Titration Polysomnography Research Articles

446 Acute effect of acetazolamide in high loop gain sleep apnea

Abstract Introduction Obstructive sleep apnea is a disease with different driver phenotypes, including high loop gain (HLG). Acetazolamide (AZT) reduces HLG through multiple mechanisms. The acute effect of AZT used during titration polysomnography in HLG sleep apnea (HLGSA, predominantly obstructive) is described here. HLGSA is a NREM-dominant disease. Methods HLGSA was identified by one or more of the following: 1) baseline or titration CAHI of 5 or more, baseline or titration periodic breathing, or high residual apnea on CPAP in the absence of large leak. Retrospective analysis of polysomnograms from patients with HLGSA who underwent a PAP titration study and took ATZ (125 or 250 mg) after a baseline component of PAP titration. A responder was defined as a minimum reduction of the AHI3% of 50%. Multivariable logistic regression model estimated responder predictors. Results Two hundred and thirty-six patients with a median age of 60 (50.25–68) years and 189 (80.1%) males, were included. 69 patients were given 125 mg ATZ and 157 patients took 250 mg after about 3 hours of initial drug-free titration. Compared to PAP alone, PAP plus ATZ reduced the breathing related arousal index (8.45[3.03–15.60] vs. 4.8[2.1–10.15], p<0.001), AHI3% (19.09[7.34–37.28] vs. 10.63[4.46–20.56], p<0.001), AHI4% (1.89[0.23–8.58] vs. 1.19 [0.42–4.70], p=0.001), RDI (24.01[10.55–41.46] vs. 13.55[7.24–25.66], p<0.001). ATZ minimally improved the Min SpO2 (90[87–92] vs. 91[88–92], p=0.014). 101 patients were responders. Multiple logistic regression analysis showed that the NREM AHI3% was the only predictor for responder status with ATZ exposure (OR 1.022, 95%CI [1.004–1.041], p=0.018) Conclusion ATZ acutely improves PAP efficacy in HLGSA. The NREM AHI3% is a predictor for the ATZ responders. Support (if any) This study was supported by American Academy of Sleep Medicine Foundation, category-I award to RJT

475 Automatic detection of self-similarity and prediction of CPAP failure

Abstract Introduction Sleep disordered breathing is a significant risk factor for cardiometabolic and neurodegenerative diseases. Tolerance and efficacy of continuous positive airway pressure (CPAP), the primary form of therapy for sleep apnea, is often poor. High loop gain (HLG) is a driving mechanism of central sleep apnea or periodic breathing. The current study aimed to develop a computational approach to detect HLG based on self-similarity in respiratory oscillations during sleep solely using breathing patterns, measured via Respiratory Inductance Plethysmography (RIP). To quantify the potential utility of the developed similarity metric, the presented algorithm was used to predict acute CPAP failure. Methods We developed an algorithm for detecting apneas as periods with reduced breathing effort, manifested in the RIP signal as low signal amplitude. Our algorithm calculates self-similarity in breathing patterns between consecutive periods of apnea or hypopnea. Working under the assumption that high loop gain induces self-similar respiratory oscillations and increases the risk of failure during CPAP, the full night similarity, computed during diagnostic non-CPAP polysomnography (PSG), was used to predict failure of CPAP, which we defined as titration central apnea index (CAI)>10. Central apnea labels are obtained both from manual scoring by sleep technologists, and from an automated algorithm developed for this study. The Massachusetts General Hospital (MGH) sleep database was used, including 2466 PSG pairs of diagnostic and CPAP titration PSG recordings. Results Diagnostic CAI based on technologist labels predicted failure of CPAP with an AUC of 0.82 ±0.03. Based on automatically generated labels, the combination of full night similarity and automatically generated CAI resulted in an AUC of 0.85 ±0.02. A subanalysis was performed on a population with technologist labeled diagnostic CAI>5. Full night similarity predicted failure with an AUC of 0.57 ±0.07 for manual and 0.65 ±0.06 for automated labels. Conclusion This study showed that central apnea labels can be derived in an automated way. The proposed self-similarity feature, as a surrogate estimate of expressed respiratory high loop gain and computed from easily accessible effort signals, can detect periodic breathing regardless of admixed obstructive features such as flow-limitation, and can aid prediction of CPAP failure or success. Support (if any):

