Treatment Of OSA Research Articles

Respiratory disturbance index as a predictor of atrial fibrillation

Abstract Background Obstructive sleep apnea (OSA) is a risk factor for development of atrial fibrillation (AF). Recent pacemakers have specific algorithms for detecting of OSA based on impedance measurement. Purpose The aim was to determine the burden of AF in patients with high respiratory disturbance index (RDI). It was also intended to determine if the onset of continuous positive airway pressure (CPAP) reduced the AF burden. Methods Retrospective observational study carried out through the analysis of the patient records. It included patients with pacemakers evaluated in an outpatient clinic during the first 8 months of 2018. All had the RDI algorithm. AF burden was assessed according to automatic mode switch (AMS) duration. The percentage of nights with an RDI>20/h was analysed to assess the risk of OSA. Results 108 patients were included (mean age=70.3±9.0 years; 56.5% men). The most prevalent indication for cardiac pacing was atrioventricular node dysfunction (59.3%). The average percentage of nights with an RDI>20/h was 44.2%. The average follow-up (FU) period was 4.1 years. Of all cardiovascular risk factors, diabetes mellitus was the only one associated with a higher incidence of AF at FU (p=0.044). Considering just the patients with an RDI >20/h in more than 20% of nights (RDI20%), male gender was associated with higher rate of major adverse cardiovascular events [(acute myocardial infarction, stroke, acute heart failure and death) (p=0.019)]. Considering patients with AF prior to pacemaker implantation (n=34), 76% of patients had an RDI >20/h in more than 20% of nights (mean of 58.1%). 23 of these patients had long standing persistent AF at the end of FU (vs 17 at the beginnig of FU). Considering patients who developed AF after pacemaker implantation (n=24), 58% of patients had an RDI>20/h in more than 20% of nights (mean of 45.3%). Most patients had paroxismal AF (83%). Patients with prior paroxysmal AF or those who developed AF during FU (n=37) had a higher burden of AF at the end of FU when they had RDI >20/h in more than 50% of nights (mean burden of 24.66% vs 14.69%, p=0.005). There was no statistically significant correlation between the percentage of nights with RDI >20/h and the Apnea Hypopnea Index (AHI) value. Patients who underwent polysomnography (n=30) had a mean AHI of 16/h (which corresponds to moderately severe OSA). 63% of patients who were referred from the pacemaker consultation to pneumology and performed polysomnography started CPAP. CPAP use was not associated with a statistically significant reduction in any endpoints or AF burden. Conclusion A high RDI was associated with onset of de novo AF and higher AF burden in patients with paroxysmal AF. Thus, there is a rationale for early diagnosis and treatment of OSAS to prevent and reduce AF progression. In this study, CPAP was not shown to significantly reduce this endpoint, probably due to reduced polysomnography and CPAP treatment. Funding Acknowledgement Type of funding sources: None.

The impact of obstructive sleep apnea on exercise capacity in a cardiac rehabilitation program.

Cardiac rehabilitation (CR) improves clinical outcomes in patients with cardiovascular disease(CDV). Patients with CVDoften have multiple comorbidities, including obstructive sleep apnea (OSA), potentially affecting their ability to participate and achieve functional improvement during CR. We aimed to test the hypothesis that OSA reduces peak exercise capacity (EC) in patients undergoing CR and to explore if OSA treatment modifies this relationship. Data from a retrospective cohort of CR patientswas analyzed. OSA was defined as a respiratory event index > 5/h or physician diagnosis. Patients with OSAwere considered "treated" if using continuous positive airway pressure regularly during the CR period. Change in METs was the primary study outcome. Among 312 CR patients, median age of 67years, 103 (33%) had known OSA (30 treated, 73 untreated). Patients withOSA vs. those withno OSA were more likely to be obese and male; otherwise, groups were similar. Compared with the no OSA group, patients withOSA had lower pre-CR METs (3.3 [2.9-4.5] vs. 3.9 [3.1-5], P = .01) and lower post-CR METs (5.3 [4-7] vs. 6 [4.6-7.6], P = .04), but achieved a similar increase in METs post-CR (1.8 [0.6-2.6] vs. 2.0 [0.9-3], P = .22). Furthermore, compared to no OSA, pre-CR and post-CR METs tended to be similar in patients withtreated OSA, but lower in untreated patients, with similar increases in METs across all groups, even when adjusting for covariates via multivariable regression. OSA is prevalent in patientswith CVD undergoing CR. CR substantially improves exercise capacity independent of OSA status, but screening for-and treatment of-OSA may improve the absolute exercise capacity achieved through CR.

