Total Arousal Index Research Articles

Assessment of sleep-related breathing disorders in patients with duchenne muscular dystrophy.

BackgroundRespiratory failure is a significant cause of morbidity and mortality in neuromuscular diseases. Although clinical findings and respiratory function tests aid in diagnosing sleep-related breathing disorders, polysomnography is the gold standard for the diagnosis of these disorders. We aimed to investigate the role of sleep-wake symptoms and clinical findings of patients with Duchenne muscular dystrophy (DMD) in predicting sleep-related breathing disorders through the comparison of polysomnography findings. In addition, we evaluated the sleep architecture of our patients.MethodsA total of 35 children (12 patients with DMD and 23 controls) were included in this cross-sectional study. Activity status and clinical severity of the patients were determined by history and clinical findings such as scoliosis, obesity. All subjects were hospitalized for one night in the Sleep Unit and their polysomnography examinations were performed. Sleep, breathing, arousals and limb movements were scored manually according to the American Sleep Disorders Association criteria.ResultsNocturnal and daytime symptoms were present in 50% of patients with DMD, 40.8% were wheelchair-bound and 58% had scoliosis. Obstructive sleep apnea was noted in 16.6% of patients with DMD. The apnea-hypopnea index, leg movement index were significantly higher in the DMD group as compared to the control group (P < 0.05). The number of desaturations, total arousal index and the percentage of total superficial sleep were significantly higher in patients with wheelchair, scoliosis, sleep-wake symptoms.ConclusionsBeing wheelchair-bound or having scoliosis do not predict sleep-related breathing disorders, so patients with DMD should be followed-up via polysomnography. Sleep-wake symptoms should be carefully questioned in these patients and symptomatic patients should be referred to pediatric respiratory units.

Gender Difference in Periodic Limb Movements in Adults with Sickle Cell Disease

Abstract 4843Periodic limb movements during sleep (PLMS) are commonly described in children with Sickle Cell Disease (SCD), however the relevance of such events in sleep disturbance or complaint of daytime fatigue remain questionable. It has been known that the dopaminergic neurotransmission has a modulator role in pain perception. Since PLMS have been suggested to be a potential biological marker of dopaminergic mechanisms, this study aimed to assess PLMS in adults with SCD and its correlations with clinical and sleep parameters. Methods:Seventy adults with SCD (50% females, matched for age and body mass index), underwent Brief Pain Inventory, overnight polysomnogram and laboratorial tests for hemoglobin, reticulocytes, ferritin, transferin saturation, haptoglobin, fetal hemoglobin, lactate dehydrogenase (LDH), and bilirrubins. Results:The mean PLMS index was higher in females (16.5±10.7/h vs. 8.7±8.2/h, p< 0.05), with 88.6% of the females having increased PLMS index (≥ 15/h) in comparison to males (22.6), p<0.01. Total arousal index and PLMS arousal index were increased in females with PLMS ≥ 15/h compared to those with PLMS < 5/h (p<0.05, both), but not in males. Females also exhibited correlation of increased PLMS index and clinical parameters such as pain score (rS =0.71), indirect bilirrubin (rS =0.42) and LDH (rS =0.38), p<0.01 in all. An interaction effect of the non-use of hydroxyurea treatment in PLMS abnormality was also observed (p<0.05). Conclusions:Elevated PLMS were more common in females with SCD than in males and correlated with pain symptoms and hematological parameters of hemolysis. Hydroxyurea treatment showed a protective effect against the PLMS index increase.Supported by AFIP, CEPID-FAPESP 98/14303-3, and CAPES/SUS. Disclosures:No relevant conflicts of interest to declare.

