Positive Airway Pressure Titration Research Articles

0502 Harmony in the Sleep Lab: A Focus on Recognition of Hypoventilation and Direct Feedback Improves Quality of Pediatric Titrations

Abstract Introduction Over 350 pediatric polysomnogram titrations (T-PSGs) are performed each year at the Sleep Laboratory at Children’s Hospital of Philadelphia in three locations by 24 different polysomnography technologists (PSGTs) on a diverse patient population, typically performed as outpatient procedures and occasionally at the bedside as inpatients. PSGTs are responsible for titration of continuous or bilevel positive airway pressure based on flow, work of breathing, arousals, and/or gas exchange. PSGTs have varying degrees of experience; thus, maintaining quality of T-PSGs is challenging. We hypothesized that a quality improvement (QI) approach to reviewing T-PSGs with interdisciplinary education and regular feedback would improve T-PSGs. Our goal was to have >/= 80% of titrations of optimal quality. Methods Each T-PSG record was reviewed by a sleep physician for optimal quality, defined as appropriate signal integrity, titration, and documentation to permit definitive interpretation. Exclusion: RAM cannula use, illness, or external signal interference. Titration QI (T-QI) comments were reviewed by the sleep lab QI team bi-weekly to plan feedback. Improvement interventions for PSGTs included didactic education: lectures, presentations, and cases focusing on recognition of hypoventilation; direct feedback with teaching points by sleep physician and small group sessions with clinical supervisors to review areas for improvement; and communication of specific titration goals. Satisfaction surveys regarding recognition/titration for OSA/hypoventilation, transcutaneous CO2 signal integrity, and documentation were administered to sleep physicians. Results From September 2020-November 2021, PSGT education included: 1 synchronous and 2 asynchronous didactic presentations; 1:1 review of didactics with each night PSGT (n=24); T-QI feedback (2/week); and small group review sessions (4/week). 408 titrations were completed; 42 (10.3%, 2.8/month) were excluded; 366 (89.7%, 24.4/month) were reviewed for T-QI. 54.8% [50,71%] were deemed optimal during the first three months (pre-intervention) vs. 80.1% [63,96%] during the intervention period. QI satisfaction survey showed improvement in 3 of 4 domains. Conclusion Quality of T-PSG is enhanced by QI review of each titration, highlighting teaching points and areas for improvement via direct feedback and small group review. Education and communication among physicians, supervisors and technologists are important to support development which can result in better titrations and satisfaction. Support (If Any) none

The Correlation Between Sleep Efficiency During Continuous Positive Airway Pressure Titration Polysomnography and Epworth Sleepiness Scale Score in Patients with Obstructive Sleep Apnea

The Correlation Between Sleep Efficiency During Continuous Positive Airway Pressure Titration Polysomnography and Epworth Sleepiness Scale Score in Patients with Obstructive Sleep Apnea

Adherence Index: sleep depth and nocturnal hypoventilation predict long-term adherence with positive airway pressure therapy in severe obstructive sleep apnea.

Treatment of obstructive sleep apnea with positive airway pressure (PAP) devices is limited by poor long-term adherence. Early identification of individual patients' probability of long-term PAP adherence would help in their management. We determined whether conventional polysomnogram (PSG) scoring and measures of sleep depth based on the odds ratio product would predict adherence with PAP therapy 12 months after it was started. Patients with obstructive sleep apnea referred to an academic sleep center had split-night PSG, arterial blood gases, and a sleep questionnaire. Multiple linear regression analysis of conventional PSG scoring and the odds ratio product both during diagnostic PSG and PAP titration provided an "Adherence Index," which was correlated with PAP use 12 months later. Patients with obstructive sleep apnea (n = 236, apnea-hypopnea index 72.2 ± 34.1 events/h) were prescribed PAP therapy (82% received continuous PAP, 18% received bilevel PAP). Each patient's adherence with PAP therapy 12 months later was categorized as "never used," "quit using," "poor adherence," and "good adherence." PSG measures that were most strongly correlated with PAP adherence were apnea-hypopnea index and odds ratio product during nonrapid eye movement sleep; the additional contribution of nocturnal hypoxemia to this correlation was confined to those with chronic hypoventilation treated with bilevel PAP. The Adherence Index derived from these measures, during both diagnostic PSG and PAP titration, was strongly correlated with PAP adherence 12 months later. Long-term adherence with PAP therapy can be predicted from diagnostic PSG in patients with severe obstructive sleep apnea, which may facilitate a precision-based approach to PAP management. Younes MK, Beaudin AE, Raneri JK, Gerardy BJ, Hanly PJ. Adherence Index: sleep depth and nocturnal hypoventilation predict long-term adherence with positive airway pressure therapy in severe obstructive sleep apnea. J Clin Sleep Med. 2022:18(8):1933-1944.