The impact of obstructive sleep apnea on growth in patients with syndromic and complex craniosynostosis: a retrospective study

Given the high prevalence of OSA in children with syndromic and complex craniosynostosis (SCC) and the consequences of untreated OSA, it is important to assess their nutritional status and growth. Yet, literature regarding growth in children with SCC remain scarce. Therefore, this study aimed to (1) illustrate the growth pattern in SCC, (2) determine the impact of OSA on this growth pattern, and (3) evaluate the effect of surgical treatment of OSA on growth over time. A retrospective study was performed in children with SCC, who were treated at the Dutch Craniofacial Center (Rotterdam, Netherlands). Growth variables (height, weight, weight-for-age standard-deviation-score (SDS), weight-for-height SDS, and height-for-age SDS) and degree of OSA (obstructive apnea–hypopnea index) were assessed. Of the 153 children with SCC, 38 (25%) were acutely malnourished at some point during follow-up, of whom 21 had disease-related acute malnutrition. Children with moderate-severe OSA had significant lower weight-for-height SDS compared to children without OSA (p = 0.0063). Growth parameters (weight-for-age SDS, weight-for-height SDS, height-for-age SDS) in children with SCC without OSA were not impaired as they did not differ from the normal healthy population, with exception of the patients with Saethre-Chotzen syndrome (SCS) who had a significantly lower SDS for height-for-age. Conclusion: Children with SCC have a substantial chance of developing acute malnutrition at some point during growth. Additionally, in children with moderate-severe OSA, a significant lower SDS for weight-for-height is present, indicating the importance of assessing the weight and growth pattern in children who are clinically suspected for OSA.What is Known:• Obstructive sleep apnea is seen in up to two-thirds of the children with syndromic and complex craniosynostosis.• Presence of obstructive sleep apnea is associated with intracranial hypertension and an increased risk of metabolic, cardiovascular, and neurocognitive consequences later in life. Untreated obstructive sleep apnea may lead to impaired growth and weight gain, which can result in growth failure.What is New:• Craniosynostosis patients with moderate-severe obstructive sleep apnea had significant lower weight-for-height standard deviation scores (SDS), compared to children without obstructive sleep apnea. • Children with syndromic and complex craniosynostosis without OSA did not significantly differ from the normal healthy population in regard to weight-for-age SDS, weight-for-height SDS, and height-for-age SDS.

Rationale and study protocol for We-PAP: a randomized pilot/feasibility trial of a couples-based intervention to promote PAP adherence and sleep health compared to an educational control

BackgroundObstructive sleep apnea (OSA) is a serious health condition that affects approximately 30-50% of older adults and contributes to risk for cardiometabolic disorders and dementia. Despite the well-documented role of partners in treatment seeking and adherence to positive airway pressure (PAP), treatments for OSA have nearly exclusively focused on the patient and current treatments for OSA do not address co-existing sleep problems such as insomnia that are prevalent in both patients with OSA and their partners. Therefore, the goal of this study is to develop and test a novel couples-based sleep health intervention to promote adherence to PAP and improve sleep health of the couple.MethodsWe are conducting a two-arm, parallel group, single blind, randomized controlled pilot/feasibility trial to compare our novel couples-based sleep health intervention (We-PAP) to an information control group (IC). We-PAP is based on a transdiagnostic model and uses a dyadic approach including increasing effective partner support, communication skills, and couple-level goal-setting. We-PAP involves 3 sessions and delivered via telehealth in weekly sessions. The IC includes standardized patient educational materials. Both groups receive the usual follow-up with their medical team. The study involves assessments at pre-treatment, post-intervention (approximately 1 month after starting PAP and completing We-PAP sessions or IC) and 3 months after starting PAP. Our main outcomes are feasibility and acceptability ratings. Secondary outcomes include comparing We-PAP to IC for PAP adherence, sleep quality (self-report and objective) and cognitive measures.DiscussionWe-PAP is the first couples-based transdiagnostic sleep health intervention for patients with OSA and their partners. Results of this study will be used to inform the design of a subsequent fully powered clinical trial. If successful, this intervention could significantly advance current clinical practice in the treatment of OSA and sleep health more comprehensively in older adults. Moreover, this intervention may be useful for improving sleep in other aging populations with multiple sleep and other health problems, including patients with chronic illnesses or those at risk for Alzheimer’s disease and their caregivers.Trial registrationNCT04759157. Date of registration: February 8, 2021. URL of trial registry record.

