technology (W91YTZ-13-C-0015; HT0014-19-C-0004).

0807 NREM Parasomnias: Retrospective Analysis Of Treatment And Outcomes

Abstract Introduction NREM parasomnias are relatively common among children and sometimes persist in adulthood. These behaviors may result in injury or have negative impacts on functioning and quality of life thus necessitating treatment. The treatment is challenging given the lack of evidence for frequently used medications such as benzodiazepines (BDZ) or tricyclic antidepressants (TCA). The aim of this retrospective analysis is to determine the most frequently prescribed medications for treatment of NREM parasomnias and evaluate reported outcomes. Methods We performed a retrospective chart review of all patients with NREM parasomnia diagnosed within BWH clinics examining the date of diagnosis, date of starting therapy, comorbidities, type of medication prescribed, and the reported change in symptoms or side effects at the individual’s follow-up visits. Results From 2012 to 2019, 123 patients (64 females, 59 male) at BWH clinics received the diagnosis of NREM parasomnia, including sleepwalking and night terrors. Mean age was 44. Comorbidities included depression=16, anxiety=32, seizures=6, RLS=9, epilepsy=5, insomnia=29, and OSA=57. Initial treatment included safety counseling (72), BDZ (7), TCA (4), and treatment of comorbidity (23). Treatment of OSA only (n=15) was effective in 66% (n=10) and 33% were lost to follow up. Of those with OSA treatment plus BDZ (n=6), treatment was effective in 50% (n=3). Of those receiving BDZ only (n=7), treatment was effective in 43%. Of those receiving Melatonin (8),treatment was effective among 62.5% (n=5). TCAS (n=4) were effective in 3 patients (75%). Treatment of comorbid conditions without pharmacotherapy (23) was effective in 35% (n=8) while the remaining 65% (n=15) were lost to follow up. Conclusion Treating comorbid conditions such as OSA, insomnia, RLS, depression, and anxiety is a frequent treatment strategy. Additional pharmacologic treatment most commonly includes melatonin, BDZs, and TCAs. Support None

1149 A Pilot Quality Improvement (QI) Study To Assess Whether Bilevel Positive Airway Pressure (bipap) Support In Acute Ischemic Stroke Patients With Sleep Disordered Breathing, Can Improve Neurological Recovery During Acute Stroke Care

Abstract Introduction Obstructive sleep apnea (OSA) has been associated with adverse outcomes in patients with stroke. While data is limited, it suggests that treatment of OSA may improve neurological recovery. With this quality improvement (QI) project, we aim to develop an interprofessional-team workflow process for screening and correction of OSA in acute ischemic stroke, with the goal to improve outcomes of neurological recovery. Methods This is an ongoing study to screen all eligible patients admitted to JFK Medical Center stroke unit, with MRI-proven Supratentorial acute ischemic stroke. The patients are screened using an overnight Pulse Oximetry test. A 3% oxygen desaturation index (ODI) of ≥10/hr or 4% ODI of ≥ 5/hr is considered at high risk for OSA. Such Patients will receive nocturnal Auto-adjusting BIPAP therapy during their acute care stay, for up to 5 days, for at least 4 hours per night. Eligible Patients who refused BiPAP therapy or were non-compliant will be considered as a controls. Baseline NIH stroke scale (NIHSS), and bilateral MCA mean flow velocity (MFV) in the morning, by transcranial doppler (TCD) will be assessed at baseline for cases and controls, and after BiPAP therapy, for the case group. The two groups of patients will also be compared in terms of Modified Rankin Scale at time of discharge and at phone follow-up after 6 weeks. Results Between Oct 17th, 2019 to current, 15 patients were admitted to the stroke unit with MRI confirmed stroke. Ages ranged from 34 - 88 years (average age 66.5 years). 8 patients (60%) were female. Of those, 6 patients consented to being screened for OSA. Of these, 1 had 4%ODI >5/hr, and therefore received treatment with BIPAP. However, compliance was < 4 hrs on 2 consecutive nights. Conclusion This is ongoing QI project and results will be available after few more months of continued recruitment. Support Auto-adjusting BIPAP machines were provided by RESMED.