Fraction of apnea is associated with the required continuous positive airway pressure level and reflects upper airway collapsibility in patients with obstructive sleep apnea.

We aimed to determine whether the fraction of apnea (Fapnea) could be used as an alternative index to reflect upper airway collapsibility. We retrospectively recruited 161 patients (16 women, mean age 47.8 years, body mass index [BMI] 28.0 kg/m2, and apnea-hypopnea index 46.4 events/h) with moderate to severe obstructive sleep apnea who had undergone nasal continuous positive airway pressure (CPAP) titration. Fapnea is defined as the percentage of apneic events relative to the total number of apneic and hypopneic events during sleep in a supine position on diagnostic polysomnography. We randomly split the data (70/30) into the development and validation datasets. In the development dataset, we conducted a multiple regression analysis to assess the association of variables, including age, sex, BMI, supine rapid eye movement (REM) sleep apnea-hypopnea index, and apnea with a CPAP level during supine REM sleep (REM_CPAP). Moreover, we developed an equation for predicting the CPAP level. Thereafter, we evaluated the correlation between the actual CPAP level and the value calculated using the model. BMI and Fapnea were the only significant factors that predicted the REM_CPAP level (adjusted r = .60, P < .001) in the development dataset. The validation data revealed a significant correlation between the actual and predicted CPAP levels (r = .69, P < .0001). We observed similar associations during supine non-REM sleep. Fapnea could significantly predict the CPAP levels during both REM and non-REM sleep, which likely reflects the upper airway collapsibility, independent of the BMI. Nakayama H, Takei Y, Kobayashi M, Yanagihara M, Inoue Y. Fraction of apnea is associated with the required continuous positive airway pressure level and reflects upper airway collapsibility in patients with obstructive sleep apnea. J Clin Sleep Med. 2022;18(5):1243-1249.

Reversible Dementia With Rapid Recovery to Normal Cognition: A Case Report

We report the case of a 54-year-old female who was diagnosed with clinical dementia and recovered to normal cognition in only 11 days through appropriate intervention. The patient was on a complicated regimen of psychiatric medications for underlying depression and panic disorder. The patient noted increased deterioration in executive function gradual memory impairment starting in early 2020. As a result of the neuroimaging, prominent neurodegeneration and in vivo brain pathology were not observed. During outpatient clinic follow-up, severe obstructive sleep apnea (OSA) was confirmed. Based on the diagnostic results, a clinical impression was made for reversible dementia due to psychiatric drugs and OSA. During hospitalization for 10 days, the patient’s regimen of psychiatric medications with anticholinergic effects was changed, and long-acting benzodiazepines were reduced. The patient also underwent continuous positive airway pressure titration to ameliorate OSA. The patient reported subjective cognitive improvement and a comprehensive neuropsychiatric test performed at discharge later showed a normal range in all cognitive domains, and the patient s activity of daily living evaluated at the outpatient clinic after discharge had recovered.

A Fuzzy Neural Network Model for Rapid Prediction of Optimal Positive Airway Pressures in OSAS Patients.

