PAP Therapy Research Articles

Subjective HRQoL in Patients with Sleep Apnea Syndrome Who Underwent PAP Therapy in a Rehabilitation Setting: A Longitudinal Study

Obstructive sleep apnea (OSA) is often associated with decreased health-related quality of life (HRQoL). The aims of this study were to evaluate HRQoL, the clinical and psychological profile of suspected or verified OSA patients, and the impact of PAP therapy at 1-year follow-up. At T0, OSA-suspected subjects underwent clinical, HRQoL, and psychological assessment. At T1, OSA patients underwent PAP therapy in a multidisciplinary rehabilitation setting. At 1 year follow-up, OSA patients were evaluated for the second time. At T0, OSA patients (n = 283) and suspected OSA subjects (n = 187) differed for AHI, BMI, and ESS. At T0, the PAP-treatment group (n = 101) showed moderate-severe anxious (18.7%) and depressive (11.9%) symptoms. At 1 year follow-up (n = 59), the sleep breathing pattern had normalized and there was a reduction of ESS scores and anxious symptoms. There was also an improvement in HRQoL (0.6 ± 0.4 vs. 0.7 ± 0.5, p = 0.032; 70.4 ± 19.0 vs. 79.2 ± 20.3, p = 0.001) and in satisfaction with sleep quantity (52.3 ± 31.7 vs. 71.4 ± 26.2, p = 0.001), sleep quality (48.1 ± 29.7 vs. 70.9 ± 27.1, p = 0.001), mood (58.5 ± 24.9 vs. 71.0 ± 25.6, p = 0.001), and physical resistance (61.6 ± 28.4 vs. 67.8 ± 27.4, p = 0.039). Considering the impact of PAP treatment on patients' psychological and HRQoL evaluations that we observed, our data are valuable for unveiling different profiles characterizing this clinical population.

The Role of Inverted Papilloma Surgical Removal for Sleep Apnea Treatment Success—A Case Report

In recent years, increased attention has been directed to sleep apnea syndrome due to its high prevalence and preventable severe health consequences. Besides enhancing the risk of cardiovascular, cerebrovascular, and metabolic disorders, it determines increased daytime somnolence, cognitive impairment, and delayed reaction time. These symptoms, determined by sleep fragmentation and chronic hypoxemia, can result in a decrease in professional performance and, moreover, could have tragic implications, especially in patients with high-risk professions. We present the case of a 58-year-old male-truck driver, known to suffer from uncontrolled OSA and chronic obstructive pulmonary disease, who presented to our ENT department for incapacitating daytime somnolence and severe nasal obstruction. These symptoms were caused by a voluminous sinonasal inverted papilloma, occupying the entire left cavity with extension in the nasopharynx. Following nose permeabilization, the patients' APAP compliance grew substantially, with a dramatic decrease in daytime sleepiness and improvement in polysomnographic parameters. Due to the overlap syndrome of OSA and COPD, an oxygen supplementation was added to PAP therapy by a pulmonologist, improving pulse-oximetry parameters and resulting in the best outcome for the patient. Through this case report, we aim to emphasize the importance of multimodal, personalized treatment of sleep apnea with a focus on nasal surgical permeabilization. At the same time, we sustain a multidisciplinary approach, especially in patients with sleep apnea and associated pathologies, to obtain therapeutic success. We propose increased attention to the early recognition and proper treatment of sleep apnea in patients with high-risk professions as it prevents catastrophes.

PAP Therapy Compliance in COVID-19: Multifactorial Etiologies to Consider.

PAP Therapy Compliance in COVID-19: Multifactorial Etiologies to Consider.

A panoramic view of a cohort of obstructive sleep apnea patients on positive airway pressure therapy using cloud based telemonitoring devices.