0686 Diabetes Sleep Treatment Trial: The Effect Of Treatment Of OSA With CPAP On Glycemic Control In Type 2 Diabetes

Abstract Introduction Evidence remains unclear whether treatment of OSA with CPAP results in improved glycemic control. This study evaluated if CPAP improved glucose control compared to sham-CPAP and the effect of adherence to active CPAP on glucose control after 6 and 12 weeks of treatment. Methods This was a multi-center, double-blind clinical trial. Participants were adults with type 2 diabetes (T2D), A1C≥6.5%, apnea + hypopnea index (AHI)≥10, and naïve to CPAP. All participants received diabetes education. Glucose control was evaluated with frucostamine and A1C levels; CPAP adherence with a wireless modem system. Statistical analysis followed an “intent-to-treat” approach with linear mixed modeling. The dose of active CPAP was calculated as the percentage of days with active CPAP use≥4 hours and the average adherence of active CPAP with sham coded as “0”dose”. Results Randomized participants (N=98, CPAP=50; sham-CPAP=48) were primarily middle-aged (age=58.7±9.8 years), White (75%), males (57%) obese (BMI=36.2±6.6), suboptimal glucose control (A1C=7.9%±0.9) and OSA (AHI=23.9±14.4). There were no significant baseline differences except in A1C (Active CPAP=7.7%±0.8; sham-CPAP=8.1%±1.0). There was no significant difference in use of their devices at 6 or 12 weeks. Based on linear mixed modeling, participants on active CPAP had improved A1C (b (SE): -.76 (.24), P<.01) and frucostamine (-21.8 (10.5), P=.04) at 6 weeks with A1C trending to significance at 12 weeks (p=0.10). Both the % of cumulative days of active CPAP usage (≥4 hours/day) (.002 (.003), P=.09) and cumulative hours of active CPAP use (.03 (.03), P=.08) showed a trend being associated with greater change in A1C but not in frucostamine (P=.61, P=.51). The rate of change in A1C varied by time, increasing the % of cumulative days of CPAP use (≥4 hours/day) at week 6 predicted greater change in A1C (.006 (.002), P=.01) than week 12 (.002 (.003), P=.38). Higher average hours of CPAP usage were associated with greater change in A1C (.08 (.03), P=.01) at week 6 compared to week 12 (.03 (.03), P=.47). Conclusion In our study, individuals with T2D and OSA, adherence to active CPAP use improved glycemic control over 6 weeks. Support NIDDK grant R01DK096028; CTRI grant UL1TR001857 and UL1TR000005.

0725 PRESHYON: The Prevalence On The Risk Of Obstructive Sleep Apnea Among Patients With Uncontrolled Hypertension Seen At The Out-Patient Department Of The University Of The Philippines- Philippine General Hospital

Abstract Introduction Obstructive Sleep Apnea (OSA) is a breathing disorder linked to increased morbidity and mortality, 1 and associated with decreased quality of life and functional impairment of daily living.2 OSA has been established to be associated with hypertension wherein the prevalence of OSA is 30%, 24,25 however, local prevalence has been lacking. The gold standard for OSA is polysomnography but this is expensive and has limited availability. Questionnaires provide risk stratification to determine if the patient needs further sleep evaluation. Recognition and treatment of OSA could lead to improving long term outcomes of patients with uncontrolled hypertension. 31-33 Methods This is a cross-sectional study that enrolled 325 adult Filipino HTN patients seen at the outpatient department (OPD) of UP-PGH from January 2019 to July 2019. Participants also answered Berlin Questionnaire (BQ), Epworth Sleepiness Scale (ESS) and the St. Lukes Medical Center-Obstructive Sleep Apnea Clinical Score (SLMC-OSACS) for their OSA risk. Descriptive statistics were used to summarize the clinical characteristics of the patients. Chi-square test was used to analyze categorical data univariately. Logistics regression analysis was used to determine the association of the different independent variable with the outcome (dependent) variable. Results The risk of OSA was significantly high among uncontrolled HTN patients: 106 (60.7%) based on BQ (p<0.0001) and 68 (69.4%) based on SLMC-OSACS (p<0.0001). OSA risk among uncontrolled HTN was 6x higher (OR=5.69; 95% CI=3.49-9.28;p<0.0001) using the BQ and 4x higher (OR=3.70; 95% CI=2.19 - 6.26;p=<0.0001) using the SLMC-OSACS than those with controlled HTN. Other variables significantly associated with high risk OSA were BMI and other comorbidities. Conclusion The risk of OSA was significantly high among uncontrolled HTN patients. In utilizing these sleep questionnaires and determining the risk for OSA among patients with uncontrolled hypertension will lead for early evaluation of OSA and complications. Locally this will aid in improving detection and provide a more strategic management of uncontrolled hypertension to decrease associated cardiovascular events. This will guide our clinicians to prioritize patients who would benefit referral to sleep specialists Support