Manual titration of positive airway pressure (PAP) is a gold standard to provide an optimal pressure for the treatment of obstructive sleep apnea-hypopnea syndrome (OSAS). Since manual titration studies were costly and time-consuming, many statistical models for predicting effective PAPs were reported. However, the prediction accuracies of the models associated with nocturnal parameters still remain low. This study proposes a fuzzy neural prediction network (FNPN) with input candidate variables, selected among easily available measurements (e.g., body mass index (BMI), waist circumstance (WC), and body composition) and OSAS related questionnaires, to rapidly predict an optimal PAP. The FNPN comprises fuzzy rules and is characterized with the ability of automatic rule growing and pruning from training data. A total of 147 participants from April 2018 to April 2019 were enrolled in Taichung Veterans General Hospital, Taiwan. After two selection processes for feature extraction, WC and BMI were the significant variables for entering the FNPN to predict optimal PAP. Experimental results showed that the average successful prediction rate of the proposed method was 71.8%. This study also found that Epworth sleepiness scales (ESS) and body composition, such as visceral fat area and percent body fat, were excluded in the final prediction model. Compared with existing models, the proposed prediction approach provided a rapid prediction of optimal PAP with higher accuracy.

Multidimensional assessment and cluster analysis for OSA phenotyping.

Obstructive sleep apnea (OSA) is a heterogeneous disease with varying phenotype. A cluster analysis based on multidimensional disease characteristics, including symptoms, anthropometry, polysomnography, and craniofacial morphology, in combination with auto-continuous positive airway pressure titration response and comorbidity profiles, was conducted within a well-characterized cohort of patients with OSA, with the aim to refine the current phenotypic expressions of OSA with clinical implications. Two hundred ninety-one patients with a new diagnosis of moderate to severe OSA referred for auto-continuous positive airway pressure titration to the sleep center were included for analysis. In-laboratory polysomnography and craniofacial computed tomography scanning were performed, followed by an auto-continuous positive airway pressure titration. The symptom of excessive daytime sleepiness was assessed using the Epworth Sleepiness Scale. Three patient phenotypes-normal weight, nonsleepy, moderate OSA; obese, nonsleepy, severe OSA; and obese, sleepy, very severe OSA with craniofacial limitation-were identified. Among the polysomnography parameters, only percentage of N3 time of total sleep time (N3%) and mean pulse oxygen saturation were found to be associated with the Epworth Sleepiness Scale score, and they only explained a small fraction of the variation (R2 = .136). Neck circumference and craniofacial limitation were associated with the more severe phenotype, which had a higher prevalence of hypertension and metabolic syndrome, greater diurnal blood gas abnormalities, and worse positive airway pressure titration response. Three OSA phenotypes were identified according to multiple aspects of clinical features in patients with moderate to severe OSA, who differed in their prevalence of hypertension, metabolic syndrome, diurnal blood gas parameters, and continuous positive airway pressure titration response. Self-reported excessive daytime sleepiness was not related with the severity of sleep breathing disturbance, and craniofacial limitation was associated with the more severe phenotype. These findings highlight the necessity of integrating multiple disease characteristics into phenotyping to achieve a better understanding of the clinical features of OSA. Zhang XL, Zhang L, Li YM, etal. Multidimensional assessment and cluster analysis for OSA phenotyping. J Clin Sleep Med. 2022;18(7):1779-1788.

The Positive Airway Pressure Therapy Compliance In Mild OSAS

Introduction: This study is designed to determine the factors for predicting the PAP compliance in mild obstructive sleep apnea syndrome (OSAS) for improving the cost-effectiveness in the treatment choices of these patients.&#x0D; Method: The study group comprises 27 mild OSAS patients who underwent automatic positive airway pressure (APAP) titration between July 2016 and December 2017. Demographic, clinic and polysomnographic characteristics of the patients were retrospectively evaluated. Compliance with PAP treatment was defined as the usage of 5 nights/week and 4 hours/night at least. Data of compliant patients were statistically compared with non-compliant patients.&#x0D; Results: Most of the patients (23 patients, 85,2%) were prescribed APAP devices. Acceptable compliance at the end of the first year of therapy was achieved by 11 patients (40,2%) whereas 8 patients used PAP device 2 months at most (29,6%) The remaining 8 patients had not taken the device at all and were considered as non-adherent to PAP treatment (29,6%). The nonadherent/non-compliant group showed statistically the same demographic, clinic, and polysomnographic characteristics when compared to the compliant group. The level of maximum pressure during the titration test was lower in the compliant group (p=0,040). &#x0D; Conclusion: The sleep-related symptoms, scores of ESS or polysomnographic parameters can not be used to predict compliance for mild OSAS. The patients with mild OSAS, especially the ones who reach higher maximum pressure on titration test, must be followed up closely during the first 2 months of PAP treatment to detect nonadherence/non-compliance earlier.