Rapid eye movement sleep and slow wave sleep rebounded and related factors during positive airway pressure therapy

This study aimed to investigate the clinical characteristics and predictors of increased rapid eye movement (REM) sleep or slow wave sleep (SWS) in patients with obstructive sleep apnea (OSA) following positive airway pressure (PAP) therapy. The study retrospectively analyzed data from patients with OSA who underwent both diagnostic polysomnography (PSG) and pressure titration PSG at the Tangdu Hospital Sleep Medicine Center from 2011–2016. Paired diagnostic PSG and pressure titration studies from 501 patients were included. REM rebound was predicted by a higher oxygen desaturation index, lower REM proportion, higher arousal index, lower mean pulse oxygen saturation (SpO2), higher Epworth sleepiness score and younger age (adjusted R2 = 0.482). The SWS rebound was predicted by a longer total duration of apneas and hypopneas, lower N3 duration, lower SpO2 nadir, lower REM proportion in diagnostic PSG and younger age (adjusted R2 = 0.286). Patients without REM rebound or SWS rebound had a high probability of comorbidities with insomnia and mood complaints. Some parameters (subjective and objective insomnia, excessive daytime sleepiness, age and OSA severity) indicate changes in REM sleep and SWS between diagnostic and titration PSG tests. Treatment of insomnia and mood disorders in patients with OSA may helpful to improve the use PAP.

Average volume-assured pressure support vs conventional bilevel pressure support in pediatric nocturnal hypoventilation: a case series.

Average volume-assured pressure support (AVAPS) is a modality of noninvasive ventilation that provides a targeted tidal volume by automatically adjusting the inspiratory pressure support within a set range. Pediatric studies evaluating the efficacy of AVAPS in treating nocturnal hypoventilation are confined to case reports. The aim of this study was to compare AVAPS to conventional bilevel positive airway pressure (BPAP) support in improving hypercarbia in a cohort of pediatric patients with nocturnal hypoventilation. Retrospective review of patient records at an established tertiary pediatric sleep laboratory over a 6-year period. Ventilatory and sleep study parameters from AVAPS and conventional BPAP titration studies were compared. AVAPS was used only if hypoventilation was not controlled using conventional BPAP. Inspiratory pressures, tidal volumes, and adherence were downloaded on final titrated ventilatory settings. Comparisons were made using paired t test. A total of 19 patients (11 boys, 8 girls; median age 10.5 years, range 1 to 20 years) were identified. Diagnoses included neuromuscular disease (n = 9), obstructive hypoventilation (n = 5), parenchymal lung disease (n = 4), and congenital central hypoventilation syndrome (n = 2). AVAPS demonstrated significant improvement in peak (P = .009) and mean (P = .001). Transcutaneous CO₂ parameters compared to conventional bilevel. Oxygenation on AVAPS showed positive trend but did not reach statistical significance. AVAPS delivered higher tidal volumes (P = .04) using similar pressures. There was no statistically significant difference in obstructive apnea-hypopnea index, respiratory arousal index, sleep efficiency, and adherence between AVAPS and conventional BPAP. AVAPS was an effective alternative to conventional BPAP in improving hypercarbia in our selective cohort of pediatric patients. Prospective, longitudinal studies are needed to evaluate the benefits of AVAPS feature in the pediatric population.

Algorithm for automatic detection of self-similarity and prediction of residual central respiratory events during continuous positive airway pressure.