1224 Treatment of Severe OSA Using Low Flow Oxygen in a Neonate with Robin Sequence

Abstract Introduction Robin Sequence (RS) involves the clinical triad of micrognathia, glossoptosis and cleft palate. There is a spectrum of severity, but most neonates with RS have upper airway obstruction, resulting in severe obstructive sleep apnea, sometimes requiring surgical interventions such as tongue-lip adhesion, mandibular distraction, or tracheostomy. We present an infant with RS and severe obstructive sleep apnea which was managed with supplemental oxygen. Report of Case Our patient was born at 39 weeks gestation with RS. He had a normal DNA microarray. He was discharged after a 3 week NICU hospitalization for poor feeding. Over the next 2 months, he had poor weight gain and worsening obstructive breathing and was evaluated by craniofacial surgery at that time. Room air polysomnography (PSG) was recommended and revealed an AHI of 21, REM AHI of 48, supine AHI of 25, prone AHI of 19, mean SPO2 of 98%, minimum SPO2 of 61%, and normal capnography with 0% of the time spent > 50 mmHg. A repeat sleep study on 1/4LPM oxygen in the supine position revealed an AHI of 1.7, mean SPO2 of 99%, minimum SPO2 of 92%, and normal capnography. He was discharged on supplemental oxygen. At 4 months of age, he had good weight gain. At 10 months of age, room air PSG revealed persistent OSA with an AHI of 7.2, REM AHI of 21, mean SPO2 of 97%, minimum SPO2 of 81%, and normal capnography. At age 3 yrs, his PSG on room air showed resolution of his OSA with an AHI of 0.6, mean SPO2 of 97%, minimum SPO2 of 87% and normal capnography. Conclusion This case illustrates the spectrum of severity of RS and the utility of low flow oxygen to treat OSA in this patient population.

0054 Metabolite Profiles of Obstructive Sleep Apnea Distinguishes Cases from Controls and Improve With CPAP

Abstract Introduction Obstructive sleep apnea (OSA) is a common sleep breathing disorder with significant public health consequences. Despite this, no clinically available objective molecular biomarkers to diagnose, risk stratify and quantify treatment efficiency exist. To this end, high-throughput metabolomics data could serve as a valuable quantitative tool. Methods We designed a pilot study to investigate the metabolomic effects of OSA and CPAP treatment. Blood serum samples were collected from OSA patients and healthy controls matched with respect to age (±5 years), BMI (±2.5 kg/m2) and gender (N = 20/group). Samples from OSA patients were obtained before and after continuous positive airway pressure (CPAP) treatment. Polar metabolites were analyzed using a targeted ultra-performance liquid chromatography-tandem mass spectrometry (UPLC-MS/MS) metabolomics technique. Results Supervised multivariate analysis using serum metabolic values of OSA patients and healthy controls showed a significantly different overall metabolic profile between the two groups (orthogonal partial least squares discriminant analysis [OPLS-DA] Q2=0.25, p=0.04). Acetylornithine, choline, cytidine, dodecenoylcarnitine, methionine sulfoxide and 3-indoxylsulfate were among the most perturbed metabolites. Major metabolic pathways altered in the OSA patients were methionine and phospholipid metabolism, as well as gut microbial co-metabolism. Lysophosphatidylcholine (16:0), a phospholipid metabolite, demonstrated significant linear association with improved oxygen saturation nadir post CPAP treatment (R2 = 0.57), suggesting the metabolic features may be used as prognostic clinical biomarkers. Conclusion These results suggest that OSA significantly impacts blood metabolites, which could potentially be used to establish OSA biomarkers. Moreover, specific metabolic features are associated with post CPAP improvement, such as phospholipids, suggesting a functional association of these metabolites that may help us understand the heterogeneity of OSA. Overall, these results demonstrate the potential of metabolic profiling to develop quantitative molecular markers of OSA. Further studies are underway to validate these findings and investigate the utility of metabolic profiles to objectively measure CPAP efficacy. Support The work was supported by the program project grant P01 HL094307.