Experience with over 10,000 sleep telemedicine visits for diagnosis and treatment of OSAS

Experience with over 10,000 sleep telemedicine visits for diagnosis and treatment of OSAS

Stress on periodontal ligaments caused by four Mandibular Advancement Devices for OSAS treatment: a Finite Element Method study

Stress on periodontal ligaments caused by four Mandibular Advancement Devices for OSAS treatment: a Finite Element Method study

The efficacy of acupuncture for patients with mild to moderate obstructive sleep apnea syndrome: A protocol for a randomized controlled clinical trial

IntroductionObstructive sleep apnea syndrome (OSAS) is considered a major public health issue due to its high prevalence and severe consequences. Several published studies have revealed that electro-acupuncture may relieve OSAS symptoms. However, the mechanism of electro-acupuncture in the treatment of patients with OSAS remains unclear. Methods and analysisWe evaluated the efficacy and mechanism of electro-acupuncture in the treatment of patients with OSAS. This was a two-group parallel randomized controlled trial. Sixty patients with OSAS will be randomly divided into an electro-acupuncture or shallow acupuncture group in a proportion of 1:1, and the patients will be administered 36 sessions of electro/shallow acupuncture treatment (three times a week for 12 weeks, 20 min for each session). The Epworth Sleepiness Scale (ESS) will be used as the primary outcome. Secondary outcomes will include polysomnography (PSG), sleep quality, emotional state, and cognitive function. In addition, patients will receive neuroimaging scanning before and after the entire acupuncture treatment to evaluate neuroplasticity changes, including gray matter density, white matter integrity, and functional connections. Expected outcomesWe believe that the use of electro-acupuncture will be more effective in patients with mild to moderate OSAS and that the cognitive and emotional status of patients will improve after acupuncture treatment. In addition, we aim to clarify which brain areas can be altered by acupuncture in patients with OSAS. DiscussionThis randomized clinical trial aims to explore the curative effect and central mechanism of acupuncture treatment for OSAS. We will explore gray matter density, white matter integrity, and functional connections of the brain using fMRI technology. The results of this study will be significant to the guidelines for clinical OSAS treatment.

High Altitude as a Risk Factor for the Development of Nonarteritic Anterior Ischemic Optic Neuropathy.

Episodic high-altitude exposure leads to optic disc edema and retinopathy. It is uncertain whether high-altitude exposure is a risk factor for nonarteritic anterior ischemic optic neuropathy (NAION). We performed a single-center, retrospective, cross-sectional case study of 5 patients with high-altitude-associated NAION (HA-NAION) from April 2014 to April 2019. Main study parameters included known vascular risk factors for NAION, evolution of visual acuity, visual field, optic disc, and macula measurements. We studied 5 eyes of 5 patients with HA-NAION that occurred at 7,000-9,000 ft above sea level, 28 patients with classic NAION that developed at sea level (normal altitude NAION or NA-NAION), and 40 controls. All 5 patients with HA-NAION had clinically confirmed NAION by a neuro-ophthalmologist within 3-21 days of onset and comprehensive follow-up evaluations (average follow-up of 23 months). Other than high-altitude exposure, 4 of 5 patients had undiagnosed obstructive sleep apnea (OSA, apnea-hypopnea index 5.4-22.2) and 1 had systemic vascular risk factors. All patients had disc-at-risk in the contralateral eye. The best-corrected distance visual acuity was 20/20 to 20/70 (median logMAR 0) at presentation and 20/70 to counting finger (median logMAR 0) at ≥6 months. Automated static perimetry revealed average mean deviation of -18.6 dB at presentation and -22.1 dB at ≥6 months. The average retinal nerve fiber layer was 244 µm (80-348 µm) at onset and 59 µm (55-80 µm) at ≥6 months. The average ganglion cell complex thickness was 50 µm (43-54 µm) at onset and 52 µm (50-55 µm) at ≥6 months. The patients with OSA were started on home continuous positive airway pressure treatment. Visual outcomes were similar in patients with HA-NAION and NA-NAION. - After addressing all NAION risk factors, no new events occurred in the HA-NAION group within 2-8 years with or without repeat high-altitude exposure. NAION can occur under high-altitude conditions. HA-NAION is associated with relatively younger age at onset, disc-at-risk, and OSA. These patients exhibit a relatively progressive course of vision loss after initial onset and severe thinning of optic nerves on optical coherence tomography. Treatment for OSA is recommended, especially with repeated high-altitude exposure.

Protocolizing perioperative OSA screening and management: moving in the right direction.

Protocolizing perioperative OSA screening and management: moving in the right direction.