Study ObjectivesSleep-disordered breathing is a significant risk factor for cardiometabolic and neurodegenerative diseases. High loop gain (HLG) is a driving mechanism of central sleep apnea or periodic breathing. This study presents a computational approach that identifies “expressed/manifest” HLG via a cyclical self-similarity feature in effort-based respiration signals.MethodsWorking under the assumption that HLG increases the risk of residual central respiratory events during continuous positive airway pressure (CPAP), the full night similarity, computed during diagnostic non-CPAP polysomnography (PSG), was used to predict residual central events during CPAP (REC), which we defined as central apnea index (CAI) higher than 10. Central apnea labels are obtained both from manual scoring by sleep technologists and from an automated algorithm developed for this study. The Massachusetts General Hospital sleep database was used, including 2466 PSG pairs of diagnostic and CPAP titration PSG recordings.ResultsDiagnostic CAI based on technologist labels predicted REC with an area under the curve (AUC) of 0.82 ± 0.03. Based on automatically generated labels, the combination of full night similarity and automatically generated CAI resulted in an AUC of 0.85 ± 0.02. A subanalysis was performed on a population with technologist-labeled diagnostic CAI higher than 5. Full night similarity predicted REC with an AUC of 0.57 ± 0.07 for manual and 0.65 ± 0.06 for automated labels.ConclusionsThe proposed self-similarity feature, as a surrogate estimate of expressed respiratory HLG and computed from easily accessible effort signals, can detect periodic breathing regardless of admixed obstructive features such as flow limitation and can aid the prediction of REC.

Positive Airway Pressure for the Treatment of OSA in Infants

Positive airway pressure (PAP) is a standard therapy for the treatment of OSA in children, but objective data on the effectiveness of PAP in infants are sparse. The aim of this study was to compare the effectiveness of PAP in infants younger than 6months of age with that in school-aged children. Compared with PAP in school-aged children, can PAP be titrated as successfully in infants, and is adherence to PAP similar in both age groups? Single-center retrospective study. For consecutive infants younger than 6months of age and school-aged children 5 to 10 years of age with OSA treated with PAP, baseline and titration polysomnography data, PAP adherence data, and parent-reported barriers to adherence were compared between groups. Forty-one infants and 109 school-aged children were included. Median obstructive apnea hypopnea index (OAHI) in infants was 25.7/h (interquartile range [IQR], 17.8-35.9/h) and was greater than that in school-aged children (12.1/hr; IQR, 7.6-21.5/h; P< .0001). After PAP titration, OAHI was reduced by a median of 92.1%in infants, similar to the median 93.4%reduction in school-aged children (P= .67). PAP was used in infants on 94.7%of nights, which was more than the 83%in school-aged children (P= .003). No differences were found in barriers to adherence between infants and school-aged children, with behavioral barriers being most common in both groups. Objective data demonstrate that PAP is both highly effective at treating OSA and well-tolerated in infants. Like older patients, PAP should be considered along with other therapies for the treatment of OSA in even the youngest children.

Auto-titrating CPAP for the treatment of obstructive sleep apnea in children.

In-laboratory titration polysomnography (PSG) is standard to determine optimal therapeutic continuous positive airway pressure (CPAP) in children with obstructive sleep apnea (OSA). The use of auto-titrating CPAP devices (autoCPAP) as an alternative to CPAP titration has not been well studied in children. We hypothesized that autoCPAP-derived pressures (PMEAN, PPEAKMEAN, P90) would be similar to titration PSG pressure (PPSG). This is a retrospective study of children with OSAS initiated on autoCPAP between 2007 and 2017, who used autoCPAP for at least 2 h/night and who had adequate titration PSG were included in the analysis. AutoCPAP-derived pressures were obtained from use downloads and compared with PPSG. PPSG predictive factors were analyzed by median regression. Nonparametric methods were used for analysis. Of 110 children initiated on autoCPAP, 44 satisfied the inclusion criteria. Age (median (interquartile range)) was 13.01 (9.98-16.72) years, and 63.6% were obese. PPSG median (interquartile range) was 8 (7-11) cmH₂O, mean autoCPAP-derived pressure (PMEAN) was 6.2 (5.6-7.6) cmH₂O, peak mean pressure (PPEAKMEAN) was 9.4 (7.7-11.1) cmH₂O, and average device pressure ≤ 90% of the time (P90) was 8.1 (7.2-9.7) cmH₂O. AutoCPAP-derived pressures correlated with PPSG (P < .05). PMEAN was lower than the other 3 pressures (P < .0002). Median regression analysis demonstrated that after adjusting for patient characteristics such as age, sex, and obesity status, autoCPAP-derived pressures remained significant predictors of PPSG (P < .05). There were no significant interactions between these patient characteristics and autoCPAP-derived pressures. This study demonstrates that autoCPAP-derived pressures correlate with the titration PSG-derived pressures. These results indicate that autoCPAP can be used in the pediatric population and can determine pressures that are close to the titration pressures.