0688 Evaluation Of A Novel Nasal Airway Stent For Snoring And OSA Treatment By Prospective Japanese Patients

Abstract Introduction This cross-sectional study evaluated a novel nasal airway stent (NAS) in the form of a single-use, disposable device (naśtent® classic, Seven Dreamers Laboratories, Inc., Tokyo, Japan), which represents a significant advancement in NAS technology for the treatment of OSA. Methods 1353 individuals whom were interested in NAS treatment for their snoring and/or OSA were enrolled in this study conducted in different districts in Tokyo, Japan from 8/21/2015 to 3/7/2016. A total of 1335 participants with complete data were included in the final dataset. Collected data included demographic features, self-reported sleep and OSA characteristics, anatomic traits, Epworth Sleepiness Scale (ESS) scores, and NAS tolerance. Results The majority of the participants were middle-aged men (91.5% male, 45±10.8 years) with normal BMI (24.5±5.7). Self-reported sleep was 9-11 hours (0.1%), 7-9 hours (8.2%), 5-7 hours (66.7%), 3-5 hours (22%), 1-3 hours (1.2%), and unreported (1.9%). Their mean Epworth Sleepiness Scale score was 9±5.56, and their peak Mallampati and tonsillar grading scores were 2/4 and 3/5, respectively. Of the participants, 87.4% were aware of possible OSA either by snoring or by prior diagnosis of OSA, and their reasons for desiring use of NAS therapy presented in a similar ratio. Over 80% of the participants had never been treated for their diagnosis of OSA; for those with current or prior treatment for their OSA, 62.9% reported PAP as their primary therapy, followed by oral appliances (25.7%), surgery (0.5%), and other therapies (10.8%). On a scale of 1 to 5 where 5 indicated good tolerance to the NAS, the mean scores were 4±1.3 for easy of insertion and 4±1.2 for convenience of use. Conclusion This large, cross-sectional study indicated that the majority of individuals seeking a novel NAS treatment for their snoring and/or OSA in Tokyo, Japan were middle-aged men with 5-7 hours of self-reported sleep whom had some daytime sleepiness, displayed signs of mild anatomic upper airway narrowing, had not been treated for their OSA, and whom felt that the NAS was easy and convenient to use. Support Seven Dreamers Laboratories, Inc. and WSS ISRTP

0907 Implementation Of Pathway For Severe Obstructive Sleep Apnea Management In Children

Abstract Introduction Obstructive Sleep Apnea (OSA) is associated with neuro-cognitive, cardiovascular and metabolic morbidity in children. Adeno-tonsillectomy is the first line of treatment for OSA with PAP therapy and Oxygen supplementation being alternative therapeutic options in select cases. Severe Obstructive Sleep Apnea is a known risk factor for postoperative respiratory complications after adenotonsillectomy. Therefore, inpatient adenotonsillectomy with close monitoring is recommended for this group of children. Challenges to safe and timely care for this high risk group of children can be overcome with effective coordination of care between different locations and health care providers. Methods All children seeking treatment at Dayton Children’s Division of Sleep Medicine were managed through a pathway developed by a multi-disciplinary team involving sleep medicine, otolaryngology and clinical logistics. Severe OSA was defined as AHI ≥15 events/hr (children <2 year old), AHI ≥15 events/hr with three or more Oxygen desaturations <80% (children ≥2 to <6 years old), AHI ≥ 30 events/hr with three or more Oxygen desaturations <80% (Children ≥6 to 18 years old). Results A total of 78 children were diagnosed with severe OSA in 2019. All children were successfully triaged to appropriate therapeutic option (Adenonotonsillectomy, PAP, O2) within 24 hours of diagnosis. Urgent adenotonsillectomy was performed on the same day in 4 children and within 2 weeks on 12 children. There was no postoperative respiratory complication after urgent adenotonsillectomy. Thirteen children had adenotonsillectomy after 2 weeks. PAP therapy was started in 28 children (34%). Therapy was initiated on the same day in 10 children and the next day on one child. Oxygen supplementation was started in 21 children (27%). Conclusion A multidisciplinary collaborative approach can result in delivery of timely and safe care for severe OSA in children. Support NA

0666 Implementing a Sleep Technician Supervised Mask/Interface Fitting Session Can Improve Adherence With Home Automatic Positive Airway Pressure Therapy