Periodic Limb Movements and Disrupted Sleep in Children with Sickle Cell Disease

To describe the rate, distribution and correlates of periodic limb movements in sleep (PLMS) in children with sickle cell disease (SCD). Prospective, cross-sectional. Hospital-based sleep laboratory. Sixty-four children aged 2-18 years with SCD, hemoglobin SS-type who had an overnight polysomnogram and a parent-completed Pediatric Sleep Questionnaire. Mean age was 8.4 years (SD 4.8); 50% were male. N/A. The mean PLMS index was 3.7 (6.6) and ranged from 0 to 31.8, with 23.4% of the sample having PLMS ≥ 5/h. Sleep efficiency was decreased (P = 0.03), and the total arousal index (P = 0.003) and PLMS arousal index (P < 0.001) were increased in children with PLMS ≥ 5/h compared to those with PLMS < 5/h. PLMS were most frequent in NREM stage 2 sleep and during the fourth hour of sleep. Inter-movement interval duration peaked at 25-30 s. "Growing pains worst in bed" or "restlessness of the legs", suggesting restless legs syndrome (RLS), were reported in 12.5% of the total sample and were more common in children with elevated PLMS. A PLMS score for identifying elevated PLMS in children, based on items from the Pediatric Sleep Questionnaire, did not significantly predict PLMS ≥ 5/h. Elevated PLMS are common in children with SCD and are associated with sleep disruption and symptoms of RLS. Future research into the time structure of PLMS, their causes and consequences, and development of a disease-specific sleep disorders screening questionnaire, is needed in children with SCD.

Sleep profile and symptoms of sleep disorders in patients with stable mild to moderate chronic obstructive pulmonary disease

Background Sleep problems associated with chronic obstructive pulmonary disease may have an important impact on quality of life and health outcome measures in patients. The aim of this study was to prospectively assess differences in symptom profile and polysomnographic parameters in patients with stable mild to moderate COPD and age, gender, and body-mass-index matched controls without airflow obstruction. Methods The Sleep Disorders Questionnaire was administered to both patients and controls prior to clinical and polysomnographic evaluation. Responses obtained from the questionnaire were used to construct four independent symptom scales: sleep apnea, periodic limb movement syndrome, psychiatric sleep disorder, and narcolepsy. Associations between each diagnostic scale and sleep parameters were considered by means of multiple analyses of covariance. Results Fifty-two patients with mild-to-moderate COPD (age 62 ± 8 years, BMI 29 ± 7 kg/sqm) and 52 age, gender, and body-weight matched controls without COPD were studied. Patients with COPD had overall lower sleep efficiency, a lower total sleep time, and lower mean overnight oxygen saturation compared to controls. Patients with COPD were significantly more likely to report symptoms such as insomnia and difficulty in initiating and maintaining sleep, resulting in overall higher psychiatric sleep disorder scale scores in patients compared with controls. Minimum oxygen saturation was an independent predictor for all symptom scales. After correcting for potentially confounding factors, including pack/years of smoking, total sleep time, sleep efficiency, arousal index, mean and minimum oxygen saturation, and apnea–hypopnea-index, the between group-differences for both the periodic limb movement and psychiatric sleep disorder scale scores remained statistically significant. Conclusions We observed significant differences in both quantity and quality of sleep between patients with stable mild to moderate chronic obstructive pulmonary disease and respective controls.

Macrophage migratory inhibitory factor (MIF) may be a key factor in inflammation in obstructive sleep apnea.

This study investigated the 24-hour variation of macrophage migratory inhibitory factor (MIF), a cytokine which induces insensitivity to the anti-inflammatory effects of glucocorticoids, in patients with untreated obstructive sleep apnea (OSA) as compared to healthy adults with no OSA. Fifty-three men and women with OSA (mean apnea/hypopnea index [AHI] = 39.5) and 24 healthy adults (Non-OSA, AHI = 5.1). Over a 24-h period, blood was collected every 2 h for MIF and cortisol determination. The following night, sleep was monitored with polysomnography. MIF showed a strong 24-h variation, with a peak at 04:00 and a nadir at 22:00. Patients with OSA showed 25% higher MIF levels (area under the curve) over 24 h than healthy controls. Furthermore, MIF levels were significantly associated with AHI and total arousal index (ArI), even after adjusting for BMI. Cortisol showed the expected 24-h variation (peaking at 06:00), but no cortisol differences were observed between OSA and Non-OSA groups. MIF is elevated in patients with OSA and is related to OSA severity, while there was no difference in cortisol levels. MIF is a pro-inflammatory cytokine which additionally inhibits the anti-inflammatory effects of glucocorticoids. Thus, elevated MIF levels in OSA may contribute to elevated inflammation.