Interpreting CPAP device respiratory indices in children.

An increasing number of children with obstructive sleep apnea (OSA) require treatment with continuous positive airway pressure (CPAP). This study aimed to determine whether automatic respiratory indices from a CPAP device accurately predict manually determined respiratory indices derived from overnight polysomnography (PSG) in children. Consecutive children undergoing manual CPAP titration PSG using a ResMed VPAP ST-A (S9) were included. The apnea-hypopnea index (AHI), apnea index (AI), and hypopnea index (HI) from automatic analysis of the CPAP device for that night (AHICPAP, AICPAP, and HICPAP) were compared with manually derived respiratory indices (RDIPSG, OAHIPSG, AIPSG, and HIPSG) using the Wilcoxon matched-pairs signed-ranks test. Forty-six children (32 boys; median age, 13.5 years; range, 4.6-20.0 years) were included. There was no difference between RDIPSG and AHICPAP (P = .6) nor between HIPSG and HICPAP (P = .2). AIPSG was significantly lower than AICPAP (mean difference -1.3 events/hr, P < .001). AIPSG and AICPAP were strongly correlated (r² = .72, P < .01), but the CPAP machine overestimated the number of apneas at higher AIs. OAHIPSG was significantly lower than AHICPAP (P = .003) but strongly correlated (r² = .87, P < .01). The CPAP device significantly underestimated the number of hypopneas at higher indices. Using the manually scored OAHIPSG of ≥5 events/hr to define significant residual OSA, the AHICPAP had a high specificity (0.95) but low sensitivity (0.20). The ResMed S9 respiratory indices are not accurate enough to guide treatment decisions in children; in particular, they do not rule out the presence of residual OSA in children that remain symptomatic on CPAP. A low AHICPAP is reassuring in the context of a stable patient but may miss ongoing hypopneas.

0902 The Use Of Auto-titrating Continuous Positive Airway Pressure (auto Cpap) For Obstructive Sleep Apnea In Children With Neurological Disorder

Abstract Introduction Multiple studies have demonstrated the effectiveness of auto-titrating continuous positive airway pressure (auto CPAP) in the adult population, but there is limited literature on the use of auto CPAP in the pediatric population. Specifically, the use of auto CPAP in children with neurological disorder(s) has not been established. Thus, we conducted a study to review the use of auto CPAP in children ages 18 years old and younger with Obstructive Sleep Apnea Syndrome (OSAS) and associated neurological disorder to document its effectiveness, adverse events and outcomes of its use. Methods A retrospective chart review was performed on patients 18 yo and younger diagnosed with OSAS and associated neurological disorder(s) who have good compliance with auto CPAP use. Good compliance was defined as &amp;gt;4 hours/night and &amp;gt;20/30 days of auto CPAP use. Compliance from the most recent 30 days was downloaded. Results 5 children met our criteria for inclusion, with a mean age of 11 years (6-18 years old). All had initial baseline sleep studies performed without PAP titration polysomnography. Associated neurological disorders were cerebral palsy, Arnold Chiari Malformation, seizure disorder and intellectual disability. The average length of use of auto CPAP was 4 months. Auto CPAP was used on average of 24/30 nights, with a mean of 7.35 hours/night. The mean baseline obstructive apnea-hypopnea (OAHI) index was 42 (8.2-94.4). The mean AHI on a 30 day download report showed a mean decrease in AHI to 2.9 (0.5-5.2) while on auto CPAP. Review of patient charts did not reveal any adverse outcomes associated with the use of auto CPAP in these patients. Conclusion This study showed that auto CPAP significantly improved the AHI in pediatric patients treated for OSA with associated neurological disorder. There were no reported adverse outcomes. Further research is needed to establish the effectiveness and safety of auto CPAP use in the pediatric population, specifically those with neurological disorder. The use of auto CPAP will help decrease the wait time for treatment in children with OSA. These patients can use auto CPAP while waiting for a titration study and for long term use. Support none