Abstract Introduction Obstructive sleep apnea (OSA) is a common disorder associated with increased risk of motor vehicle accidents in addition to cardiovascular and neurocognitive comorbidities. Home Automatic Positive Airway Pressure (APAP) therapy is becoming a mainstay treatment of OSA in the outpatient setting. It is typically prescribed without any prior supervised titration. Discomfort related to the APAP interface is thought to contribute to poor adherence with home APAP use. We examined whether implementing a dedicated and personalized interface fitting session improves APAP adherence. Methods After obtaining IRB approval, 132 adult patients newly diagnosed with OSA were prospectively randomized into two groups (Groups A and B). Group A received a personalized interface/mask fitting session supervised by a sleep technician prior to starting home APAP therapy. During this 30-minute session, patients were educated on APAP use and sampled different masks to address any issues with comfort, leaks, etc. Group B received the usual care where they obtained an interface through Durable Medical Equipment. APAP adherence and interface air leaks during the initial 30 days of home APAP use were compared between the two groups. Results Mean APAP adherence during the initial 30 days of APAP therapy was 12.9% higher in Group A compared to Group B; p=0.05. Fewer APAP interface air leaks were present in Group A (14.8 l/min) compared to Group B (21.2 l/min); p=0.04. Conclusion Discomfort related to the APAP interface can quickly lead to non-adherence with APAP therapy. Initial experience of APAP treatment is important in determining subsequent use. Our findings demonstrate that implementing a personalized interface fitting session supervised by a sleep technician can improve APAP adherence. Potential benefits of increased APAP adherence include improvement in quality of sleep and in turn improvement in quality of life. Support Prior studies have shown that the initial experience of APAP treatment was highly important in determining subsequent use. Patients establish a pattern of APAP adherence during the early days of treatment and maintain this pattern long-term. Early intervention with solutions may help improve APAP adherence.

0632 The Correlation Between Severity of Obstructive Sleep Apnea and Patient Compliance

Abstract Introduction Obstructive sleep apnea (OSA) is a prevalent disorder affecting 9-38% of the global population and is linked to multiple health complications. Continuous Positive Airway Pressure (CPAP) is regarded as the gold standard treatment for OSA, but its efficacy is limited by poor patient compliance. Studies have linked many clinical and lifestyle factors to CPAP adherence, but have produced conflicting outcomes. Based on the current literature, it is assumed patients diagnosed with severe OSA are more likely to be compliant with CPAP due to a greater improvement in quality of life. The goal of this study is to compare the compliance rate of CPAP for patients with mild, moderate, and severe OSA, as well as identify other potential predictors of CPAP compliance. Methods This study is a retrospective chart review of 100 patients who were newly diagnosed with OSA and started on CPAP between January 1, 2017 and January 1, 2018. Baseline demographic data, past medical history, OSA severity, Epworth sleepiness scale, and compliance to CPAP therapy were recorded. Compliance was defined as CPAP usage greater than four hours per night for at least 21 days per month. Results Mean follow-up time after CPAP initiation was 3.19 months. Overall 77% of patients were compliant to CPAP therapy, of which 48% were males and 52% were females (P=0.48). CPAP compliance rates for mild OSA (79.3%), moderate OSA (73.7%), and severe OSA (78.8%) showed no significant difference for independence (P=0.83) or correlation with compliance (P=0.99). Only seasonal allergic rhinitis showed a positive association with CPAP adherence (P=0.031) and depression showed a negative association (P=0.027). Conclusion The level of OSA severity is not a significant predictor of short-term CPAP compliance among newly diagnosed patients. Support Parkview Physicians Group, Indiana School of Medicine - Fort Wayne, and the Dr. Luis and Anne B Schneider Foundation.

1176 Survey Of Knowledge Of Pediatric Trainees Regarding Obstructive Sleep Apnea In Children

Abstract Introduction Obstructive sleep apnea (OSA) causes significant morbidity in children. Very few studies were conducted among pediatricians regarding sleep and sleep disorders in children and adolescents. They demonstrated significant gaps in knowledge in the recognition and management of OSA. Methods We conducted a survey among the pediatric residents in the screening and diagnosis of OSA. The survey consist of 15 questions related to OSA in children. It aimed at identifying gaps in their knowledge and educating them accordingly. Following the survey, core lectures were included in the pediatric curriculum which aimed at educating them with the causes, diagnosis, management and sequelae of untreated OSA. Results 37 pediatric residents took part in the survey. They were from first, second and third year of the pediatric residency training program respectively in an university hospital. 45% of them belong to the first year, 29% of them belong to the second year and 24% of them belong to the third year of training.Only a quarter of them had completed rotations in Pediatric Pulmonology for at least two weeks at the time of the survey. Three questions related to identifying at risk groups, four questions related to identification of the signs and symptoms, and three questions related to the diagnostic criteria and five questions related to the treatment and follow up of OSA. 46% of the residents accurately answered the questions related to screening and identifying children at risk of OSA. 57% of them identified the signs and symptoms of OSA in children.41% of them answered the questions related to diagnosis appropriately and 49% had correct responses for the questions related to treatment of OSA and follow up. Conclusion Less than 50% of the pediatric trainees could accurately identify the at risk groups and symptoms of OSA. These pediatric trainees who are future pediatricians form the referral source for children with OSA and educating them is vital.This reemphasizes the need for the pediatric training programmes to include mandatory training modules related to Pediatric sleep disorders, OSA in particular in the pediatric core curriculum. Support None