Motor disturbances during non-REM and REM sleep in narcolepsy-cataplexy: a video-polysomnographic analysis

Motor events during sleep can be frequently observed in patients with narcolepsy-cataplexy. We hypothesized that increased motor events and related arousals contribute to sleep fragmentation in this disease. We aimed to perform a detailed whole-night video-polysomnographic analysis of all motor events during non-rapid eye movement and rapid eye movement sleep in a group of narcolepsy-cataplexy patients and matched controls, and to assess the association with arousals. Video-polysomnographic registrations of six narcolepsy-cataplexy patients and six sex- and age-matched controls were analysed. Each motor event in the video was classified according to topography, number of involved body parts, duration and its association with arousals. The mean motor activity index was 59.9 ± 23.0 h(-1) in patients with narcolepsy-cataplexy compared with 15.4 ± 9.2 h(-1) in controls (P = 0.004). Distribution of motor events was similar in non-rapid eye movement and rapid eye movement sleep in the patient group (P = 0.219). In narcolepsy-cataplexy, motor events involved significantly more body parts (≥ 2 body regions: 38.2 ± 15.6 versus 14.9 ± 10.0; P = 0.011). In addition, the proportion of motor events lasting longer than 1 s was higher in patients than controls (88% versus 44.4%; P < 0.001). Both total and motor activity-related arousal indices were increased in narcolepsy-cataplexy (total arousal index: 21.6 ± 9.0 versus 8.7 ± 3.5; P = 0.004; motor activity-related arousal index: 17.6 ± 9.8 versus 5.9 ± 2.3; P = 0.002). Motor activity and motor activity-related arousal indices are increased in both non-rapid eye movement and rapid eye movement sleep in narcolepsy-cataplexy compared with controls. This supports the concept of a general sleep motor dysregulation in narcolepsy-cataplexy, which potentially contributes to or even underlies sleep fragmentation in this disease.

Polysomnographic Characteristics of a Referred Sample of Children with Sickle Cell Disease

To describe polysomnographic parameters and their clinical correlates in a referred sample of children with sickle cell disease (SCD). This was a retrospective medical record review of 55 consecutive children aged 2-18 years with SCD (hemoglobin [Hb] SS and Hb SC genotypes) undergoing polysomnography for evaluation of sleep disordered breathing. Polysomnography values were compared between SCD genotypes, 4 age groups, and adenotonsillectomy status using descriptive and nonparametric statistics. Obstructive sleep apnea (OSA) was diagnosed in 38/55 (69%) children. Polysomnographic parameters differed significantly between Hb SS and Hb SC genotypes only on arterial oxyhemoglobin saturation (SpO2; 95.2 +/- 3.8 vs. 98.0 +/- 0.8, respectively, p < 0.01) and percent of sleep time below SpO2 90% (T90; 8.0 +/- 22.0 vs. 0.01 +/- 0.02, respectively, p < 0.05). Increasing age was associated with decreasing SpO2 (rho = -0.282, p < 0.05), obstructive apnea-hypopnea index (OAHI; rho = -0.364, p < 0.01), total arousal index (rho -0.272, p < 0.05) and respiratory arousal index (rho = -0.349, p < 0.01). Periodic limb movements in sleep (PLM) averaged 4.7 +/- 8.8/h, with a PLM index > 5/h in 5/17 children without OSA. Post- adenotonsillectomy, 8/10 children had OSA, but compared to untreated OSA-positive children they had a lower mean OAHI (4.4 +/- 5.5 vs. 8.9 +/- 12.5) and a lower T90 (1.6 +/- 4.2 vs. 9.2 +/- 24.9). Both OSA and PLMs were common in children with SCD. Children with Hb SS experienced more severe nocturnal oxygen desaturation than did those with Hb SC. Post-adenotonsillectomy, most children had OSA, although they experienced fewer obstructive respiratory events and less severe nocturnal oxygen desaturation than did untreated OSA-positive children.

Sleep-disordered breathing, behavior, and academic performance in Taiwan schoolchildren