The correlations between pulmonary function tests and polysomnographic parameters in overlap syndrome

Aim: This study aims to reveal the relationship between Pulmonary Function Tests (PFTs) parameters and polysomnographic parameters. It aims to determine the guiding values in treatment selection, with the hypothesis that easily accessible PFTs parameters can be useful in clinical evaluation for patients with restrictive or obstructive type disorders.&#x0D; Material and Method: One hundred and forty-six patients with obstructive and/or restrictive pulmonary dysfunction who underwent polysomnography in the sleep clinic of our hospital between June 2019 and December 2019 were included in the study. Polysomnography (PSG) parameters and PFTs results were obtained. Age, gender, body mass index (BMI), Epworth Sleepiness Scale (ESS) score, PFTs parameters, apnea-hypopnea index (AHI), nocturnal oxygen saturation, tolerable positive airway therapy modality, and pressures were recorded.&#x0D; Results: Of 146 patients 34.9% were women and most (92.5%) had an obstructive disorder in PFTs. Of the patients with the obstructive disorder, 71 were being followed up with a diagnosis of chronic obstructive pulmonary disease (COPD) and 64 with a diagnosis of asthma. Interstitial lung disease was observed in 5 out of 11 cases (7.5%) with restrictive type disorder, and obesity resulted in restrictive disorder for the remaining 6 cases. Simple snoring was observed in 5.5%. Mild OSAS was observed at a rate of 30.1%. Moderate-severe OSAS was detected in 64.4% of the patients. When the relationship between optimal inspiratory/ expiratory positive airway pressure (IPAP/EPAP) values determined by automatic bilevel positive airway pressure (ABPAP) titration and PFTs parameters were analyzed, a moderate negative correlation was observed between IPAP value and forced vital capacity (FVC) (L) (r=-0.432, p=0035)&#x0D; Discussion: The results of this study show that PFTs parameters can be used to predict polysomnographic findings for patients with obstructive/restrictive disorders. Almost two-thirds of the patients with obstructive sleep apnea (OSA)-related symptoms in this group were observed to have moderate-severe obstructive sleep apnea syndrome (OSAS). Based on our results in ROC analysis, we believe that it would be appropriate to recommend titration with bilevel devices, especially for patients with forced expiratory volume in one second (FEV1)

Periodic Legs Movements in Sleep Persisting after Positive Airway Pressure Titration is Significantly Associated with Cardiovascular Diseases

Purpose: Obstructive sleep apnea syndrome (OSAS) and periodic limb movement disorder in sleep (PLMS) are highly prevalent diseases of sleep and both are associated with a negative cardiovascular outcome. The purpose of this study was to investigate the presence of PLMS in patients with OSAS in positive airway pressure (PAP) titration and examine its relation to cardiovascular diseases. Materials and Methods: All patients who were diagnosed as having OSAS after one-night polysomnographic (PSG) recording during a 1-year period and were been treated successfully through PAP titration PSG were investigated retrospectively. Results: Out of 460 medical files investigated, 300 patients were included in the study (204 males, 68%) with a mean age of 54.2 ± 10.6 years. A comparison between patients with a PLMS index &gt;15/h and PLMS index &lt;15/h revealed that cardiac diseases (P = 0.040), hypertension (HT) (P = 0.006), and hyperlipidemia (P = 0.019) were all more common if patients had a PLMS index &gt;15/h. Furthermore, a significant correlation was detected between the PLMS index and cardiac diseases (ß = 39.908, P = 0.012) and HT (ß = 32.884, P = 0.021). Conclusions: The risk of cardiovascular diseases is markedly increased in patients with OSAS with PLMS, and this was positively correlated with the PLMS index. Physicians should be aware that PLMS persisting after PAP titration might prevent the efficiency of PAP therapy in OSAS, especially in preventing cardiovascular complications.

