Treatment Of Obstructive Sleep Apnea Research Articles

Burdened breaths: The influence of depression on obstructive sleep apnea

Depression and metabolic syndrome could exacerbate the risks of the other, leading to a series of severe coexisting conditions. One notable comorbidity that must be mentioned is obstructive sleep apnea (OSA). Current studies suggested that depression increases susceptibility to OSA. As the prevalence of depression rises, it becomes critical to prevent and manage its complications or comorbidities, including OSA. Predictive models, non-invasive electroencephalogram monitoring, genetic research, and other promising technologies are being applied to the prevention, diagnosis, and personalized treatment of depression and OSA.

Real world challenges and barriers for positive airway therapy use in acute ischemic stroke patients.

Untreated obstructive sleep apnea (OSA) in patients with acute ischemic stroke (AIS) is associated with increased morbidity and mortality. However, diagnosing and treating OSA in AIS is challenging. We aimed to determine the feasibility of portable monitoring (PM) for diagnosis and positive airway pressure therapy for treatment of OSA in an inpatient stroke population. We recruited inpatients with AIS from Cleveland Clinic. Those who consented underwent PM; participants with a respiratory event index (REI) ≥ 10 were offered auto-titrating positive airway pressure therapy (APAP). Ease-of-use questionnaires were completed. We summarized categorical variables using n(%) and continuous variables using mean ± SD or median [IQR]. 27 participants (age 59.8 ± 11.8, 51.9% female, 51.9% Black, BMI 33.4 ± 8.5) enrolled. The study ended early due to Medicare contracting that forced most patients to complete stroke rehabilitation outside the Cleveland Clinic health system. 59.3% had large vessel occlusions and 53.8% had moderate/severe disability (Modified Rankin score ≥ 2). PM was attempted in 21 participants, successful in 18. Nurses and patients rated the PM device as highly easy to use. 13 of 18 (72%) patients who had an REI ≥ 10 consented to APAP titration, but only eight (61.5%) of those 13 used APAP for more than one night, and only five (27.8%) used APAP up to 90 days with data captured for only one participant. Five required troubleshooting at titration, and only one had adherent APAP usage by objective assessment after discharge. This study demonstrates the real-world challenges of assessing and treating OSA in an AIS population, highlighting the necessity for further research into timely and feasible screening and treatment.

Racial and ethnic differences in the receipt of continuous positive airway pressure treatment for obstructive sleep apnea

ObjectiveTo examine the pattern of health services access and utilization that may contribute to racial/ethnic disparities in receiving continuous positive airway pressure (CPAP) treatment for obstructive sleep apnea (OSA). MethodsThis cross-sectional study used a national sample from the All of Us Research Program, which included over 80 % of participants from underrepresented populations in biomedical research. Study participants included adults aged 18 years and older diagnosed with OSA (N = 8518). Diagnosis of OSA and CPAP treatment were ascertained by diagnostic and procedural codes from the electronic health records. Sociodemographic characteristics and health service utilization factors were identified using self-reported survey data. ResultsWith this national survey, the overall diagnosed prevalence of OSA was 8.8 %, with rates of 8.12 % in non-Hispanic (NH) Black adults, 5.99 % in Hispanic adults, and 10.35 % in NH White adults. When comparing to NH White adults, Hispanic adults were less likely to receive CPAP treatment for OSA after adjusting for socioeconomic and demographic characteristics, access to and utilization of health services, and comorbidities such as obesity and having multiple chronic conditions (OR = 0.73, 95 % CI = 0.59,0.90), p < 0.01. ConclusionsThe rates of CPAP treatment among OSA patients are not consistent across racial and ethnic groups. Unequal access to health services based on residence may contribute to these differences. Interventions that target disparities in OSA diagnosis, access to treatment, and barriers in insurance coverage could potentially help reduce racial and ethnic differences in OSA diagnosis and management.

Screening for moderate to severe obstructive sleep apnea by using heart rate variability features based on random forest algorithm.