Positive airway pressure therapy is mainstay of treatment of obstructive sleep apnea (OSA). But long-term compliance with is poor with such therapy. A proactive and vigilant management may improve the PAP therapy usage. Cloud-based telemonitoring PAP devices offer an opportunity for proactive monitoring and prompt interventions related to PAP troubleshooting. This technology is also used in India for adult OSA patients. But we lack our own data on behavior of Indian patients as a cohort on PAP therapy. The present study is an attempt to look at the behavior a cohort of PAP users in OSA. This study was planned as a retrospective analysis of data of OSA patients who were using a cloud-based PAP devices. First 100 patients were chosen for data retrieval that who was on this therapy. The data was obtained for those patients who were on PAP for at least 7 days and maximum follow-up was available up to 390 days. Descriptive statistical analysis has been carried out in the present study. The number of male and female patients was 75 and 25, respectively. Overall good compliance was present in 66% of patients. 34% of patients were not compliant with PAP during follow-up. The compliance was statistically same in both the sexes (P = 0.8088). Incomplete data recovery was present in 17 patients and 11 (64.70%) were non-compliant among them. In the initial, 60 days non-compliant patients were more than compliant patients. The difference was lost in 60 to 90 days of use. The air leak was present more in the compliant group than non-compliant group (P = 0.0239). 75.75% of compliant patients had achieved AHI control, whereas 35.29% of non-compliant patients also achieved AHI control. But overall, AHI control was poor in non-compliant patients and 61.76% of non-compliant patients had an AHI uncontrolled. We conclude that 3/4th of the compliant patients achieve AHI control while 1/4th didn't. This 1/4th population needs further exploration to determine the causes of poor AHI control. Cloud-based PAP devices give an easy opportunity to monitor patients of OSA. It gives an instant panoramic view of behavior of OSA patients on PAP therapy. The compliant patients can be tracked, and non-compliant patients can be segregated quickly.

Efficacy of positive airway pressure therapy and high flow nasal cannula oxygen in acute cardiogenic pulmonary oedema: A protocol for systematic review and network meta-analysis.

Positive airway pressure (PAP) therapy is currently the first-line respiratory support technique for acute respiratory failure (ARF) due to acute cardiogenic pulmonary edema (ACPE), but the accompanied adverse events and patient's intolerance with treatment in some cases limited its use in clinical practice. Some recent trials indicated that high-flow nasal cannula oxygen (HFNO) is a promising alternative to PAP therapy. In order to choose the optimum treatment for patients with ACPE, this network meta-analysis will firstly compares the efficacy of HFNO, PAP, and conventional oxygen therapy (COT). The Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols 2015 statement and its extension for network meta-analysis will be followed in the conduct of this investigation. We will examine these databases: PubMed, EMBASE, Cochrane Central Register of Controlled Trials and Web of Science. The ClinicalTrials.gov and World Health Organization International Clinical Trials Registry Platform Search Portal will be used to search ongoing trials. Only randomized controlled trials meeting the eligibility criteria will be included. Through the Cochrane Collaboration's tool, the included studies' risk of bias will be assessed. The pairwise meta-analysis will be performed with RevMan 5.4.1 software. A Bayesian network meta-analysis will use random-effects models to derive odds ratios for the treatment effects of all interventions compared to each other using R software (version 3.6.1), and the rjags and gemtc packages. The Q statistic and I2 index will be used for investigating the heterogeneity, and subgroup analysis or sensitivity analysis will be used to explore the source of heterogeneity. In addition, the Grading of Recommendations Assessment, Development and Evaluation system will be used to inspect the quality of evidence.

Schlafmedizin für den Hals-Nasen-Ohren-Facharzt

Sleep-related breathing disorders can be divided into obstructive and central sleep apnea, and hypoventilation syndromes. The diagnosis is made according to an algorithm in which clinical symptoms and a polygraphy or polysomnography usually point the way. After initial diagnosis of the most common obstructive sleep apnea, conservative therapies such as positive airway pressure therapy (PAP therapy), positional therapy, and/or mandibular advancement splint are used in many cases, supplemented by treatment of risk factors. If PAP therapy is not possible, more detailed diagnosis of airway obstruction, often with sleep videoendoscopy, is required. In general, "muscle-sparing" surgical techniques such as tonsillectomy with uvulapalatopharyngoplasty (TE-UPPP) should be considered whenever possible. This is especially important in the surgical treatment of snoring. More surgical therapy alternatives are for example barbed wire pharyngoplasty, tongue pacemaker and bimaxillary advancement. Optimal therapy alternatives should be evaluated in a sleep medicine center.

A Review of PAP Therapy for the Treatment of OSA

A Review of PAP Therapy for the Treatment of OSA

Switch of Nocturnal Non-Invasive Positive Pressure Ventilation (NPPV) in Obstructive Sleep Apnea (OSA).