Activity of pontine A7 noradrenergic neurons is suppressed during REM sleep

The activity of hypoglossal motoneurons plays an important role in the maintenance of upper airway patency. Both withdrawal of noradrenergic excitatory drive and increase of cholinergic inhibition markedly decrease excitability of hypoglossal motoneurons during sleep and especially during rapid-eye-movement (REM) stage. This leads to increased collapsibility of upper airway during sleep, which is the major neurological factor of obstructive sleep apnea (OSA) pathophysiology. Anatomical and functional data suggest that noradrenergic A7 neurons are the main source of noradrenergic drive to hypoglossal motoneurons. However, it is unknown whether the behavior of A7 neurons during sleep-wake cycle is in accord with their proposed involvement in sleep-related depression of hypoglossal motoneuron activity. Therefore, we sought to assess the behavior of A7 neurons during sleep and wakefulness in naturally sleeping head-restrained rats. We have found that, similar to other pontine noradrenergic neurons, the putative A7 noradrenergic neurons fired with relatively long-lasting action potentials with a low-frequency regular discharge. Importantly, noradrenergic A7 neurons were predominantly silent during REM sleep. The REM-off activity of the A7 neurons supports our hypothesis that these neurons may significantly contribute to the withdrawal of excitatory noradrenergic drive from upper airway motoneurons during REM sleep and, consequently, play an essential role in maintaining upper airway patency and pathophysiology of OSA. Therefore, noradrenergic A7 neurons may serve as an additional target for designing pharmacological approaches to treat OSA.NEW & NOTEWORTHY Noradrenergic A7 neurons are mostly silent during REM sleep. This is in accord with their role in the control of upper airway muscles and important contribution to OSA pathophysiology. Therefore, a modulation of A7 neuron activity can serve as a novel therapeutic target for pharmacological treatment of OSA.

0763 Couples-based treatment for OSA: Qualitative analysis of patient, bedpartner and provider perspectives

Abstract Introduction Obstructive sleep apnea (OSA) and its treatment (positive airway pressure; PAP) impacts both patient and bedpartner health and their respective quality of life. Despite the effectiveness of PAP at treating OSA and evidence that PAP adherence benefits both patient and partner, over half of OSA patients are not adherent. Thus, non-adherence to OSA treatment is a couple-level problem, with significant health impacts for both parties. However, bedpartners are rarely integrated into OSA treatments. The current study presents a qualitative analysis of patients, bedpartners, and provider perspectives to inform a novel, couples-based intervention to promote adherence to PAP and sleep health for the couple. Methods We conducted 3 focus group discussions with patients and their partners, and 3 focus group discussions with sleep medicine providers. Focus groups utilized a standardized interview guide to examine: 1) impact of OSA and PAP treatment on the couple, 2) interdependence of sleep and 3) feasibility of a couples-based sleep health and PAP adherence intervention. Transcripts were transcribed and analyzed using thematic analysis using Dedoose. A thematic analysis process coded for emerging themes across a deductive framework. Results Participants included 7 heterosexual couples, 2 patients who participated without their partners and 9 sleep medicine providers (1 nurse practitioner, 3 PSG techs and 5 sleep medicine physicians). Results demonstrated awareness of how sleep impacts patient and partner mood, next day functioning, and relationship quality. Patients and partners reported working together using a variety of strategies to overcome challenges to OSA treatment. Couple-level barriers to treatment were discussed, including sleep disruptions from PAP and the impacts of treatment on intimacy. Providers reported the utility of involving partners in the sleep evaluation and during equipment set up. Couples-based treatment was viewed as helpful for facilitating adjustment and adherence to PAP, particularly to help patients trouble-shoot common challenges, such as adjusting to the mask. However, providers expressed some concerns about couples-based treatment among couples with poor relationship quality. Conclusion Results demonstrate the impact of OSA on the couple and awareness of the importance of including partners in the adjustment to PAP treatment. Findings will be discussed in the context of developing novel behavioral interventions for older adults who face a variety of sleep health issues, in addition to sleep apnea, and in recognition of the dyadic nature of sleep for most adults. Support (If Any) 1 R21 AG067183-01A1

0721 Correlation between Oxygen Desaturation Index and Apnea Hypopnea Index for Diagnosis of Obstructive Sleep Apnea

Abstract Introduction Obstructive sleep apnea (OSA) is diagnosed through polysomnography (PSG) which can be done in lab or outpatient. PSG is conventionally not approved by insurance companies’ in-patient which can result in delay in diagnosis and treatment of OSA. High resolution pulse oximetry (HRPO) done inpatient is easy to perform and calculates oxygen desaturation index (ODI) to asses’ nocturnal desaturations which solely, is insufficient for diagnoses of OSA according to current treatment guidelines. We hypothesize that there may be a correlation between ODI and apnea hypopnea index (AHI) which can facilitate in earlier diagnosis of OSA. Methods We conducted a retrospective chart review to compare patients who underwent HRPO resulting in a sleep medicine consult inpatient followed by polysomnography outpatient over a 2-year period at a tertiary care academic center. Demographic data, ODI, AHI and oxygen nadir levels were collected. Results Sixty-five patients (47 males, 18 females; mean age of 59.1 years) with suspected OSA underwent inpatient HRPO during their hospital stay, followed by a PSG in the outpatient setting. The strength of association between ODI and AHI was determined using a Pearson’s analysis after adjusting to a logarithmic scale. There was a statistically significant weakly positive association between ODI and AHI (Pearson correlation=0.33, p=0.008). Linear regression analysis demonstrated a predictive value of 0.419 (p=0.008) between AHI and ODI. However, there was no statistically significant predictive value between ODI and AHI when adjusted for age, sex, body mass index (BMI) and ethnicity (beta =0.169; p=0.330). This may be limited by small sample size. HRPO nadir oxygen saturation (NOS) also correlated with polysomnography NOS with a Pearson correlation coefficient of 0.353 (p=0.006). Linear regression analysis showed a predictive value beta of 0.149 (p=0.006). When adjusted for age, sex, BMI and race, beta was equal to 0.156 (p=0.007). Conclusion ODI calculated through HRPO may be correlated with AHI. NOS determined through HRPO is weakly positively predictive of NOS calculated through PSG. To initiate treatment of OSA sooner, HRPO may be considered for screening or diagnostic purposes. The correlation between ODI and AHI needs to establish further in randomized controlled setting. Support (If Any)