Reconfiguration of Upper Airway Stimulation Devices Utilizing Awake Endoscopy

Determine the rates of, reasons for, and effectiveness of device reprogramming utilizing in-office awake endoscopy (AE) in subjects who underwent upper airway stimulation (UAS) surgery. Retrospective chart review. Retrospective chart review at a tertiary care center on patients implanted with UAS devices from November 2015 to July 2018. Sixty patients were implanted with UAS devices. Average pre- and postsurgical total apnea-hypopnea index (AHI) was 40.6 and 4.2 with a 36.4 total AHI reduction. Treatment success based on Sher criteria was observed in 88% of patients. Postoperative titration polysomnography revealed an average functional threshold (FT) and minimum therapeutic amplitude (MTA) of 1.6 and 2.1 V, respectively. A total of 24 AEs were performed in 19 (32%) patients. The most common complaints and reasons for AE were perceived stimulus discomfort (42%), frequent awakenings (32%), and persistent fatigue or non-normalized AHI (21%). After first AE, there was a 0.87 (53%) and 0.93 (45%) V reduction in FT and MTA, respectively. Patients with obstructive sleep apnea continue to succeed with UAS. Fewer than one-third of patients had postsurgical complaints requiring device reconfiguration utilizing AE to assess the pharyngeal airway and optimize device settings. Reduction in the FT and MTA after AE may improve compliance by reducing discomfort and frequent awakenings. Periodic monitoring of patients with implanted UAS devices is necessary to optimize efficacy and maintain patient compliance. 4 Laryngoscope, 130:2494-2498, 2020.

A case of comorbid obstructive sleep apnea syndrome and epilepsy, presenting as repetitive central sleep apnea following nonconvulsive epileptic seizure during CPAP titration polysomnography

A case of comorbid obstructive sleep apnea syndrome and epilepsy, presenting as repetitive central sleep apnea following nonconvulsive epileptic seizure during CPAP titration polysomnography

Baseline Lighter Sleep and Lower Saturation Are Associated With Improved Sleepiness and Adherence on Continuous Rather Than Autotitrating Positive Airway Pressure.

The objective was to test whether there were better outcomes on switching from autotitrating positive airway pressure (APAP) to continuous positive airway pressure (CPAP) in a clinic sample of patients with obstructive sleep apnea (OSA). Patients prescribed APAP in 2015-2016 and belonging to a subset characterized by side effects, or suboptimal response or adherence, were advised a switch to CPAP following a CPAP titration polysomnography. The main analysis was for improvement (after switch from APAP to CPAP) in (1) sleepiness, wakefulness inability, and fatigue, using change from baseline in the Sleepiness-Wakefulness Inability and Fatigue Test (delta SWIFT), and Epworth Sleepiness Scale (delta ESS), and (2) adherence using percentage of days with ≥4-hour use and whether there was ≥4-hour use on ≥70% days. To determine possible predictors for switching, additional analysis was performed for differences at baseline between patients switching and those staying on APAP. A total of 148 patients were switched from APAP to CPAP and had greater improvement in delta SWIFT (5.2 vs 4.1, P = .004), greater improvement in delta ESS (3.6 vs 2.9, P = .011), and better adherence (79.4% vs 74.3%, P = .006) on CPAP than on APAP. More patients were adherent on CPAP than on APAP (83.1% vs 68.9%, P = .006). Patients switching had higher baseline arousal index and stage N1 sleep, and lower nadir oxygen saturation, than 96 patients not switching. Thus, there is a subset of patients with better outcomes after switching to CPAP than on APAP. Patients with baseline lighter sleep (indicated by more arousals and stage N1), or greater desaturation, may be more likely to do better on CPAP than on APAP. CPAP may be the preferable treatment in a significant subset of patients. If APAP is used first anyway, side effects, or suboptimal response or adherence, should lead to consideration of switching to CPAP based on a CPAP titration polysomnography.