More than 80% of patients with moderate to severe obstructive sleep apnea (OSA) are still not diagnosed timely. The prediction model based on random forest (RF) algorithm was established by using heart rate variability (HRV), clinical and demographic features so as to screen for the patients with high risk of moderate and severe obstructive sleep apnea. The sleep monitoring data of 798 patients were randomly divided into training set (n = 558) and test set (n = 240) in 7:3 proportion. Grid search was applied to determine the best parameters of the RF model. 10-fold cross validation was utilized to evaluate the predictive performance of the RF model, which was then compared to the performance of the Logistic regression model. Among the 798 patients, 638 were males and 160 were females, with the average age of 43.51 years old and the mean body mass index (BMI) of 25.92kg/m2. The sensitivity, specificity, accuracy, F1 score and the area under receiver operating characteristic curve for RF model and Logistic regression model were 94.68% vs. 73.94%; 73.08% vs. 86.54%; 90.00% vs. 76.67%; 0.94 vs. 0.83 and 0.83 vs. 0.80 respectively. The RF prediction model can effectively distinguish patients with moderate to severe OSA, which is expected to carry out in a large-scale population in order to screening for high-risk patients, and helps to evaluate the effect of OSA treatment continuously.

Baseline Characteristics Associated with Hypoglossal Nerve Stimulation Treatment Outcomes in Patients with Obstructive Sleep Apnea: A Systematic Review

Hypoglossal nerve stimulation (HGNS) has emerged as an effective treatment for obstructive sleep apnea (OSA). Identifying baseline characteristics that prospectively could predict treatment outcomes even better is crucial for optimizing patient selection and improving therapeutic success in the future. A systematic review was conducted following PRISMA guidelines. Literature searches in Medline, Web of Science, and Cochrane databases identified studies assessing baseline characteristics associated with HGNS treatment outcomes. Inclusion criteria focused on studies with adult patients diagnosed with OSA, treated with HGNS, and assessed using full-night efficacy sleep studies. Risk of bias was evaluated using the NICE tool. Twenty-six studies met the inclusion criteria. Commonly reported baseline characteristics with predictive potential included BMI, site of collapse, and various pathophysiological endotypes. Most studies used the original Sher criteria to define treatment response, though variations were noted. Results suggested that lower BMI, absence of complete concentric collapse at the palatal level, and specific pathophysiological traits were associated with better HGNS outcomes. This review identified several baseline characteristics associated with HGNS outcomes, which may guide future patient selection. Importantly, patients were already preselected for HGNS. Standardizing response criteria is recommended to enhance the evaluation and effectiveness of HGNS therapy in OSA patients.

The Emerging Role of Pharmacotherapy in Obstructive Sleep Apnea

Obstructive sleep apnea (OSA) is a prevalent pathology with current modalities of treatment including continuous positive airway pressure (CPAP), surgery, weight loss, hypoglossal nerve stimulation, and pharmacotherapy. While CPAP is the current standard treatment for OSA, lack of tolerance and side effects necessitate alternative modalities of treatment. Various pharmacologic agents exist with mechanisms that may target OSA. Early trials have demonstrated efficacy of noradrenergic-antimuscarinic combinations to stimulate the airway, promote pharyngeal muscle tone, and prevent airway collapse. These agents, which we discuss in detail, have demonstrated significant reductions in apnea-hypopnea index (AHI) and lowest oxygen saturations based on preliminary studies. Glucagon-like peptide 1 receptor agonists (GLP-1RA), which stimulate endogenous insulin, reducing glucagon release, and decreasing gastric emptying, have shown positive results for OSA patients through weight loss with reductions in AHI. In this narrative review article, we highlight the mechanisms, current data, and future potential for multiple drug classes, including respiratory stimulants and GLP-1RAs.

Factors Affecting CPAP Adherence in an OSA Population during the First Two Years of the COVID-19 Pandemic.