Background. Continuous positive airway pressure (CPAP) is considered the first-line treatment for patients with OSA, but Bilevel-PAP (BiPAP) therapy is a recognized option for noncompliant/unresponsive patients to CPAP. The present study was designed to evaluate the role of ResMed VAuto in the management of two different issues raised because of the Philips recall: the treatment of naïve noncompliant/unresponsive patients to CPAP (Group A) and the switch to VAuto for patients already on treatment with Philips Auto-BiPAP (Group B). Methods. Sixty-four patients who required auto-BiPAP treatment from August to December 2021 were included in the study. The efficacy of each mode of PAP therapy was compared between the two groups of patients. Results. Group A showed a statistically significant improvement in the apnea–hypopnea index (AHI) (7.4 ± 8.5 events·h−1 vs. 15.2 ± 12.1 events·h−1, p < 0.001), and oxygen desaturation index (ODI) (9.4 ± 8.9 events·h−1 vs. 15.2 ± 8.8 events·h−1, p = 0.029) during VAuto in comparison to CPAP, respectively. Conversely, a similar trend was found for patients in Group B for global AHI, but a statistically significant reduction was just found in supine AHI and ODI. In group B, an AHI <5 events·h−1 was found in 89.3% during VAuto in comparison to 82.1% with Philips Auto-BiPAP (p = ns). The levels of IPAPmax and EPAPmin were not statistically different between the two devices (p = 0.69 and p = 0.36, respectively). Conclusion. Bilevel ventilation in VAuto mode is effective in the clinical management of two different issues derived from the Philips recall. The switching between two different auto-BiPAP devices can be performed easily and successfully.

0858 Under reporting of Apnea Hypopnea Index (AHI) in patients with predominant REM sleep disordered breathing on antidepressants

Abstract Introduction The prevalence of Rapid Eye Movement (REM) related Sleep Disordered Breathing (SDB) ranges from 13.5% to 36.7% in patients suspicious to have SDB.1 It is reported that patients with REM related SDB often have associated depression and are commonly on anti-depressants.2 Antidepressants suppress overall REM sleep duration. Significant sleep disordered breathing is known to occur during REM sleep. These patients commonly present with excessive daytime sleepiness and fatigue. Obstructive sleep apnea (OSA) diagnosis is often missed in these patients secondary to REM sleep suppression and subsequent underreporting of AHI.1. Conwell W, Patel B etal 2012 PMID: 21614575. 2. Geckil AA, Ermis H. 2020 PMID: 30949927. Report of Cases: Case 1 is a 53-year-old obese white female with stable depression on citalopram 20mg presented with witnessed loud snoring and apneas, sleep onset and maintenance insomnia, daytime fatigue and hypersomnolence. Her Epworth Sleep Score (ESS) was 13/24. Her in lab baseline polysomnogram demonstrated overall AHI 3.8/hour and REM only AHI 24.3/hour. To further explore her persistent daytime sleepiness a Mean Sleep Latency Test (MSLT) was ordered. Citalopram was held 2 weeks prior to MSLT. In the PSG her overall AHI increased to 7.6/hour diagnosing her with mild OSA. PAP therapy was initiated that improved patients nocturnal sleep, daytime fatigue and hypersomnolence. Case 2 is a 54-year-old overweight white female with past medical history of chronic stable depression on Wellbutrin SR 100 mg daily presented with significant day time fatigue and hypersomnolence (ESS 15/24). Her baseline PSG reported AHI 1.7/hour with REM only AHI 10.7/hour. However due to persistent excessive daytime sleepiness MSLT was ordered. Her Wellbutrin was held 2 weeks prior to testing. Her overnight PSG demonstrated increase in her AHI to 7.9/hour and REM AHI to 34.2/hour. Mild obstructive sleep apnea was diagnosed, and PAP therapy was initiated that improved her hypersomnolence. Conclusion These cases illustrate that antidepressants likely mask obstructive sleep apnea by suppressing REM sleep. Given the underreported AHI in patients with REM SDB who are on anti-depressants it may be prudent to hold anti-depressants for 2 weeks to establish an accurate diagnosis of sleep apnea. Support (If Any)