The behaviors of children may be affected by sleep-disordered breathing (SDB). This study adopts a cross-sectional approach to investigate the relationship between the sleep apneas-hypopneas index during sleep and the behavioral and academic performance of schoolchildren in Taiwan. A total of 138 children (85 boys and 53 girls), ages 6-11, were recruited from two elementary schools to participate in this study. Overnight polysomnographic examinations in hospital were performed to assess sleep quality, including total sleep time, arousal index, apneas-hypopneas index, desaturation index, and lowest oxygen saturation, as well as the percentage of total sleep time spent in rapid eye movement, stage 1, stage 2, stage 3, and stage 4. The children's parents and teachers were required to complete a Chinese version of the Child Behavior Checklist and Teacher's Report Form to assess child behavior and academic achievement. Compared with children without SDB (apneas-hypopneas index ≤1), those with severe SDB (apneas-hypopneas index >15) exhibited more irregular behavioral performance in somatic complaints (odds ratio (OR) = 9.43; 95% confidence interval (CI) = 1.04-85.71) and attention (OR = 9.95; 95% CI = 1.02-97.00). However, different severities of SDB groups did not show significant associations in academic performance. Our study suggests that children with severe SDB may predispose to somatic complaints and attention problems so that sleep examination or medical intervention might be provided at an early age in these children.

Sleep architecture changes during a trek from 1400 to 5000 m in the Nepal Himalaya

The aim of this study was to examine sleep architecture at high altitude and its relationship to periodic breathing during incremental increases in altitude. Nineteen normal, sea level-dwelling volunteers were studied at sea level and five altitudes in the Nepal Himalaya. Morning arterial blood gases and overnight polysomnography were performed in 14 subjects at altitudes: 0, 1400, 3500, 3900, 4200 and 5000 m above sea level. Subjects became progressively more hypoxic, hypocapnic and alkalinic with increasing altitude. As expected, sleep architecture was affected by increasing altitude. While time spent in Stage 1 non-rapid eye movement sleep increased at 3500 m and higher (P < 0.001), time spent in slow-wave sleep (SWS) decreased as altitude increased. Time spent in rapid eye movement (REM) sleep was well preserved. In subjects who developed periodic breathing during sleep at one or more altitudes (16 of 19), arousals because of periodic breathing predominated, contributing to an increase in the total arousal index. However, there were no differences in sleep architecture or sleeping oxyhaemoglobin saturation between subjects who developed periodic breathing and those who did not. As altitude increased, sleep architecture became progressively more disturbed, with Stage 1 and SWS being affected from 3500 m, while REM sleep was well preserved. Periodic breathing was commonplace at all altitudes, and while associated with increases in arousal indices, did not have any apparent effect on sleep architecture.

Periodic Limb Movements in Complex Sleep Apnea Syndrome

Introduction: The development of repetitive central apneas during application of CPAP in patients initially showing obstructive apneas, a condition called complex sleep apnea syndrome (CompSAS), implies respiratory control instability. Respiratory control is known to be transiently destabilized by arousals. We hypothesized that PLMS and PLM- related arousals would be more frequent in patients with CompSAS compared to those with obstructive sleep apnea (OSA) and could account for some of the respiratory instability. Methodology: Comparative retrospective review of patients studied in our Sleep Disorders Center. Results: 88 patients with CompSAS were compared with 112 patients with OSA. Total arousal index (TAI), respiratory- related arousal index (RRAI), and PLM-related arousal index (PLMAI) were similar during the diagnostic polysomnogra- phy of CompSAS and OSA patients. Following CPAP application, patients with CompSAS had a higher TAI (27.2 (15.5 - 39.9) vs. 16.6 (10.7 - 26.5); p� 0.001; median (interquartile range)), but a lower PLMI (0 (0 - 21.1) vs. 12.6 (0 - 36.2); p=0.009) and PLMAI (0 (0 - 1.3) vs. 0.8 (0 - 4.2); p=0.004) than patients with OSA. Conclusion: PLMS and PLM-related arousals are not more common in CompSAS than in OSA patients and do not appear to play a significant role in destabilizing respiratory control in CompSAS patients.