Nocturnal arrhythmia during split-night positive airway pressure titration polysomnography in obstructive sleep apnea patients at central chest institute of Thailand

Nocturnal arrhythmia during split-night positive airway pressure titration polysomnography in obstructive sleep apnea patients at central chest institute of Thailand

Remotely controlled mandibular positioning of oral appliance therapy during polysomnography and drug-induced sleep endoscopy compared with conventional subjective titration in patients with obstructive sleep apnea: protocol for a randomized crossover trial

BackgroundThe amount of mandibular protrusion is a key factor in optimizing the efficacy of mandibular advancement device (MAD) therapy in an individual patient diagnosed with obstructive sleep apnea. This process is called titration and is generally based on resolution of subjective symptoms like snoring and/or daytime sleepiness as a function of protrusion. An objective approach uses a remotely controlled mandibular positioner (RCMP) during a full-night polysomnography (PSG), in analogy with continuous positive airway pressure (CPAP) titration. More recently, the feasibility of RCMP use during drug-induced sleep endoscopy (DISE) titration was reported.MethodsThis randomized crossover trial will compare DISE-assisted titration to PSG-guided titration, as well as with the conventional subjective titration method. The primary outcome is the actual mandibular protrusive position found to be the most optimal for each tested titration procedure. Furthermore, the therapeutic efficacy will be compared among the different titration modalities using level 1 sleep studies.DiscussionCurrently, the optimal titration of MAD therapy is most often based on ‘trial and error’. The conventional method relies on subjective improvement in symptoms, although this may not provide the most accurate indicator for efficient titration. Therefore, relying on objective criteria in the titration process should be advantageous. In analogy with CPAP, titration of the most optimal mandibular protrusion could be performed using RCMP during an overnight titration PSG. Recently, it was shown that titration under direct visualization of upper airway patency and collapsibility is feasible using the RCMP during DISE. However, no clinical results for such a procedure are as yet available. This study is the first to compare the most optimal mandibular protrusive position according to three titration procedures, as well as to compare the therapeutic efficacy of these titration methods.Trial registrationClinicalTrials.gov, NCT03716648. Registered on 23 October 2018.

Hypoglossal Nerve Stimulator Outcomes for Patients Outside the U.S. FDA Recommendations

The hypoglossal nerve stimulator (HGNS) is currently approved for the treatment of obstructive sleep apnea (OSA) in patients with an apnea-hypopnea index (AHI) of >15 to ≤65 events/hour, and a central apnea index (CAI) <25% of the AHI, no complete concentric collapse on drug-induced sleep endoscopy, and a recommended body mass index (BMI) <32 kg/m2 . We present 18 patients implanted as a salvage procedure despite being outside these guidelines. We included all patients who underwent HGNS but who did not meet all FDA guidelines. Demographic data, previous OSA treatments, polysomnographic (PSG) parameters from baseline and HGNS titration PSG, Epworth sleepiness score (ESS), and BMI were compared before and after surgery. Eighteen patients were identified: 94.4% male, median age 63 years. Seven underwent previous sleep surgery. Four had an AHI <15 (mean 10.5 events/hour), four had an AHI >65 (mean 86.9 events/hour), two had an elevated CAI (mean 31.3% of AHI), and 12 had a BMI >32 kg/m2 (range 32.1-39.1). Median AHI decreased from 25.3 to 3.75 events/hour on titration polysomnography (P = .0006), oxyhemoglobin saturation nadir increased from 82% to 88.5% (P = .0001) and median ESS dropped from 11 to 7.5 (P = .0016). Fifteen (83.3%) patients achieved surgical success (decrease in AHI >50% and AHI <20 events/hour) and 12 (66.7%) had an AHI <5 events/hour. Neither patient with CAI >25% was successfully treated. Median adherence = 33.5 hours/week. Our success rate for patients outside the Food and Drug Administration guidelines for HGNS (67%) was similar to the 1-year STAR trial results (66%). Future studies are necessary to consider expansion of these guidelines. 4 Laryngoscope, 130:866-872, 2020.