0754 Effects of Atomoxetine plus a Hypnotic on Obstructive Sleep Apnea (OSA) Severity in Patients with a Moderately Collapsible Pharyngeal Airway

Abstract Introduction The combination of atomoxetine and oxybutynin has demonstrated efficacy in the treatment of OSA. Oxybutynin may play a role as an upper airway dilator muscle activator and/or a hypnotic to improve sleep quality. We assessed the effectiveness of atomoxetine when combined with one of two hypnotics. Trazodone is a known hypnotic with possible effects on pharyngeal muscle activity. The other is lemborexant, an orexin antagonist. The effects of both combinations were assessed in patients with OSA and a moderately collapsible pharyngeal airway. Methods Recruited patients were 18 – 65 years of age, with an AHI 4 (4% desaturation criteria) of 10 – 55 and a BMI < 40 kg/m2. Each had to have a moderately collapsible pharyngeal airway using previously defined criteria based on the average percent desaturation during obstructive events (< 8%) and the ratio of hypopneas to total events (> 50%). After a qualifying PSG, each patient spent three nights in the sleep laboratory with approximately one week between studies. Nights were randomized to placebo, atomoxetine 80 mg plus trazodone 100 mg, and atomoxetine 80 mg plus lemborexant 10 mg. Primary outcomes were AHI 4 and the sleep apnea specific hypoxic burden (HB), the area under the SpO2 curve associated with disordered breathing events. Results Fifteen patients completed the trial (median [interquartile range] age was 52 [48-55] and BMI was 33.6 [30 – 35.1] kg/m2. Atomoxetine plus trazodone showed a strong trend for AHI 4 reduction from placebo (from 18.2 [11.8 – 31.3] to 7.4 [5.4 – 16.1] events/h, p=0.064), a significant reduction in HB from placebo (from 48.2 [31.2 – 79.6] to 18.7 [14.9 – 43.5] % min/h) and a trend for a reduction in HB with atomoxetine plus lemborexant (from 34.1 [12.1 – 128.8] to 18.7 [14.9 – 43.5] % min/h, p=0.055). There was no change in total sleep time or arousal index between treatment arms. Mild adverse events were reported on atomoxetine plus trazodone (2/15 sinusitis, 1/15 heartburn). Conclusion In OSA patients with a moderately collapsible upper airway, the combination of atomoxetine plus trazodone yielded clinically meaningful improvements in measures of sleep disordered breathing and oxygenation while atomoxetine plus lemborexant produced smaller effects. Support (If Any) This study was supported by Apnimed.

0565 Examining obstructive sleep apnea knowledge and attitudes of providers in southern West Virginia

Abstract Introduction Obstructive sleep apnea (OSA) syndrome is a common but underdiagnosed clinical problem with multiple health implications. The rising prevalence of OSA has been linked to increasing obesity. Because the obesity rate of West Virginia (WV) is almost 40%, successful identification and treatment of OSA is essential to improving the health of WV communities. Our previous work demonstrated that OSA is ineffectively managed in our rural communities. This study aimed to evaluate OSA knowledge and attitudes of primary care providers (PCPs) practicing at Federally Qualified Health Centers (FQHC) serving rural communities with significant health disparity in southern WV. Methods We assessed OSA knowledge and attitudes of 14 PCPs in southern WV (n=6 physicians and 8 mid-level providers; 53.2 + 12.2 years of age; 78% female) practicing at FQHC. The OSA Knowledge and Attitudes (OSAKA) questionnaire assesses providers’ knowledge via 18 true-false statements and importance and attitude via five Likert. OSA attitudes are assessed via two items for importance of OSA and three items for confidence in identifying and treating OSA. Results No respondents answered the 18-knowledge portion with 100% accuracy (mean = 14.3). Mann Whitney U tests were then used to compare Physicians’ and mid-level providers’ years in practice and OSAKA responses. Knowledge scores in physicians (Mdn = 16) significantly differed from mid-level providers scores (Mdn = 13.5) in our sample (U = 5.5, p < 0.05, r = -0.66). OSAKA Importance and Confidence questions revealed that PCPs felt OSA identification was important, but were not confident in their ability to manage OSA. Conclusion Our results demonstrate that rural PCPs have fairly good knowledge of OSA in general but lack knowledge in specific domains. Interestingly, providers feel OSA is an important disease and were fairly knowledgeable with the disease, but lacked confidence to manage OSA. Further explanatory studies are warranted to more robustly examine these findings. Our prior work demonstrates sleep apnea is ineffectively managed in the region. Thus, targeted training and further engagement with rural providers may well address disparity in OSA management for Appalachian communities. Support (If Any) (NIH/NIGMS 5U54GM104942-03).