0792 Exploring Symptomatic Relief of Patients with Central Sleep Apnea when using CPAP or BiPAP Therapy

Abstract Introduction About 0.9% of peoples over the age of 40 in the United States have Central Sleep Apnea (CSA). The key to treating CSA is to address any underlying health issues causing the condition as there are no clear, established treatment guidelines. For example, approaches will be made to mitigrate congestive heart failure. Often, patients may require the use of CPAP or BiPAP device to decrease cessations in respiration during sleep. Methods We investigated those patients diagnosed with CSA who use CPAP or BiPAP therapy and it's potential therapeutic effects through a retrospective chart review over a three-year period. We excluded those who were diagnosed with treatment emergent CSA and those using ASV. Data was collected from each patient's chart about patient demographics, modality of PAP therapy, and information pertaining to symptomatic relief. Results 42 patients were identified who had a diagnosis of CSA. 25 of 42 (59.5%) were excluded as they were using alternative therapies. Of the 17 patients, 14 (82.4%) were male with an average age of 70.7 and 3 (17.6%) were females with an average age of 50. 15 of the 17 (88.2%) used CPAP therapy and the 2 (11.8%) patients used BiPAP.Prior to PAP therapy, the average Epworth Sleepiness Scale was 8.08 which improved to 3.79 post therapy. 9 out of the 17 (52.9%) patients reported improvement in nocturnal gasping while 2 (11.8%) did not report relief and 6 (35.3%) patients we were unable to determine through chart review. 9 out of 17 (52.9%) patients reported unrefreshed sleep and later 6 of the 9 (66.7%) patients reported refreshed sleep with initiation of PAP therapy while 1 patient reported no improvement and 2 (22%) we were unable to determine. 15 of the 17 (88.2%) patients complained of waking up multiple times throughout the night before PAP therapy. 5 (33.3%) patients had improvement of the frequency of nighttime awakenings while we were unable to determine the remaining 10 patients. Conclusion When central sleep apnea persists despite adequate treatment of the primary cause, CPAP or BiPAP may be used for symptomatic relief. Support (If Any)

0360 PAP Adherence, Follow-Up, and Telehealth During the COVID-19 Pandemic

Abstract Introduction Positive airway pressure (PAP) is the gold standard therapy for OSA. However, patient follow-up and adherence to PAP therapy remains variable. With the onset of the COVID-19 pandemic, many sleep centers shifted towards telemedicine. In order to evaluate the impact of telehealth, we assessed the rates of follow-up and PAP adherence among patients newly diagnosed with OSA prior to and after the onset of the COVID-19 pandemic. Methods Patients aged 18-75 years enrolled in our military sleep center who met eligibility criteria were divided into a pre-pandemic group and a pandemic group. For the pre-pandemic group, initial and follow-up clinic appointments occurred via face-to-face encounters. For the pandemic group, these clinic appointments occurred via telephone encounters. PAP follow-up was defined as a clinic appointment occurring within 6 months of the initial OSA diagnosis and the onset of PAP therapy. Adequate PAP adherence was defined as usage of the device ≥ 4 hours per night on ≥ 70% of nights during a consecutive 30-day period. Differences among the two groups regarding PAP follow-up, PAP adherence, and demographic data were analyzed. Results Eligible patients (n=234) were divided into a pre-pandemic group (n=117) and a pandemic group (n=117). Demographic data for the pre-pandemic group vs. pandemic group included the following: mean age 42.2 vs. 40.3 years; 78.6% vs. 88.0% male; 60.7% vs. 76.9% active duty military, mean BMI 30.1 vs. 30.1; mean AHI 28.5/hr vs. 27.7/hr; mean Epworth Sleepiness Scale score 11.7 vs. 12.0; mean Insomnia Severity Index 16.9 vs. 16.8. The rates of PAP follow-up were 59.0% (pre-pandemic group) vs. 41.0% (pandemic group). The rates of adequate PAP adherence were 34.8% (pre-pandemic group) vs. 25.0% (pandemic group). Conclusion There were higher rates of PAP follow-up and PAP adherence among patients seen via face-to-face encounters occurring prior to the onset of the COVID-19 pandemic. While utilization of telehealth in our center did not result in improved outcomes, there may still be utility in offering telehealth to the sleep patient population. Additional studies are needed to identify effective interventions that can be implemented to improve rates of PAP follow-up and PAP adherence. Support (If Any) There were higher rates of PAP follow-up and PAP adherence among patients seen via face-to-face encounters occurring prior to the onset of the COVID-19 pandemic. While utilization of telehealth in our center did not result in improved outcomes, there may still be utility in offering telehealth to the sleep patient population. Additional studies are needed to identify effective interventions that can be implemented to improve rates of PAP follow-up and PAP adherence.

0774 Positive Airway Pressure Utilization, Major Adverse Cardiovascular Events Incidence Risk and Mortality in Medicare Beneficiaries with Obstructive Sleep Apnea