Using craniofacial characteristics to predict optimum airway pressure in obstructive sleep apnea treatment

IntroductionManual titration is the gold standard to determinate optimal continuous positive airway pressure, and the prediction of the optimal pressure is important to avoid delays in prescribing a continuous positive airway pressure treatment. ObjectiveTo verify whether anthropometric, polysomnographic, cephalometric, and upper airway clinical assessments can predict the optimal continuous positive airway pressure setting for obstructive sleep apnea patients. MethodsFifty men between 25 and 65 years, with body mass indexes of less than or equal to 35kg/m2 were selected. All patients had baseline polysomnography followed by cephalometric and otolaryngological clinical assessments. On a second night, titration polysomnography was carried out to establish the optimal pressure. ResultsThe average age of the patients was 43±12.3 years, with a mean body mass index of 27.1±3.4kg/m2 and an apnea–hypopnea index of 17.8±10.5 events per hour. Smaller mandibular length (p=0.03), smaller atlas–jaw distance (p=0.03), and the presence of a Mallampati III and IV (p=0.02) were predictors for higher continuous positive airway pressure. The formula for the optimal continuous positive airway pressure was: 17.244−(0.133×jaw length)+(0.969×Mallampati III and IV classification)−(0.926×atlas–jaw distance). ConclusionIn a sample of male patients with mild-to-moderate obstructive sleep apnea, the optimal continuous positive airway pressure was predicted using the mandibular length, atlas–jaw distance and Mallampati classification.

Coping Processes, Self-Efficacy, and CPAP Use in Adults With Obstructive Sleep Apnea

ABSTRACTBackground: Coping strategies are predictive of 1 week CPAP use. Coping strategies may predict longer-term CPAP use among adults with obstructive sleep apnea (OSA). Objectives: To investigate the influence of two coping styles (active and passive) and individual coping processes on CPAP use at 1 week and 1 month; and explore the association between self-efficacy and coping on CPAP use. Participants: CPAP-naïve adults (52.3% male, 90.9% White) newly diagnosed with OSA (AHI ≥ 5 events/hr) from two U.S. clinical sleep centers (n = 66). Methods: A post-hoc analysis from a prospective, longitudinal study that examined influential factors on CPAP use among CPAP-naïve patients with newly diagnosed OSA. The Ways of Coping Questionnaire and the Self-Efficacy Measure for Sleep Apnea were completed immediately after CPAP titration polysomnography. Objective 1 week and 1 month CPAP use (mean hr/night) were the primary outcomes. Descriptive analyses and stepwise multiple linear regression analyses modeling for CPAP use (mean hr/night). Results: Active coping was significantly associated with greater CPAP use (mean hr/night) at 1 week, but not at 1 month (p = 0.0397; p = 0.0556, respectively). Higher Planful Problem Solving was significantly associated with greater average CPAP use at 1 week and 1 month (p = 0.0117, p = 0.0378, respectively). Self-efficacy was significantly associated with greater average CPAP use at 1 week (p = 0.0056) and 1 month (p = 0.0056). Conclusions: Self-efficacy and Planful Problem Solving coping are promising behavioral intervention targets to promote CPAP use in newly diagnosed OSA.

Clinical pathways and wait times for OSA care in Ontario, Canada: A population cohort study

RATIONALE: Lengthy wait times for obstructive sleep apnea (OSA) in Canada remain a concern.OBJECTIVES: To describe the clinical pathway for OSA and determine wait times from assessment of OSA until continuous positive airway pressure (CPAP) treatment in Ontario.METHODS: We conducted a population-based cohort study from 2006 to 2013. We used billing information to identify clinic visits for sleep complaints and polysomnography (PSG). We calculated the time from primary care visits until diagnostic PSG (diagnostic time) and from PSG until CPAP initiation (treatment time) for each year. We used logistic regression to identify factors associated with diagnostic and treatment time >6 months.RESULTS: A total of 216 514 CPAP users were included. Most (52%) had a diagnostic PSG without a sleep assessment and 52% underwent a titration PSG. The median diagnostic wait for hospital and community-based facilities were 260 (IQR 87–869) days and 203 (36–838) days, respectively, with less than 50% of patients undergoing PSG within 6 months of PC assessment. The median treatment wait was 108 days (57–193) at hospital and 82 days (45–143) at community-based facilities; less than 70% started on CPAP within 6 months. Female sex, recent hospitalization and having diagnostic PSG at a hospital were associated with longer diagnostic and treatment times.CONCLUSIONS: The clinical pathway for assessment and treatment of OSA in Ontario is highly variable and current wait times in Ontario remain lengthy. Interventions to improve physician education, redistribute sleep medicine resources and adopting new technologies should be considered.