0776 The 2021 CPAP Recall. A Report from a Single Practitioner’s Experience

Abstract Introduction CPAP is the gold standard in the treatment of OSA. While CPAP has been characterized as cumbersome, patients derive benefit from this therapy and many report inability to sleep without the use of CPAP. In this context, the 2021 CPAP recall has represented a major challenge for all stakeholders in the delivery and management of OSA. Patients have been the most affected by the uncertainties triggered by the recall. The purpose of this report is to evaluate continued therapy among patients who have been able to replace their PAP equipment. Methods Consecutive patients seen in follow-up visit following replacement of the recalled unit are included. At the time of writing, the cohort includes 49 patients (age 64+/- 10; BMI: 34 +/- 9; AHI: 35+/-26; male: 27). Prior to the unit replacement (T1), 20 were on Auto-PAP, 2 on Auto-BiPAP, and 23 on CPAP. Only 6 units have been replaced by the manufacturer with the remaining patients opting to have their units replaced with the other main brand available in the US. At follow-up (T2), only 4 continued CPAP, 2 on Auto-VPAP and the remaining on Auto-PAP. Replacement units were prescribed based on the previous settings with modifications based on the clinical assessment. For those on Auto-PAP (or bilevel settings), their pressures were not significantly different from baseline to follow-up (T1: minimum pressure 7.2+/-3; maximum pressure 10.8+/-4. T2: minimum pressure: 7.1+/-3; maximum pressure 11.5+/-3). For those on CPAP who have continued therapy with Auto-PAP, the T1 pressure was 8.8+/-3 and their 90-95% pressure at T2 was 9+/-3 cwp (p<0.01). Results The cohort showed adherence of 442+/-79 min at T1, which was increased at T2 (455+/-69, p<.05). 4-hr adherence was comparable at 94+/-9 and 96+/-9, respectively. The Epworth Sleepiness Scale (ESS) was comparable at T1 (4.3+/-3) and T2 (4.6+/-3). Of interest, the unit’s estimated AHI was improved at T2 1.9+/-2 when compared to T1 at 3.7+/-4 (p<0.01), which was not explained by type or brand of therapy. An unexpected finding was the differential improvement in the level of adherence between males and females where the change in adherence from T1 to T2 for males was 24+/-39 min, and for females 0.5+/-42. Conclusion Patients on CPAP therapy have faced significant challenges due to the 2021 recall from one of the main producing brands. The results of the study illustrate the slow response in the replacement of the recalled units. Only 12% of the units in the present cohort were replaced within the recall program. The results document the resilience of this cohort in maintaining a high therapeutic adherence despite the uncertainties created by the recent recall. Support (If Any)

0068 Impact of OSA Therapy on Healthcare Economics: Actuarial Analysis of OSA Prevalence, Therapy Adherence, Co-morbidity, and Costs in a Large CMS Population Cohort

Abstract Introduction Research studying the economics of OSA therapy faces confounds including the prevalence of undiagnosed OSA, rate of diagnosed patients declining therapy, spectrum of treatment adherence, and effects of concurrent co-morbidity. We provide an actuarial analysis to study the economic impact of OSA therapy, accounting for these confounds, using the 2016-2018 Medicare 5% LDS Analytical File, a random sample of Medicare Claims containing approximately 2.9 million patients/year, resulting in N=2,001,538 eligible Fee-For-Service patients excluding managed care patients and incomplete data. Methods We segmented the study population into three cohorts and three 12-month time-periods. The cohorts analyzed were A) patients with OSA diagnosis and >12 months treatment, B) patients with OSA and <12 months treatment, and C) patients with OSA diagnosis who never received treatment, resulting in 1,351,838 patient-months. We analyzed the healthcare costs in each cohort in the year before treatment, the first year of treatment, and following treatment year. We applied actuarial risk adjustment within each cohort and time-period to provide a risk-adjusted cost comparison. Results were analyzed cross-sectionally given zero-to-seven co-morbidities among obesity, hypertension, type-II diabetes, depression, COPD, CHF, and/or prior stroke, facility-vs-home testing, and with-or-without surgical procedures. Results The average per-patient-per-month (PPPM) total medical spending was highest in the diagnosed-but-never-treated cohort-C ($1,375), second highest in <12-months treatment cohort-B ($1,005), and lowest in >12-months treatment cohort-A ($983). In both cohorts that started therapy, average/quantile costs decreased from pre-treatment year to post-treatment year, and from the first-to-second year on therapy. Compared to no-therapy cohort-C, costs were 29% lower in cohort-A and 27% lower in cohort-B. Among co-morbid, 75th quartile of cost members, we observed similar differences (18% and 16%) but larger absolute dollars. Patients undergoing surgical procedures had higher costs but lower spend reduction in initial and following year of therapy (22% and 5%). Conclusion We observed significant differences in cost between OSA patients that started treatment versus those that did not, and those differences further increased the year following therapy onset. These findings imply that receiving treatment for OSA reduces a patients overall medical spend. In terms of mean cost, the >12-month and <12-month cohorts costs fell in both follow-up treatment years. Support (If Any)