Abstract Introduction Positive airway pressure (PAP) is the first line treatment for moderate-severe or symptomatic obstructive sleep apnea (OSA). Randomized controlled trials have established that PAP therapy has beneficial impact on cardiovascular and metabolic functions. However, evidence on the benefits of PAP for preventing major adverse cardiovascular events (MACE) is limited. We aimed to determine the association between PAP utilization and incidence of MACE and all-cause mortality in a large sample of Medicare beneficiaries. Methods Medicare beneficiaries (&amp;gt;65 years) with at least 5 years of consecutive enrollment to part A and B and ≥2 distinct OSA claims were collected from multi-state (Kansas, Missouri, Iowa, Wisconsin, Nebraska, Minnesota, Texas, Utah, North Dakota, South Dakota and Indiana), multi-year (2011-2017) Medicare fee-for-service claims data. We further required at least 1-year enrollment before the first OSA claim. Evidence of PAP utilization and index date was defined based on the first Healthcare Common Procedure Coding System PAP initiation codes (E0601, E0470, E0471) after first OSA diagnosis. MACE was defined as the first occurrence of myocardial infarction, coronary revascularization, stroke, or heart failure (identified by diagnostic and procedure code claims) after PAP initiation. Analyses were adjusted by age at initial OSA diagnosis, sex, race and presence of hypertension, type 2 diabetes, obesity, and evidence of MACE prior to the index date. Results Our sample included 212,445 eligible Medicare beneficiaries with evidence of OSA diagnosis (mean [SD] age 75 [5.7] years; 45.2% women; median [Q1, Q3] follow-up 4 [2.0, 4.9] years at censoring). Five-year MACE cumulative incidence rate was 59.3% and the mortality rate was 17.8%. In adjusted analyses, OSA patients with evidence of PAP utilization (50.8%) had significantly lower MACE incidence risk (HR=0.812; 95%CI=0.803-0.822; p&amp;lt;0.0001) when compared to those without evidence of using PAP. OSA patients with evidence of PAP utilization also had significantly lower mortality risk (HR=0.575; 95%CI=0.560-0.591; p&amp;lt;0.0001). Pre-existing hypertension, type II diabetes and obesity were also significantly associated with increased mortality and MACE risk. Conclusion PAP utilization based on device initiation derived from claims data is associated with lower MACE incidence and mortality in older adults that are Medicare beneficiaries. Support (If Any) American Heart Association (20CDA35310360), Patient-Centered Outcomes Research Institute (RI-CRN-2020-003-IC); NIH CTSA NCATS Frontiers: University of Kansas Clinical and Translational Science Institute (UL1TR002366); Tier 2 grant, University of Missouri.

0808 Worsening central sleep apnea: A sole diagnostic marker of a brain tumor in a child

Abstract Introduction Central sleep apnea (CSA) in children is a relatively uncommon and under-studied sleep disorder. A small subset of patients may have intracranial anomalies, but clinical presentation varies. We present a case of malignant intracranial tumor diagnosed primarily due to the unusual presentation and progression of CSA. Report of Cases: The presented patient is a 12-year-old developmentally appropriate female with a history of obstructive sleep apnea (OSA) status post adenotonsillectomy at two years of age who presented with snoring without witnessed apnea, sleep interruptions, and unrefreshing sleep. Other sleep-related history was unremarkable. No daytime sleepiness or behavioral or learning concerns were noted. Physical examination was unremarkable with normal growth parameters. Initial diagnostic PSG demonstrated severe OSA with an obstructive apnea-hypopnea index (OAHI) of 16/h and mild CSA (CAI:6.7/h); therefore, PAP therapy was pursued after ruling out adenoid regrowth. However, during the first PAP titration study(incomplete study due to mask intolerance), treatment-emergent central apneas were noted (OAHI: 9.8/h; CAI:25.8/h), which were noted even during the second titration study (OAHI:2.7/h; CAI:59.2/h). Even though ordered earlier, the brain MRI was not performed until after the repeat PSG one year later showed persistence of severe CSA (OAHI of 4.5/h and CAHI of 39.5/h) after much persuasion. Interestingly, snoring had reportedly improved with no daytime symptoms or neurologic complaints. The brain MRI demonstrated compressing brainstem lesion highly suspicious for glioma. The patient was emergently sent to neurosurgical care and had chosen hospice care after a few weeks. Conclusion CSA can be an early or the only finding in patients with brainstem tumors, even before neurologic signs and symptoms. The PSG findings changed from mild CSA to treatment-emergent CSA to severe CSA, possibly with the progression of underlying disease. Close follow-up and ensuring patient compliance are essential in CSA patients. CSA severity should prompt MRI brain even with an intact neurological examination. More research is needed to fully understand the link between cerebral disease and polysomnographic data. This could aid in early diagnosis and treatment. Support (If Any) no conflicting or financial interests to disclose