Síndroma de apneia obstrutiva do sono como causa de acidentes de viação

Several studies have demonstrated that obstructive sleep apnoea syndrome (OSAS) patients have a higher rate of road traffic accidents. Our study aimed to analyse any differences in OSAS patients between those who reported having had road traffic accidents and/or near misses and those who did not.Methods: We studied 163 patients with OSAS (ap-noea-hypopnoea index (AHI)>10/h) diagnosed using nocturnal polysomnography (NPSG), all drivers, 18.4% of whom drove for a living. Patients were asked at their first clinical interview to self-report road traffic accidents and/or near misses over the past 3 years which had been caused by abnormal daytime drowsiness. This allowed patients to be divided into two groups, those who had had road traffic accidents and/or near misses and those who had not. Both were compared as to age, body mass index (BMI), Epworth Sleepiness Scale (ESS), daytime PaO2 and PaCO2, Functional Outcomes of Sleep Questionnaire (FOSQ) test and NPSG data. This latter was total sleep time (TTS), sleep efficiency, sleep stages, arousal index (ARI), AHI, minimal and average SaO2, % of time with SaO2<90% (T90), desaturation index (ODI), total duration of apnoea-hypopnoea (TDAH) (T test).Results: Group I (no road traffic accidents) No=89 patients; group II (road traffic accidents) No=74 patients. Age (years) was 57.6±11.8 vs. 54.7±10.9 (ns); male gender, 75% vs. 78.4%; ESS, 12.3±5.4 vs. 17.6±4.3 (p<0.001); BMI, (Kg/m2) 36.2±8.1 vs. 35.6±6.3 (ns); PaO2 (mmHg), 76.1±11.4 vs. 78.5±12.6 (ns); PaCO2 (mmHg), 42.6±5.1 vs. 42.2±4.7 (ns); FOSQ, 15.1±3.1 vs. 12.9±3.4 (p<0.001).NPSG data revealed differences only in AHI: 45.0±21.6 vs. 56.2±29.7 (p=0.01) and in TDAH (minutes), 98.5±63.7 vs. 133.3±83.2 (p=0,005).Conclusions: In our experience patients who had road traffic accidents and/or near misses had a more severe OSAS, with higher AHI, excessive daytime sleepiness and lower quality of life.Rev Port Pneumol 2009; XV (3): 419-431

Obstructive sleep apnoea syndrome as a cause of road traffic accidents

Several studies have demonstrated that obstructive sleep apnoea syndrome (OSAS) patients have a higher rate of road traffic accidents. Our study aimed to analyse any differences in OSAS patients between those who reported having had road traffic accidents and/or near misses and those who did not. MethodsWe studied 163 patients with OSAS (apnoea- hypopnoea index (AHI)>10/h) diagnosed using nocturnal polysomnography (NPSG), all drivers, 18.4% of whom drove for a living. Patients were asked at their first clinical interview to self-report road traffic accidents and/or near misses over the past 3 years which had been caused by abnormal daytime drowsiness. This allowed patients to be divided into two groups, those who had had road traffic accidents and/or near misses and those who had not. Both were compared as to age, body mass index (BMI), Epworth Sleepiness Scale (ESS), daytime PaO2 and PaCO2, Functional Outcomes of Sleep Questionnaire (FOSQ) test and NPSG data. This latter was total sleep time (TTS), sleep efficiency, sleep stages, arousal index (ARI), AHI, minimal and average SaO2, % of time with SaO2<90% (T90), desaturation index (ODI), total duration of apnoea-hypopnoea (TDAH) (T test). ResultsGroup I (no road traffic accidents) No=89 patients; group II (road traffic accidents) No=74 patients. Age (years) was 57.6±11.8 vs. 54.7±10.9 (ns); male gender, 75% vs. 78.4%; ESS, 12.3±5.4 vs. 17.6±4.3 (p<0.001); BMI, (Kg/m2) 36.2±8.1 vs. 35.6±6.3 (ns); PaO2 (mmHg), 76.1±11.4 vs. 78.5±12.6 (ns); PaCO2 (mmHg), 42.6±5.1 vs. 42.2±4.7 (ns); FOSQ, 15.1±3.1 vs. 12.9±3.4 (p<0.001). NPSG data revealed differences only in AHI: 45.0±21.6 vs. 56.2±29.7 (p=0.01) and in TDAH (minutes), 98.5±63.7 vs. 133.3±83.2 (p=0,005). ConclusionsIn our experience patients who had road traffic accidents and/or near misses had a more severe OSAS, with higher AHI, excessive daytime sleepiness and lower quality of life.