Hypoglossal Nerve Stimulator Implantation in a Non-Academic Setting: Two-Year Result.

Objectives/HypothesisUpper Airway Stimulation (UAS) is an FDA approved treatment option for patients with moderate‐to‐severe obstructive sleep apnea (OSA) who could not adhere to continuous positive airway pressure (CPAP). Previous studies have shown UAS reduced apnea‐hypopnea index (AHI) in controlled clinical trials and from academic institutions. We report patient outcomes and therapy adherence of UAS in a non‐academic hospital and clinic setting.Study DesignCase series of consecutive patients.MethodsConsecutive implants completed at a community hospital between January 2015 to Feb 2017 are included in this report. All patients underwent baseline polysomnography (PSG) recording and drug‐induced sleep endoscopy (DISE) prior to the implant. All patients had returned for standard post‐implantation titration PSG at a community sleep clinic to validate and adjust the stimulation setting for optimal response. Results were in mean ± SD, and pre‐ and post‐implant data were compared using a paired student t‐test.ResultsA total 22 patients undergoing UAS implant were overweight (BMI of 28.9 ± 5.0 kg/m2) and middle aged (63.2 ± 11.1 years), and had severe OSA (AHI of 35.9 ± 19.1). The AHI from the entire night of the titration study was 16.0 ± 10.4 (P < .01, compared with baseline), and the treatment AHI from the sleep period when the optimal setting was programmed was 1.2 ± 1.1 (P < .001, compared with baseline), and 90% patients had titrated AHI less than 5. The lowest SpO2 increased from 81% ± 8% at baseline to 91% ± 3% at the titrated setting (P = .001). After an average follow up of 95 ± 28.5 days, the therapy use per night was 7.0 ± 1.9 hours per night. The average postoperative ESS was 6.7 ± 5.3 of 18 patients, a reduction from the baseline of 10.9 ± 4.8. A total of 13 of 18 patients with postoperative ESS < 10, a measure indicated normalization of daytime sleepiness.ConclusionPatients who elected to receive UAS implant surgery at a non‐academic hospital and followed at a sleep clinic showed significant reduction in OSA severity with strong adherence to treatment. These results supported that UAS as a valid treatment option for OSA can be successfully implemented in the non‐academic hospital and clinic settings.Level of Evidence4

Efficacy of Oral Appliance Therapy in the Treatment of Severe OSA in CPAP-Resistant Cases

Continuous positive airway pressure (CPAP) is the current standard of care for the treatment of obstructive sleep apnea (OSA). It is known that there is a low rate of adherence in many patients. Oral appliance therapy (OAT) is effective in patients with mild-to-moderate OSA. The efficacy of OAT in severe patients is unknown. The aim of this study is to evaluate treatment using an in-laboratory titration method to determine whether OAT might be appropriate for patients with severe OSA. This is an IRB approved, retrospective study of 41 adults (mean age 51 years; 73% male) with severe OSA who were intolerant of CPAP therapy. All patients were treated with OAT (OASYS Oral–Nasal Airway System™). The sample was sub-divided into severe [Apnea–Hypopnea Index (AHI > 30 50) groups. Informed consent was obtained from all patients included in the study. The device was custom fit by a dentist. After patients reported subjective symptom improvement, titration polysomnography was performed. If obstructive events were still noted after 90 min of the sleep study, an attending sleep technologist titrated the device in vivo in 1 mm increments for a maximum of 3 mm to optimize effectiveness. For severe cases, almost half (46%) were resolved with a post-treatment AHI < 5, while two-thirds (66%) had an AHI < 10. For very severe cases, 43% were resolved with a post-treatment AHI < 5, while 64% had an AHI < 10. All findings were statistically significant (p < 0.001). This preliminary study supports the notion that oral appliance therapy using the OASYS Oral–Nasal Airway System™ may be effective in severe cases of OSA.