0861 Sleepy in the Mountains

IntroductionCentral sleep apnea (CSA) is a rare disorder caused by a reduction of airflow and ventilatory effort during sleep. CSA is rarely idiopathic and associated with medical conditions including heart failure, opioid medications, treatment emergent and high-altitude periodic breathing. At higher altitudes, hypoxemia induces periodic breathing with periods of deep and rapid breathing alternating with central apnea. Patients with high-altitude periodic breathing experience fragmented sleep, poor sleep quality, excessive daytime sleepiness, morning headaches and witnessed apnea. We discuss a patient with obstructive sleep apnea (OSA) who developed new-onset central sleep apnea after relocating to a higher altitude location. Report of Cases: A 75-year-old male with a history of moderate obstructive sleep apnea well controlled on CPAP for eight years, with no known cardiovascular or pulmonary disease, presented with new-onset excessive daytime sleepiness. He had recently relocated to an area in the Colorado mountains (7000 ft elevation) from his previous home in Los Angeles (sea level). His residual apneahypopnea index (r-AHI) displayed on his CPAP machine increased to 7-14/hr from his normal of 1-2/hr after his relocation. Review of his compliance data revealed his central apnea index was elevated, contributing to his high r-AHI. A one-night nocturnal oximeter was mailed to the patient to use while on CPAP. Data revealed oxygen desaturation to less than 88% for about 2 hours of the night, worse during the early morning hours. The patient was advised to undergo a polysomnography and adaptive servo-ventilation titration if significant central sleep apnea was present. The patient declined due to concern about the COVID-19 pandemic. Supplemental nocturnal oxygen was initiated at 2L/min with normalization of the r-AHI.ConclusionPatients with OSA who experience worsening symptoms or increased r-AHI despite excellent compliance with PAP therapy should be considered for repeat polysomnography or titration study. While it is expected that high-altitude central sleep apnea will improve with acclimatization, nocturnal supplemental oxygen in addition to PAP therapy is indicated for patients with high-altitude central sleep apnea to diminish hypoxemia and improve residual AHI and sleep quality.Support (If Any)

0854 A case of complete heart block in a patient with severe obstructive sleep apnea

Abstract Introduction Obstructive sleep apnea (OSA) has been associated with bradycardic arrythmias and cases of transient heart block. Heart block occurring during sleep has been described in up to 10% of patients with obstructive sleep apnea, most commonly during stage R sleep and through a mechanism known as vagal activation. Stage R sleep is associated with desynchronization of respiratory and cardiovascular functions, and the excessive autonomic response (vagal activation) occurs due to the stronger stimulation of chemoreceptors and baroreceptors induced by hypoxemia, intrathoracic pressure swings, and hemodynamic alterations. Treatment of the underlying sleep-disordered breathing will typically treat the bradycardic arrythmia as well. Report of Cases: A 49-year-old male with a BMI of 30 kg/m , neck circumference of 16 inches, and obstructive sleep apnea presented to the sleep center to establish care for management of his preexisting OSA. He was previously diagnosed with moderate OSA in 2007 but had discontinued therapy shortly after due to Continuous Positive Airway Pressure (CPAP) intolerance. The patient complained of snoring, nocturia, and excessive daytime sleepiness (18/24 on Epworth Sleepiness Scale). During the split night study, the patient was noted to have 2:1 second degree heart block followed by a transient episode of complete heart block, manifested by 4 non-conducted p-waves. The patient remained asymptomatic throughout the night. Upon study completion, the patient denied any prior chest pain, presyncope, syncope, or medications that might cause heart block. Conclusion Bradyarrythmias can be seen in severe obstructive sleep apnea in the setting of excessive vagal stimulation through increased stimulation of chemoreceptors and baroreceptors. Treatment with PAP therapy can lead to prevention of heart block in 80-90% of these patients. Support (If Any)

0537 Symptom Improvement Reported with Some PAP Use in Non-adherent Pediatric Patients with OSA

Abstract Introduction Positive airway pressure (PAP) is commonly used in children to treat obstructive sleep apnea (OSA) when surgery is not an option or is ineffective1-3, but adherence is often poor. Observational studies suggest utilization of PAP improves symptoms, signs, and polysomnogram indices of OSA in at least 85% of children4-9. The Agency for Healthcare Research and Quality released the report “Continuous Positive Airway Pressure Treatment for Obstructive Sleep Apnea”10. Conclusions of this report determined that the published evidence reviewed does not support that PAP affects long term outcomes. No pediatric studies were included in this report. Objectives of this study were to determine if pediatric patients with OSA who are non-adherent to PAP therapy report an improvement in symptoms with some use of PAP. Methods A retrospective chart review was performed on patients with OSA on PAP seen in the pediatric sleep clinic. Patients were considered adherent to PAP if usage was longer than 4 hours/night for 70% of nights or more. Follow up visits occurred around 3 months, 6 months, 1 year, and 18 months-2 years. Adherence data and reported improvement in symptoms were documented at each visit, and demographical information was obtained. Results 235 patients were included in the analysis (63.9% male, 32.3% female, 3.8% missing), with a mean age (SD) at PAP initiation of 12 years (4.5). The sample was predominately Caucasian (51.5%) or African American (38.3%), 85.9% were non-Hispanic, and 53.2% obese. The mean (SD) apnea-hypopnea index was 24.7(27.6)/hr. At first visit post-initiation, of the 138 patients that had adherence data available, 80.4% reported improvement in symptoms with PAP use. Of these patients, 55.86% were non-adherent but reported symptom improvement with some use of PAP. Visit 4 data was available for 74 patients. At visit 4, 91.9% reported improvement in symptoms. Of these, 48.53% were considered non-adherent but reported symptom improvement with some use of PAP. Conclusion Historically, PAP adherence in children has been relatively poor11. Utilizing PAP therapy to treat OSA may result in an improvement in symptoms when used in patients who are considered non-adherent to therapy. Support (If Any)