Prevalence of EEG Paroxysmal Activity in a Population of Children with Obstructive Sleep Apnea Syndrome

Sleep breathing disorders may trigger paroxysmal events during sleep such as parasomnias and may exacerbate preexisting seizures. We verified the hypothesis that the amount of EEG paroxysmal activity (PA) may be high in children with obstructive sleep apnea syndrome (OSAS). Prospective study Sleep unit of an academic center. Polysomnographic studies were performed in a population of children recruited prospectively, for suspected OSAS, from January to December 2007, with no previous history of epileptic seizures or any other medical conditions. All sleep studies included ≥ 8 EEG channels, including centrotemporal leads. We collected data about clinical and respiratory parameters of children with OSAS and with primary snoring, then we performed sleep microstructure analysis in 2 OSAS subgroups, matched for age and sex, with and without paroxysmal activity. We found 40 children who met the criteria for primary snoring, none of them showed PA, while 127 children met the criteria for OSAS and 18 of them (14.2%) showed PA. Children with PA were older, had a predominance of boys, a longer duration of OSAS, and a lower percentage of adenotonsillar hypertrophy than children without PA. Moreover, PA occurred over the centrotemporal regions in 9 cases, over temporal-occipital regions in 5, and over frontocentral regions in 4. Children with PA showed a lower percentage of REM sleep, a lower CAP rate and lower A1 index during slow wave sleep, and lower total A2 and arousal index than children without EEG abnormalities. We found a higher percentage of paroxysmal activity in children with OSAS, compared to children with primary snoring, who did not exhibit EEG abnormalities. The children with paroxysmal activity have peculiar clinical and sleep microstructure characteristics that may have implications in the neurocognitive outcome of OSAS.

Prevalence of EEG paroxysmal activity in a population of children with obstructive sleep apnea syndrome.

Sleep breathing disorders may trigger paroxysmal events during sleep such as parasomnias and may exacerbate preexisting seizures. We verified the hypothesis that the amount of EEG paroxysmal activity (PA) may be high in children with obstructive sleep apnea syndrome (OSAS). Prospective study. Sleep unit of an academic center. Polysomnographic studies were performed in a population of children recruited prospectively, for suspected OSAS, from January to December 2007, with no previous history of epileptic seizures or any other medical conditions. All sleep studies included > or = 8 EEG channels, including centrotemporal leads. We collected data about clinical and respiratory parameters of children with OSAS and with primary snoring, then we performed sleep microstructure analysis in 2 OSAS subgroups, matched for age and sex, with and without paroxysmal activity. We found 40 children who met the criteria for primary snoring, none of them showed PA, while 127 children met the criteria for OSAS and 18 of them (14.2%) showed PA. Children with PA were older, had a predominance of boys, a longer duration of OSAS, and a lower percentage of adenotonsillar hypertrophy than children without PA. Moreover, PA occurred over the centrotemporal regions in 9 cases, over temporal-occipital regions in 5, and over frontocentral regions in 4. Children with PA showed a lower percentage of REM sleep, a lower CAP rate and lower A1 index during slow wave sleep, and lower total A2 and arousal index than children without EEG abnormalities. We found a higher percentage of paroxysmal activity in children with OSAS, compared to children with primary snoring, who did not exhibit EEG abnormalities. The children with paroxysmal activity have peculiar clinical and sleep microstructure characteristics that may have implications in the neurocognitive outcome of OSAS.

Arousal frequency is associated with increased fatigue in obstructive sleep apnea.

ObjectiveFatigue is an important and often underemphasized symptom in patients with obstructive sleep apnea (OSA). Sleep fragmentation, i.e., arousals and disruptions in sleep architecture, is common in patients with OSA and may potentially contribute to their fatigue. We hypothesized that arousal frequency and changes in sleep architecture contribute to the fatigue experienced by patients with OSA.DesignSeventy-three patients with diagnosed but untreated OSA (AHI ≥ 15) were enrolled in this study. A baseline polysomnogram was obtained, and fatigue was measured with the Multidimensional Fatigue Symptom Inventory-short form (MFSI-sf). We evaluated the association between fatigue and arousals and various polysomongraphic variables, including sleep stages and sleep efficiency.ResultsSignificant correlations between MFSI-sf subscale scores and various arousal indices were noted. Emotional fatigue scores were associated with total arousal index (r = 0.416, p = .021), respiratory movement arousal index (r = 0.346, p = .025), and spontaneous movement arousal index (r = 0.378, p = .025). Physical fatigue scores were associated with total arousal index (r = 0.360, p = .033) and respiratory movement arousal index (r = 0.304, p = .040). Percent of stage 1 sleep and REM sleep were also associated with physical and emotional fatigue scores. Hierarchal linear regression analysis demonstrated that emotional fatigue scores were independently associated with spontaneous movement arousals after controlling for age, body mass index, depression, and sleep apnea severity.ConclusionsThese findings suggest that arousals may contribute to the fatigue seen in patients with OSA.