0773 When CPAPs are in Short Supply: A Review of Other FDA Approved OSA Interventions

Abstract Introduction The CPAP recall of 2021 has highlighted an inherent problem that occurs when a field of medicine is overly dependent on a single class of medical devices to treat a condition. The global shortage of CPAP devices has led to numerous individuals with OSA being unable to obtain a CPAP machine to treat their condition, including those with severe OSA. CPAP is well known to be efficacious in treating OSA, but has limited effectiveness, particularly for mild-to-moderate cases. It has been reported that there are nearly 200 different medical devices approved by the FDA to treat OSA. The goal of this project was to search the FDA databases to investigate the number of devices currently on file with the FDA. A secondary goal was to examine the range of FDA product categories for the treatment of OSA. Methods An FDA database (AccessGUDID; https://accessgudid.nlm.nih.gov) with a release date of December 1, 2021 was searched for devices that are approved for the treatment of sleep apnea. The text string “sleep apnea” was used for the search. Diagnostic devices, duplicate versions of the same treatment devices, and device accessories were excluded from the total counts. The FDA classifies medical devices into three categories (I, II, III), with a higher classification level indicating greater risk to patients. Results The FDA AccessGUDID database search returned 166 results, which resulted in 72 unique devices across 10 product code categories. 9 of the 10 product codes in the FDA database were class II (medium risk) and 1/10 was classified as III (high risk). 65 of the devices were reported to be in commercial distribution at the time of the search and 7 were not. Conclusion This analysis found that a relatively large number of FDA-approved devices exist for the treatment of OSA across a range of product categories. The field is encouraged to develop a better understanding of which subgroups of OSA patients could benefit from alternative forms of treatment in an effort to diversify treatment options and reduce the field’s reliance on a single type of device, particularly for patients with mild-to-moderate OSA. Support (If Any) VA IIR 16-277

0790 Racial Differences in Self-Efficacy for Positive Airway Pressure Therapy Among Individuals Newly Diagnosed with Obstructive Sleep Apnea

Abstract Introduction Continuous positive airway pressure (CPAP) therapy is the first-line treatment for OSA, yet its effectiveness is limited by poor adherence. Self-efficacy is an individual’s belief that they can successfully execute a behavior to achieve a desired outcome. Evidence shows that self-efficacy predicts adherence to and outcomes of CPAP therapy, as do race and ethnicity. Little, however, is known about how self-efficacy may differ between racial and ethnic groups. Accordingly, we aimed to determine whether self-efficacy for CPAP differs by race and ethnicity among individuals newly diagnosed with OSA. Methods Adults newly diagnosed with OSA and prescribed CPAP who were enrolled in the NICEPAP Study (n=267, NCT05067088), a prospective, observational cohort study investigating predictors of CPAP adherence were assessed. Those with need for non-CPAP therapy or with unstable medical conditions (e.g., cancer receiving chemotherapy, severe lung, heart or mental health disorders) were excluded. Exposures were race and ethnicity. Outcomes were subscale scores of the Self-Efficacy Measure for Sleep Apnea (SEMSA) completed prior to CPAP initiation: perceived risk, outcome expectancy, and self-efficacy. SEMSA sub-scale scores for race/ethnicity were compared using Kruskal-Wallis test. Medians (Q1, Q3) are reported. Results We analyzed data for 52 participants (33 women) enrolled to date who identified as White (n=29), Black (n=14), More than one race (n=5) and Other (N=5). Participants were 51.0 (36.8, 58.8) years old with an apnea-hypopnea index of 17.0/hour (11.1, 26.0) and body-mass-index of 35.0 (31.6, 43.5) kg/m2. Baseline characteristics did not differ by race, except higher poverty (p=0.005) and less completed years of education (p=0.010) for Black participants. The SEMSA scores were not statistically different between each race. However, self-efficacy was significantly lower for Black participants vs. rest of the cohort combined (2.4 (1.9, 3.1) vs. 3.3 (2.7, 3.8) p=0.020). Poverty, but not education, may be a potential mediator of this relationship (mediation analysis p=0.052). There were no differences in SEMSA scores between Hispanic and Non-Hispanic participants. Conclusion In our cohort, self-efficacy for OSA therapy was lower for Black participants compared to those of other races. Targeting early interventions to improve CPAP self-efficacy in Black patients may improve OSA therapy outcomes. Support (If Any)