0654 Obstructive Sleep Apnea in Older Adults: Geographic Variation in CPAP Treatment

Abstract Introduction Obstructive sleep apnea (OSA) is prevalent and consequential among older adults. Positive airway pressure (PAP) is likely to reduce associated morbidity, but adherence is inconsistent. Regional treatment variations that may reflect addressable differences in care are not sufficiently studied. We examined geographic variations in PAP treatment among older US adults. Methods A representative 5% sample of all Medicare beneficiaries, age 65+, enrolled in fee-for-service program in 2013 was analyzed. OSA diagnosis was defined by ICD-9 codes. PAP treatment was identified by HCPCS codes. Treatment adherence was defined as ≥2 HCPCS claims for PAP supplies on separate months. We examined state-specific proportions of Medicare beneficiaries with OSA who obtained PAP and showed adherence. Maps were created to represent state-specific proportions of beneficiaries who were treated and adherent, by quantiles. To examine more granular regional variations, we created maps representing hospital referral region (HRR)-specific proportions of treated among diagnosed, and adherent among treated. Scatterplots were used to identify the relationship between proportions of PAP treatment and adherence, by state. Results For the state-level data, PAP treatment and adherence rates were between 54%-87% and 59%-81%, respectively. Midwest states had higher CPAP treatment proportions (>80%), while Northeast, Southwest and Southern states had CPAP treatment rates <73%. State-level CPAP adherence showed similar patterns, with lowest rates in southern states and California (<70%). Within-state variability of treatment patterns were observed, especially along the east and the west coasts. A scatterplot revealed that state-level CPAP treatment and adherence rates were linearly correlated, with Washington D.C., NY and NJ ranked lowest. In contrast, MT, ND and VT had the highest treatment and adherence rates. Conclusion These data show substantial state-level and regional variability of CPAP treatment and adherence among Medicare beneficiaries. Some geographic areas may merit prioritization in efforts to improve OSA treatment and adherence. Support This study was supported by The American Sleep Medicine Foundation Strategic Research Award 115-SR-15

0568 Physiologic OSA Traits and CPAP Adherence Among Patients with Coronary Artery Disease and OSA

Abstract Introduction Obstructive sleep apnea (OSA) is common in patients with coronary artery disease (CAD), but adherence to continuous positive airway pressure (CPAP) in this population is poor. Low arousal threshold (ArTH), a pathophysiologic OSA trait, is associated with low rates of regular CPAP use in sleep clinic populations. We aimed to determine whether ArTH or other physiologic OSA traits (i.e. pharyngeal collapsibility, muscle compensation, loop gain) are associated with CPAP adherence in patients with CAD and OSA. Methods A secondary analysis of a randomized controlled trial of OSA treatment in patients with CAD (RICCADSA) was performed. OSA (apnea hypopnea index, AHI≥5/hour) was assessed by polysomnography. Arousal threshold (% eupneic ventilation, %Ve), loop gain (LG), pharyngeal collapsibility (%Ve) and compensation (%Ve) were estimated from polysomnography using a validated method. Adherence to auto-titrated CPAP (hours/night) was obtained from machine downloads at 1, 3, 6, 12 and 24 months. Mixed modelling was used to assess the association between OSA traits and CPAP adherence. Results Participants (n=262) were 64.1±7.9 years old, with BMI of 29.2±4.2 and 86% were men. The mean AHI was 40.8±23.6 events/hour with oxygen nadir of 81.3±7.1%. The median (IQR) CPAP adherence (hrs/night) was 3.0 (0.9, 5.8) at 1-mo and 3.0 (0.0, 5.6) at 24-mo. Compared to reference studies, the CAD patients exhibited an elevated LG 0.63 (0.53, 0.79), similar ArTH (%Ve) of 117.5% (106.5%, 136.4%), higher collapsibility (%Ve) at 90.1% (82.3%, 94.8%) and lower compensation (%Ve) at 3.7% (-0.7%, 8.7%).Only increasing pharyngeal muscle compensation was associated with lower CPAP adherence (β -0.04, p-value 0.048), effect modified by pharyngeal collapsibility (Compensation x Collapsibility, β <0.01, p-value 0.042). Conclusion In this group of patients with CAD, increasing muscle compensation was associated with lower CPAP adherence. Physiologic OSA traits may provide insight into prediction of CPAP adherence among patients with OSA and CAD. Support Zinchuk: Parker B. Francis Fellowship Program in Clinical Research. Sands: American Heart Association. Peker: Swedish Research Council, Swedish Heart-Lung Foundation.