Relationship between Arousal Indices and Clinical Manifestations in Patients Who Performed Polysomnography

Background: Repeated arousals during sleep have been known to be associated with excessive daytime sleepiness and cardiovascular complications. We investigated the relationship between arousal indices and clinical parameters. Methods: We retrospectively reviewed medical records of 41 patients who performed polysomnography for a diagnosis of obstructive sleep apnea syndrome. We defined total arousal index (TAI) as the number of arousals per hour and respiratory arousal index (RAI) as the number of arousals associated with apnea or hypopnea per hour. Results: There were significant positive correlations between arousal indices and apnea-hypopnea index (AHI) (RAI vs. AHI, r=0.958, p＜0.001; TAI vs. AHI, r=0.840, p＜0.001). RAI and mean oxygen saturation showed a significant negative correlation with each other (r=－0.460, p=0.002). TAI revealed a significant positive correlation with mean systolic blood pressure (MSBP) and mean diastolic blood pressure (MDBP) (TAI vs. MSBP, r=0.389, p=0.014; TAI vs. MDBP, r=0.373, p=0.019). There was no significant correlation between arousal indices and parameters of sleepiness. RAI had a significant positive correlation with body mass index (BMI) and neck circumference (NC) (RAI vs. BMI, r=0.371, p=0.017; RAI vs. NC, r=0.444, p=0.004). When partial correlation analysis was performed to adjust for other variables, there was significant correlation between RAI and AHI (r=0.935, p ＜0.001). Conclusion: This study shows that respiratory arousal index could be a useful index reflecting of severity of obstructive sleep apnea syndrome. Arousal during sleep would be concerned in the development of cardiovascular complication of obstructive sleep apnea. And some anthropometric factors would contribute to the development of arousals during sleep. Further studies are needed to clarify any cause-effect relationship.

Relationship between atherosclerosis and the sleep apnea syndrome: An intravascular ultrasound study

Background Sleep apnea hypopnea syndrome (SAHS) is a predictive factor of cardiovascular disease. We hypothesized that SAHS could influence coronary atherosclerosis plaque volume as assessed by 3-dimensional intravascular ultrasound (3D-IVUS). Methods Participating patients were identified from 2 studies assessing the progression of atherosclerosis in stable coronary artery disease using coronary 3D-IVUS. Results Nineteen patients, aged 61 ± 8 years, with a body mass index of 29 ± 5 kg/m 2 were studied. Increased apnea–hypopnea index (AHI) ≥ 15 was found in 12/19 patients (63%). Patients with AHI ≥ 15 had larger coronary atherosclerotic plaque volume than patients with AHI < 15 (238 ± 69 mm 3 vs 169 ± 64 mm 3, p = 0.047) and the difference was even larger in patients with obstructive apnea/hypopnea episodes compared to patients without (243 ± 70 mm 3 vs 170 ± 59 mm 3, p = 0.03). There was a significant positive correlation between obstructive AHI and coronary atherosclerotic plaque volume ( r = 0.6, p = 0.01). A significant positive correlation was also demonstrated between respiratory arousal index and coronary atherosclerotic plaque volume ( r = 0.6, p = 0.02) and between total arousal index and coronary atherosclerotic plaque volume ( r = 0.5, p = 0.03). Conclusion In patients with stable coronary artery disease, there was a significant relationship between the frequency of obstructive sleep apnea/hypopnea episodes and sleep fragmentation and the importance of coronary atherosclerotic plaque volume. 3D-IVUS is well suited to correlate coronary atherosclerosis and sleep breathing disorders at early stages.