0771 Artificial Intelligence Based Mask Fit Algorithm Application in the Pittsburgh Veteran Population

Abstract Introduction Positive airway pressure (PAP) therapy has been used for obstructive sleep apnea (OSA) since 1980 and remains the treatment of choice for moderate to severe OSA. Proper mask fitting for patient comfort is essential to continued success on PAP therapy, as early adherence rates are strong predictors of future use. Mask selection continues to be challenging given the significant heterogeneity in craniofacial phenotypes and the rapidly growing mask options. Artificial intelligence software has combined survey data and digital photography to algorithmically predict PAP masks for best fit. This study aimed to describe mask failure rates in the Pittsburgh Veteran population with OSA following mask selection utilizing this specialized software. Methods Retrospective chart review was performed on 124 patients who underwent mask fitting with AI software May through November 2021. The primary outcome was to determine the rate of mask success within 1-3 months of fitting as defined by absence of mask switching. Mask switch was identified when patients underwent re-evaluation for new mask selection either by the AI software or had evidence of new mask selection from supply orders. Results Of the 124 patients who underwent evaluation with AI mask fit software, 96% were male with an average AHI 35/hr, BMI 34 and average age of 58 years. Of the 65 patients who were new to PAP therapy, 14 patients required refitting, yielding an initial mask acceptance rate of 78%. Of the 59 patients established on PAP, 8 required subsequent mask switches, yielding a refit mask acceptance rate of 86%. Overall mask acceptance rate after first exposure to fitting software across both groups was 82%. Conclusion AI software appears to result in successful mask fitting in a high proportion of VA patients. Higher mask acceptance rate was noted in the refit group, suggesting a particular use-case for this software. Most importantly, this software allows for remote mask fitting. This is ideal given recent telehealth growth and can save time and visits, leading to expedited therapy and increased access. Support (If Any)

0857 How To Fix Mask Leak For Those With No Teeth

Abstract Introduction Mask fit is a crucial factor for patient adherence and effective use of PAP therapy. However, patients using dentures may face significant challenges to achieving a good mask seal, resulting in mask leak and inefficacy of therapy. Report of Cases A 67-year-old male with Obstructive Sleep Apnea (OSA) previously adherent to Bi-level Positive Airway Pressure (BPAP) therapy presented to clinic for complaints of mask leak. Due to a suspected dental infection, he had had all his teeth removed three years prior to this visit and had been instructed by his dentist to remove the dentures each night when he slept. However, removal of the dentures affected the fit of his full-face mask, and he experienced significant mask leak with return of pre-PAP symptoms. He was a habitual mouth-venter and preferred full-face masks. Despite trialing different masks, he was no longer able to tolerate his BPAP secondary to the leak and discontinued PAP therapy altogether. During his visit to the sleep center, a mask refit was performed with and without his dentures in place. While no masks sealed effectively with his dentures out, a satisfactory alternative was found if he wore his dentures. He was counseled to wear his dentures while using PAP, remove his dentures for the recommended minimum amount of time during the day instead of removing them for sleep, and to follow up with his denturist/prosthodontist for further instructions. Conclusion Edentulous patients may pose difficulties with mask fit, and a multi-modal approach may be necessary to effectively treat their sleep apnea. Luckily, our patient was able to find a mask that he found comfortable while wearing his dentures and had minimal leak. Alternatives may include consideration of positional therapy with lower pressures for a potential nasal mask, weight loss, hypoglossal nerve stimulator, or referral to an oral surgeon, denturist, or prosthodontist for guidelines on sleeping with dentures. Close monitoring of symptoms and download data is recommended following oral surgery and switch of mask interface. Support (If Any)