The relationship between severity of obstructive sleep apnea and maxillofacial morphology and BMI; from the point of view of sex and age distribution

AbstractPurposeObstructive sleep apnea (OSA) is generally more common in men than in women, so many studies have only involved male OSA patients as subjects. However, a certain proportion of OSA patients are female, and few studies have addressed this population. Maxillofacial morphology and obesity are now being shown to be intimately connected with OSA, but the details remain unclear. The objective of this retrospective study was to identify the clinical features of OSA in men and women of different ages, with a focus on maxillofacial morphology and body mass index (BMI).MethodsThe subjects comprised 112 patients (56 men and 56 women) randomly selected from adult patients in the Niigata University Medical and Dental Hospital. We investigated the results of lateral cephalogram measurements and polysomnography (PSG) conducted before the start of OSA treatment. We then divided the patients by age (with 50 years as the cutoff value) and sex, and performed statistical comparisons among these four groups.ResultsThe findings showed that the hyoid bone was lower in men aged ≥50 compared with <50, and the cross‐sectional area of the tongue was larger. This suggested that aging changes in maxillofacial morphology may be a risk factor in men. In women, however, only slight morphological differences were found between the two age groups.ConclusionsThis comparative study of sex and age groups in OSA patients suggests that the different groups have different clinical characteristics and may have different risk factors for developing OSA.

Evaluating the feasibility of implementing a Telesleep pilot program using two-tiered external facilitation

BackgroundObstructive sleep apnea (OSA) can negatively impact patients’ health status and outcomes. Positive airway pressure (PAP) reverses airway obstruction and may reduce the risk of adverse outcomes. Remote monitoring of PAP (as opposed to in-person visits) may improve access to sleep medicine services. This study aimed to evaluate the feasibility of implementing a clinical program that delivers treatment for OSA through PAP remote monitoring using external facilitation as an implementation strategy.MethodsParticipants included patients with OSA at a Veteran Affairs Medical Center (VAMC). PAP adherence and clinical disease severity on treatment (measured by the apnea hypopnea index [AHI]) were the preliminary effectiveness outcomes across two delivery models: usual care (in-person) and Telehealth nurse-delivered remote monitoring. We also assessed visit duration and travel distance. A prospective, mixed-methods evaluation examined the two-tiered external facilitation implementation strategy.ResultsThe pilot project included N = 52 usual care patients and N = 38 Telehealth nurse-delivered remote monitoring patients. PAP adherence and disease severity were similar across the delivery modalities. However, remote monitoring visits were 50% shorter than in-person visits and saved a mean of 72 miles of travel (median = 45.6, SD = 59.0, mode = 17.8, range 5.4–220). A total of 62 interviews were conducted during implementation with a purposive sample of 12 clinical staff involved in program implementation. Weekly external facilitation delivered to both front-line staff and supervisory physicians was necessary to ensure patient enrollment and treatment. Synchronized, “two-tiered” facilitation at the executive and coordinator levels proved crucial to developing the clinical and administrative infrastructure to support a PAP remote monitoring program and to overcome implementation barriers.ConclusionsRemote PAP monitoring had similar efficacy to in-person PAP services in this Veteran population. Although external facilitation is a widely-recognized implementation strategy in quality improvement projects, less is known about how multiple facilitators work together to help implement complex programs. Two–tiered facilitation offers a model well-suited to programs where innovations span disciplines, disrupt professional hierarchies (such as those between service chiefs, clinicians, and technicians) and bring together providers who do not know each other, yet must collaborate to improve access to care.