0539 Obstructive sleep apnea symptoms and their improvement with PAP in the pediatric population: A Retrospective Study in a Pediatric Sleep Disorders Center

Abstract Introduction Obstructive sleep apnea (OSA) is estimated to occur in 1% to 5% of the pediatric population1. The Agency for Healthcare Research and Quality (2021) recently released a draft report titled, “Continuous Positive Airway Pressure Treatment for Obstructive Sleep Apnea.”2 The conclusions of this report determined that the published evidence reviewed by the agency did not support that positive airway pressure (PAP) affects long term, clinically important outcomes. No pediatric studies were included in this report. Pediatric patients who require PAP are held to the same standards as adults regarding adherence and insurance requirements3. However, clinical symptoms to determine improvement of OSA symptoms in adults are not the same in children. Symptoms in the pediatric population such as decreased concentration, hyperactivity, memory impairment, learning disorders, nocturnal enuresis and growth impairment have improved with PAP and are important indicators in this population of improved clinical outcomes4. Methods Retrospective chart review was used to examine symptoms reported by pediatric patients initiated on PAP for OSA. Symptom information was extracted before and after initiation of PAP. A chi-Square test was used to determine if there was an association between PAP treatment and improved clinical symptoms. Results 235 patient records were reviewed. The distribution of sex was 150 (63.9%) males and 76 (32.3%) females. The mean age at PAP initiation was 12.0 (SD = 4.5), age range from 9 months to 19 years. Most frequent symptoms pre PAP initiation included excessive daytime sleepiness (51%), at least one of the daytime behaviors above (45%), and nocturnal enuresis (14%). Excluding patients with missing data, first and fourth visit post PAP initiation, 78% (221 patients; 66 missing) and 90% (90 patients; 12 missing), respectively, reported improvement in symptoms. Conclusion Results indicate that PAP is a beneficial treatment of OSA with improvement in symptoms specific to the pediatric population. Due to the clinically significant outcomes to growth and development that PAP provides to pediatric patients with OSA, we suggest that they should not be held to the same insurance requirements as adults and further studies should be conducted to validate these findings. Support (If Any)

0747 Polysomnogram characteristics associated with artificial Intelligence enabled electrocardiogram algorithm predicted probability of atrial fibrillation in patients with obstructive sleep apnea

Abstract Introduction Obstructive sleep apnea (OSA) is associated with atrial fibrillation (AF). Several features of OSA are thought to play role in the development of AF. A recently developed artificial intelligence (AI) enabled electrocardiogram (ECG) algorithm predicts the probability of future development of AF from a single ECG. We sought to examine the relationship between polysomnogram (PSG) and clinical features of patients with OSA and the probability of future AF (P-AF). Methods Consecutive adults (age ≥ 18) with OSA and with an ECG obtained within 2 years of their attended polysomnograms (PSG) were examined. We excluded patients with AF, left ventricular ejection fraction < 50%, implanted pacemaker or cardioverter defibrillator. We recorded demographics, apnea-hypopnea index (AHI), respiratory arousal threshold (RAT), percent sleep time with SpO2 < 89%, arousal index, and a comorbidity score composed of presence of coronary artery disease (CAD), hypertension (HTN), diabetes mellitus (DM), stroke, and chronic lung disease. One and two-way ANOVA was used to examine the relationship of OSA severity (mild, moderate, or severe) with P-AF. Multiple linear regression further characterized associations with P-AF. Results Mean AI determined P- AF was 0.052±0.012 (mean±SE) in mild, 0.064±0.014 in moderate, and 0.105 + 0.014 in severe OSA, demonstrating a significant association of OSA severity with P-AF (p = 0.01). Post-hoc pairwise tests showed a significant difference in P-AF between mild and severe (p = 0.008) but not between moderate and severe OSA (p = 0.083). Multiple linear regression with all the variables listed above showed the association between OSA severity and P-AF remains significant (P = 0.044). Age (p<0.001) and comorbidity score (p<0.001) were the only other variables significantly associated with P-AF. Conclusion OSA severity determined by AHI was significantly associated with P-AF as determined by a novel ECG-based AI algorithm independent of other variables. Given the strength of association with age and the comorbidity score, OSA severity may have been associated as it is known to increase with age and comorbid conditions. Future directions include incorporating AI enabled algorithms to identify individuals with the highest risk of AF in whom the role of OSA treatment in reducing risk of AF may be examined. Support (If Any)