Polysomnographic Study of Intermittent Zolpidem Treatment in Primary Sleep Maintenance Insomnia

Treatment of chronic insomnia with nightly hypnotics is efficacious, but discontinuation is recommended after 1 month, less than the average disease duration. This study was undertaken to determine the efficacy of intermittent administration. A double-blind study was carried out on 8 patients (age, 32.8 +/- 9 years; 3 men) with primary sleep maintenance insomnia longer than 1 month. Polysomnography of conventional sleep parameters, cyclic alternating patterns (CAPs), and arousals was performed. Perception of sleep quality was assessed on a visual analog scale. After an adaptation night, baselines were recorded followed by 6 consecutive nights of alternating treatment with zolpidem (10 mg) or placebo. Significant improvements on baseline values (P < 0.0001) were observed on all 3 active treatment nights for total sleep time, sleep efficiency, CAP time, CAP rate, subtype A2, arousals, and arousal index. Deep non-rapid eye movement sleep increased with the second and third doses of active treatment (P < 0.0001). Rapid eye movement sleep increased during the last 3 polysomnographic recordings (P < 0.014). Sleep quality (visual analog scale) improved on all nights after the initial dose of active treatment (P < 0.0001). There was no evidence of rebound insomnia with placebo. Intermittent treatment with zolpidem in primary insomnia patients improves CAP parameters and arousals, as well as sleep duration and quality, in the absence of rebound insomnia.

EEG Arousal Norms by Age

Brief arousals have been systematically scored during sleep for more than 20 years. Despite significant knowledge concerning the importance of arousals for the sleep process in normal subjects and patients, comprehensive age norms have not been published. Seventy-six normal subjects (40 men) without sleep apnea or periodic limb movements of sleep, aged 18 to 70 years, slept in the sleep laboratory for 1 or more nights. Sleep and arousal data were scored by the same scorer for the first night (comparable to clinical polysomnograms) and summarized by age decade. There were no statistically significant differences for sex or interaction of sex by age (p > .5 for both). The mean arousal index increased as a function of age. Newman-Keuls comparisons (.05) showed arousal index in the 18- to 20-year and 21- to 30-year age groups to be significantly less than the arousal index in the other 4 age groups. Arousal index in the 31-to 40-year and 41-to 50-year groups was significantly less than the arousal index in the older groups. The arousal index was significantly negatively correlated with total sleep time and all sleep stages (positive correlation with stage 1 and wake). Brief arousals are an integral component of the sleep process. They increase with other electroencephalographic markers as a function of age. They are highly correlated with traditional sleep-stage amounts and are related to major demographic variables. Age-related norms may make identification of pathologic arousal easier.

Ethnic difference in periodic limb movements in children

Background Epidemiological studies have suggested that ethnicity is a risk factor for sleep-disordered breathing (SDB) and that African-American children are three times more likely than Caucasian children to have SDB. Ethnic differences in sleep architecture and other routinely assessed sleep parameters have not been critically assessed, thus the aim of this study was to compare sleep characteristics in African-American and Caucasian children. Methods A total of 41,363 sleep questionnaires were mailed to parents of children aged 5–7 years in Jefferson County, KY. Parents of snoring and non-snoring children were invited to have their child undergo overnight polysomnography. Results Complete questionnaires were returned by 9872 families (23% response rate). Of these, 689 agreed to undergo polysomnography, and 542 complete polysomnograms were obtained (5.7% of questionnaire respondents). There were 391 Caucasian and 151 African-American children with a mean age of 6.7 ± 0.5 years who underwent overnight polysomnographic evaluation. No differences between groups were observed for sleep latency, total sleep time, sleep efficiency, or rapid eye movement (REM) latency. African-American children had slightly increased stage 3 sleep (6.0 ± 2.8% vs. 5.4 ± 2.8%; p = 0.01), although the total proportion of slow wave sleep was similar. Higher respiratory arousal index (3.6 ± 6.5/h vs. 1.4 ± 2.7/h; p < 0.001) and total arousal index (11.5 ± 5.2/h vs. 9.8 ± 4.8/h; p < 0.001) emerged in African-American children, who were more likely to have mild SDB (AHI > 1:34% in African-American vs. 24% in Caucasian; p = 0.017) and SDB (AHI > 5: 22.5% vs. 7%; p < 0.001). However, Caucasian children were more likely to have periodic leg movements during sleep (PLMS; 16.5% vs. 7% in AA; p = 0.004). The odds ratio for a Caucasian child to have PLMS was 2.6 (95% confidence interval (CI) 1.3–5.3; p = 0.006). Furthermore, in the absence of SDB, the odds ratio for a Caucasian child to have PLMS was 9.5 (95% CI: 2.2–39.9; p = 0.002). Conclusions African-American and Caucasian children have similar sleep architecture. African-American children are more likely to display respiratory disturbances during sleep, while PLMS are significantly more prevalent among Caucasian children.