Quantitative Changes in Muscular and Capillary Oxygen Desaturation Measured by Optical Sensors during Continuous Positive Airway Pressure Titration for Obstructive Sleep Apnea.

Obstructive sleep apnea (OSA) is a common sleep disorder, and continuous positive airway pressure (CPAP) is the most effective treatment. Poor adherence is one of the major challenges in CPAP therapy. The recent boom of wearable optical sensors measuring oxygen saturation makes at-home multiple-night CPAP titrations possible, which may essentially improve the adherence of CPAP therapy by optimizing its pressure in a real-life setting economically. We tested whether the oxygen desaturations (ODs) measured in the arm muscle (arm_OD) by gold-standard frequency-domain multi-distance near-infrared spectroscopy (FDMD-NIRS) change quantitatively with titrated CPAP pressures in OSA patients together with polysomnography. We found that the arm_OD (2.08 ± 1.23%, mean ± standard deviation) was significantly smaller (p-value < 0.0001) than the fingertip OD (finger_OD) (4.46 ± 2.37%) measured by a polysomnography pulse oximeter. Linear mixed-effects models suggested that CPAP pressure was a significant predictor for finger_OD but not for arm_OD. Since FDMD-NIRS measures a mixture of arterial and venous OD, whereas a fingertip pulse oximeter measures arterial OD, our results of no association between arm_OD and finger_OD indicate that the arm_OD mainly represented venous desaturation. Arm_OD measured by optical sensors used for wearables may not be a suitable indicator of the CPAP titration effectiveness.

Predictors of changes in cerebral perfusion and oxygenation during obstructive sleep apnea

Obstructive sleep apnea syndrome (OSAS) is a common sleep disorder. Severe OSAS defined as apnea–hypopnea index (AHI) ≥ 30/h is a risk factor for developing cerebro-cardiovascular diseases. The mechanisms of how repetitive sleep apneas/hypopneas damage cerebral hemodynamics are still not well understood. In this study, changes in blood volume (BV) and oxygen saturation (StO2) in the left forehead of 29 newly diagnosed severe OSAS patients were measured by frequency-domain near-infrared spectroscopy during an incremental continuous positive airway pressure (CPAP) titration protocol together with polysomnography. The coefficients of variation of BV (CV-BV) and the decreases of StO2 (de-StO2) of more than 2000 respiratory events were predicted using linear mixed-effect models, respectively. We found that longer events and apneas rather than hypopneas induce larger changes in CV-BV and stronger cerebral desaturation. Respiratory events occurring during higher baseline StO2 before their onsets, during rapid-eye-movement sleep and those associated with higher heart rate induce smaller changes in CV-BV and de-StO2. The stepwise increased CPAP pressures can attenuate these changes. These results suggest that in severe OSAS the length and the type of respiratory event rather than widely used AHI may be better parameters to indicate the severity of cerebral hemodynamic changes.

Different Continuous Positive Airway Pressure Titration Modalities in Obstructive Sleep Apnea Syndrome Patients.

BackgroundPatients with obstructive sleep apnea syndrome are mainly treated with continuous positive airway pressure. Polysomnography-guided full-night manual titration is the gold standard for continuous positive airway pressure titration, but it is cost-, time-, and effort-consuming. Alternative ways of titration are easier with less cost, time, and effort. In the era of the COVID-19 pandemic, the need to establish more safe strategies is increased.AimTo choose a rapid, efficient, simple, and safe method with less effort and cost in the measurement of a suitable level of positive airway pressure in the management of obstructive sleep apnea syndrome.MethodsThis study enrolled 48 adult patients who had been diagnosed with obstructive sleep apnea syndrome at our sleep unit and were candidates for treatment with continuous positive airway pressure according to AASM 2008 after exclusion of other sleep-related breathing disorders. All patients underwent both laboratory full-night manual titration and auto-titration (by Prisma20A of WEINMANN medical technology, Germany). Manual titration pressure and P95 of auto-titration were obtained and compared with calculated pressures by five predictive formulas (Miljeteig and Hoffstein, Sériès, Stradling, Loredo, and Lee).ResultsPatients included in the study were 25 females (52.1%) and 23 males (47.9%) with a mean±SD of age of 49.98±10.36 years. Mean±SD of manual pressure was 10.44±2.49 cmH2O, P95 was 10.16±2.64 cmH2O, and calculated pressures by different equations were: Miljeteig and Hoffstein, 8.53±2.03; Sériès, 11.40±1.81; Stradling, 9.68±1.65; Loredo, 9.90±1.79; and Lee, 10.61±2.68 cmH2O. No significant differences were reported between manual pressure and pressures of auto-titration with Sériès, Stradling, Loredo, and Lee equations (p=0.112, 0.09, 0.212, 0.213, and 0.657, respectively).ConclusionAuto-titration can be used as an effective alternative to manual titration with less cost and effort and is more comfortable to patients. Predictive formulas can be used instead of standard and auto-titration especially in resource-limited facilities and in pandemics.