0840 Be Wary Of Adjustment Disorder with Anxiety In Patient With Insomnia And Discomfort With Positive Pressure Airway Therapy

Abstract Introduction Insomnia is a common complaint. When it occurs in the context of treatment with continuous positive airway pressure (CPAP), it can complicate treatment and lead to dissatisfaction with CPAP therapy. Adjustment disorder with anxiety (ADWA) is a condition that develops following an identifiable stressor and can be associated with insomnia. We describe a case of ADWA causing disrupted sleep and dissatisfaction with CPAP therapy. Report of Cases: The patient is an 80-year-old man with history of severe obstructive sleep apnea (OSA) and chronic obstructive lung disease, under stable management with CPAP. During a routine follow up visit, he reported the recent onset of frequent, and often prolonged, nocturnal awakenings associated with daytime sleepiness and fatigue. Insomnia was associated with discomfort with breathing, especially during exhalation, while using CPAP. His machine report indicated a significant decrement in compliance. Upon questioning, he reported that a few of his family members had died unexpectedly, following which he began to experience significant anxiety. His wife noted that he had become moody and irritable. On examination, the patient was visibly anxious; his speech was accelerated and animated, and he displayed psychomotor activation. Affect also displayed despondency. The patient was diagnosed with ADWA leading to insomnia and discomfort with CPAP use. He was prescribed buspirone 10 mg twice daily. On two week follow up patient reported no improvement in symptoms and was switched to escitalopram 10 mg daily. Following approximately three weeks, his clinical evaluation revealed significant improvement in mood; anxiety had dissipated, and sleep was more continuous with infrequent and brief awakenings. Daytime alertness had been restored. Of interest was the temporary return of anxiety and insomnia symptoms following the brief discontinuation of escitalopram because of hospitalization. Conclusion ADWA can occur in the setting of recent stressors and can result in sudden onset of insomnia, compromise CPAP adherence and decrease subjective benefit from PAP therapy. This case highlights the importance of questioning patients for the possibility of recent stressors and traumatic events when they develop difficulties with PAP use. These may indicate the presence of ADWA, whose management can restore CPAP compliance and improve sleep quality and daytime functioning. Support (If Any)

0782 Changes in markers of ventricular repolarization and positive airway pressure therapy: A pilot study

Abstract Introduction Positive airway pressure (PAP) therapy is the mainstay treatment for obstructive sleep apnea (OSA). Continuous PAP (CPAP) therapy has been shown to decrease QTc length in electrocardiograms in patients with OSA in small studies. The impact of higher pressures of CPAP and Bilevel PAP (BPAP) on ventricular repolarization—QTc length and QT variability in OSA is unknown. The goal of this pilot study is to explore this relationship. Methods 10 consecutive patients who underwent polysomnography during which they had a diagnostic, CPAP titration, and BPAP titration portion were included for analysis. Bazett’s heart rate correction was used to calculate QTc. QT variability was measured as short-term interval QT variability (STVQT) and normalized QT interval variance (QTVN). All variables were analyzed for the entire duration of the diagnostic period, on the highest CPAP pressure and highest BPAP pressure delivered. Results The patients were 49 ± 15 years of age and 60% women. Median CPAP pressure was 14.5 cm H2O (mean 13.5 ± 5 cm H2O). For BPAP, the median inspiratory PAP was 21.5 cm H2O (mean 20.5 ± 5 cm H2O) and EPAP median was 16 cm H2O (mean 15.9 ± 4 cm H2O). Mean QTc for the diagnostic portion, highest CPAP pressure and highest BPAP pressure were 430 ± 17 ms, 445 ± 15 ms and 441 ± 21 ms, respectively (p=0.141). Mean QTVN for the diagnostic portion, highest CPAP pressure and highest BPAP pressure settings were 0.0011 ± 0.0008 dimensionless units (du), 0.0012± 0.0008 du and 0.002 ± 0.0012 du, respectively (p=0.127). STVQT for the diagnostic portion, highest CPAP pressure and highest BPAP pressure settings were 6.62 ± 4.13 ms, 9.12 ± 4.7271 ms and 12.62 ± 4.99 ms, respectively (P=0.041). Post-hoc pairwise comparisons between BPAP and diagnostic portions of the study were significant for STVQT (P=0.034). Conclusion Short-term QT variability, STVQT, was significantly increased on BPAP when compared to the diagnostic portion of the study. Support (If Any) American Academy of Sleep Medicine Foundation (203-JF-18), National Institutes of Health (HL126140, 2L30HL154400-023) University of Arizona Health Sciences Career Development Award (5299903), and University of Arizona Faculty Seed Grant (5833261)