Clinical utility of repeated positive airway pressure titrations in children with obstructive sleep apnea syndrome.

Positive airway pressure (PAP) is the second line of treatment for obstructive sleep apnea syndrome in children. It is common practice following initiation of PAP to perform repeat titration polysomnography to re-evaluate the patient's therapeutic pressure; however, data supporting this practice are lacking. We hypothesized that repeat PAP titration would result in significant setting changes in children with obstructive sleep apnea syndrome. We retrospectively analyzed demographic, polysomnographic, and PAP data of children with obstructive sleep apnea syndrome aged 0-18 years who were initiated on PAP and underwent 2 titration studies over a 2-year period. PAP mode and recommended pressure differences between the 2 titrations were compared. 64 children met inclusion criteria. The median (interquartile range) baseline obstructive apnea-hypopnea index and SpO2 nadir were 14.8 (8.7-32.7) events/h and 88.5% (85-92%), respectively. The mean differences in obstructive apnea-hypopnea index, SpO2 nadir, and % total sleep time with SpO2 < 90% between both titrations were negligible, including children with obesity, adenotonsillar hypertrophy, and trisomy 21. Additionally, there was no significant difference in mean PAP pressure between 2 separate titration studies for those on continuous PAP or bilevel PAP. Overall, repeat PAP titration in children with obstructive sleep apnea syndrome within the timeframe here described did not result in significant changes in PAP mode, continuous PAP pressure, or obstructive apnea-hypopnea index. Based on these data, repeat PAP titration within 2 years of an initial titration does not appear to be necessary. Yendur O, Feld L, Miranda-Schaeubinger M, etal. Clinical utility of repeated positive airway pressure titrations in children with obstructive sleep apnea syndrome. J Clin Sleep Med. 2022;18(4):1021-1026.

Wavelet-based CNN for Predicting PAP Adherence Using Overnight Polysomnography Recordings: a Pilot Study.

Obstructive sleep apnea (OSA) is a common sleep disorder. Positive airway pressure (PAP) therapy is the first-line treatment, while its effectiveness is significantly limited by incomplete adherence in many patients. This work aims to find a predictive association between data from in-laboratory sleep studies during treatment (PAP titration polysomnogram, or PSG) and PAP adherence. Based on a PAP titration PSG database, we present a pipeline to develop a wavelet-based deep learning model and address two challenges. First, to tackle the problem of extremely long overnight PSG signals, it randomly draws segments and extracts features locally. The global representation for the entire signal is achieved by local feature P-norm pooling. Second, to tackle the problem of limited dataset size, the pre-trained EfficienNet-B7 is used as an unsupervised feature extractor to transfer ImageNet knowledge to PSG signals in the wavelet domain. The trained pipeline achieves 78% balanced accuracy and 83% AUC on the test set using airflow and frontal EEG signals, which, we believe, is a compelling result as a pilot study.

Continuous Positive Airway Pressure Titration During Pediatric Drug Induced Sleep Endoscopy.

To observe the degree of airway collapse at varying levels of continuous positive airway pressure (CPAP) during drug pediatric induced sleep endoscopy. Using our institutional anesthesia protocol for pediatric DISE procedures, patients were anesthetized followed by evaluation of the nasal airway, nasopharynx, velum, hypopharynx, arytenoids, tongue base, and epiglottis. CPAP titration was performed under vision to evaluate the degree of airway collapse at the level of the velum. Comparison was made with pre-operative polysomnography findings. Twelve pediatric patients underwent DISE with intraoperative CPAP titration. In 7/12 patients, DISE observed CPAP titration was beneficial in elucidating areas of obstruction that were observed at pressures beyond those recommended during preoperative sleep study titrations. In 3 patients, DISE observations provided a basis for evaluation in children not compliant with sleep study CPAP titration testing. With regard to regions effected, airway collapse was observed at the velum and oropharynx to a greater degree when compared with the tongue base and epiglottis. DISE evaluation of the pediatric patient with obstructive sleep apnea may present a source for further patient evaluation with respect to CPAP optimization and severity of OSA assessment, particularly in syndromic patients.

A randomized controlled trial of cognitive behavioral therapy for insomnia and PAP for obstructive sleep apnea and comorbid insomnia: effects on nocturnal sleep and daytime performance.

This study examines the impact of cognitive behavioral therapy for insomnia (CBT-I) and positive airway pressure (PAP) therapy for comorbid insomnia and sleep apnea on nocturnal sleep and daytime functioning. A partial factorial design was used to examine treatment pathways with CBT-I and PAP and the relative benefits of each treatment. One hundred eighteen individuals with comorbid insomnia and sleep apnea were randomized to receive CBT-I followed by PAP, self-monitoring followed by CBT-I concurrent with PAP, or self-monitoring followed by PAP only. Participants were assessed at baseline, PAP titration, and 30 and 90 days after PAP initiation. Outcome measures included sleep diary- and actigraphy-measured sleep, Flinders Fatigue Scale, Epworth Sleepiness Scale, Functional Outcome of Sleep Questionnaire, and cognitive emotional measures. A main effect of time was found on diary-measured sleep parameters (decreased sleep onset latency and wake after sleep onset; increased total sleep time and sleep efficiency) and actigraphy-measured sleep parameters (decreased wake after sleep onset; increased sleep efficiency) and daytime functioning (reduced Epworth Sleepiness Scale, Flinders Fatigue Scale; increased Functional Outcome of Sleep Questionnaire) across all arms (all P < .05). Significant interactions and planned contrast comparisons revealed that CBT-I was superior to PAP and self-monitoring on reducing diary-measured sleep onset latency and wake after sleep onset and increasing sleep efficiency, as well as improving Functional Outcome of Sleep Questionnaire and Flinders Fatigue Scale compared to self-monitoring. Improvements in sleep and daytime functioning were found with PAP alone or concomitant with CBT-I. However, more rapid effects were observed on self-reported sleep and daytime performance when receiving CBT-I regardless of when it was initiated. Therefore, concomitant treatment appears to be a favorable approach to accelerate treatment outcomes. Registry: ClinicalTrials.gov; Name: Multidisciplinary Approach to the Treatment of Insomnia and Comorbid Sleep Apnea (MATRICS); URL: https://clinicaltrials.gov/ct2/show/NCT01785303; Identifier: NCT01785303. Tu AY, Crawford MR, Dawson SC, etal. A randomized controlled trial of cognitive behavioral therapy for insomnia and PAP for obstructive sleep apnea and comorbid insomnia: effects on nocturnal sleep and daytime performance. J Clin Sleep Med. 2022;18(3):789-800.

WITHDRAWN

TOPIC: Sleep Disorders TYPE: Fellow Case Reports INTRODUCTION: Vagal nerve stimulation (VNS), which was approved by the FDA in 1997, has been used to treat refractory partial and complex seizures in patients with epilepsy. In this case report, we describe an important adverse effect of vagal nerve efferent stimulation to upper airway structures. Multiple studies have shown that VNS can induce or worsen obstructive sleep apnea (OSA). For treating patients with VNS-induced OSA, manufacturers suggest decreasing VNS frequency and increasing the cycle off time. However, this recommendation rarely provides successful results. Here, we illustrate a case of a woman with VNS-induced OSA and show how small adjustments to VNS current and pulse width parameters can significantly reduce the effects of VNS-induced obstructive respiratory events during a PAP titration without breakthrough seizures. CASE PRESENTATION: The patient is a 52-year-old woman who had a vagal nerve stimulator placed in 1998 for refractory left frontal lobe focal seizures. She presented to the sleep medicine clinic for excessive daytime sleepiness, non-refreshing sleep, and reports of loud snoring. Her symptoms were present despite adequate sleep hygiene and a consistent 8.5 hours of sleep each night. A split night study revealed an apnea-hypopnea index (AHI) of 32.8 with predominant obstructive hypopneas and occasional obstructive apneas. Her obstructive respiratory events occurred coincidentally in sequence with 30 seconds of electromyography (EMG) chin tone every 108 seconds. Subsequent, bilevel positive airway pressure (BPAP) titration was unsuccessful. The patient's neurologist was notified of the sleep study findings and the patient's VNS was adjusted. The output current, pulse width, magnet current, and a magnet pulse bandwidth were reduced. All other parameters remained unchanged including frequency and cycle time. On her subsequent BPAP titration, her OSA was successfully controlled at a BPAP pressure of 23/19 cm H2O, with a residual AHI of 0. On follow-up, the patient was adherent to her BPAP therapy with subjective improvement in quality of her sleep. The patient did not have breakthrough seizures over one year with the decrease in current and pulse width settings on her VNS. She averaged 5.5 hours of BPAP use each night with 73% of days used over one year. DISCUSSION: In this case report, we have outlined a successful BPAP titration with minor adjustments in VNS parameters in a patient with epilepsy and severe OSA. The success of this BPAP titration was likely facilitated by the reduction in VNS output current and pulse bandwidth, which reduced the efferent motor nerve stimulation of upper airway structures. CONCLUSIONS: This case demonstrates how adjustment of specific VNS parameters may potentially provide an alternative to the recommended adjustment in frequency and cycle times; however, this strategy will ultimately need to be tested and closely monitored in more patients. REFERENCE #1: Howland RH. Vagus Nerve Stimulation. Curr Behav Neurosci Rep. 2014;1(2):64-73. REFERENCE #2: Parhizgar F, Nugent K, Raj R. Obstructive sleep apnea and respiratory complications associated with vagus nerve stimulators. J Clin Sleep Med. 2011 Aug 15;7(4):401-7. REFERENCE #3: Ebben MR; Sethi NK; Conte M; Pollak CP; Labar D. Vagus nerve stimulation, sleep apnea, and CPAP titration. J Clin Sleep Med. 2008;4(5):471–473. DISCLOSURES: No relevant relationships by Jovica Veljanovski, source=Web Response No relevant relationships by Joshua Won, source=Web Response

The "Traffic Light OSA-SARS": a tool for the management of obstructive sleep apnea in the pandemic era.

The "Traffic Light OSA-SARS": a tool for the management of obstructive sleep apnea in the pandemic era.

Sleep parameters during polysomnography and continuous positive airway pressure titration in severe obstructive sleep apnea adult patients

Objectives: The aim of the present study was to demonstrate the effect of continuous positive airway pressure treatment on sleep parameters in severe obstructive sleep apnea patients. Patients/methods: Data regarding apnea-hypopnea index, total sleep time, sleep efficiency, rapid-eye-movement (REM) density, REM latency, total REM episodes during polysomnography and continuous positive airway pressure titration according to the obstructive sleep apnea severity were compared. Results: Of the 51 patients whose charts were reviewed, the average age was 46.47±10.62 years and the mean body mass index was 31.71±4.97 kg/m2. Thirty-two patients who had an apnea-hypopnea index between 30 and 60/h included to the Group 1 and 19 patients who had an apnea-hypopnea index ≥60/h included to the Group 2. Among all studied parameters, only rapid-eye-movement latency showed statistical significance between the studied groups. Changes in rapid-eye-movement latency differed significantly among patients during polysomnography and continuous positive airway pressure titration in Group 2 (p=0.003). Indeed, these changes were higher in Group 2 patients with more severe obstructive sleep apnea compared to those with Group1 severe obstructive sleep apnea (p=0.003). Conclusion: In conclusion, our investigations show that continuous positive airway pressure treatment results in a significant decrease in rapid-eye-movement latency among patients with more severe obstructive sleep apnea.