Background: Obstructive sleep apnea (OSA) is a common disorder associated with major cardiovascular and neurocognitive sequelae. Continuous positive airway pressure (CPAP) is the standard treatment for OSA. The aim of this study was to investigate the prevalence and associations of long-term CPAP adherence in newly diagnosed OSA patients. Methods: We enrolled patients who were diagnosed with OSA during the COVID-19 pandemic. Adherence was defined as CPAP use ≥4 h per night on ≥70% of nights over 30 consecutive days. Patient demographics were retrieved from medical records, and CPAP adherence at 6 months and 1 year after initiation was monitored. Results: Overall, 107 patients were included in the analysis. A number of 73 (68%) and 63 (59%) patients were adherent to CPAP treatment at 6 months and 12 months accordingly. Among the factors examined and analyzed (age, gender, BMI, Apnea-Hypopnea Index (AHI)), no significant correlation was found. Further analysis revealed the potential role of comorbidities. CPAP compliance at 6 months was shown to be associated with better CPAP adherence at 12 months. Conclusions: CPAP adherence at 6 months is correlated to long-term adherence to treatment. Therefore, early close follow-up is important. Further prospective studies are needed to identify other potential predictors.

Cost-effectiveness analysis of continuous positive airway pressure treatment for obstructive sleep apnea in Singapore from a health system perspective.

This study assessed the cost-effectiveness of continuous positive airway pressure treatment for obstructive sleep apnea in Singapore from a health system perspective. The analysis evaluated a 5-year care pathway using a Markov model, considering per-patient costs of treatment, health system cost savings of obstructive sleep apnea and attributed conditions, the effectiveness measured in disability-adjusted life years with a discount rate of 3% and a weighted 5-year continuous positive airway pressure adherence of 74.1% from Singapore studies. Per-patient costs of treatment were from a large public hospital in Singapore. Efficacy of continuous positive airway pressure treatment, health system costs and disability-adjusted life years were obtained from literature; costs are in US dollars. We conducted probabilistic sensitivity analysis, one-way sensitivity analysis and what-if analysis. Based on a willingness-to-pay threshold of US $50,000 per disability-adjusted life year in USA, continuous positive airway pressure therapy was highly cost-effective, with an incremental cost-effectiveness ratio of $13,822 per disability-adjusted life year averted. Compared with the annual total costs of $856 for patients with continuous positive airway pressure treatment diagnosed by an inpatient sleep study, the total costs for those diagnosed by a home sleep test were $625, resulting in a remarkable 27% reduction per patient per year. One-way sensitivity analysis indicated that costs of treatment, effectiveness of continuous positive airway pressure treatment and adherence had a higher impact on the cost-effectiveness of continuous positive airway pressure therapy. The what-if analysis suggested that for continuous positive airway pressure treatment to be cost-effective, adherence rate should be at least 16.1%. These findings provide valuable insights for policymakers in making informed decisions on funding diagnosis and continuous positive airway pressure therapy within Singapore's healthcare system.

Positive Airway Pressure, Mortality, and Cardiovascular Risk in Older Adults With Sleep Apnea

Positive airway pressure (PAP) is the first-line treatment for obstructive sleep apnea (OSA), but evidence on its beneficial effect on major adverse cardiovascular events (MACE) and mortality prevention is limited. To determine whether PAP initiation and utilization are associated with lower mortality and incidence of MACE among older adults with OSA living in the central US. This retrospective clinical cohort study included Medicare beneficiaries with 2 or more distinct OSA claims identified from multistate, statewide, multiyear (2011-2020) Medicare fee-for-service claims data. Individuals were followed up until death or censoring on December 31, 2020. Analyses were performed between December 2021 and December 2023. Evidence of PAP initiation and utilization based on PAP claims after OSA diagnosis. All-cause mortality and MACE, defined as a composite of myocardial infarction, heart failure, stroke, or coronary revascularization. Doubly robust Cox proportional hazards models with inverse probability of treatment weights were used to estimate treatment effect sizes controlling for sociodemographic and clinical factors. Among 888 835 beneficiaries with OSA included in the analyses (median [IQR] age, 73 [69-78] years; 390 598 women [43.9%]; 8115 Asian [0.9%], 47 122 Black [5.3%], and 760 324 White [85.5%] participants; median [IQR] follow-up, 3.1 [1.5-5.1] years), those with evidence of PAP initiation (290 015 [32.6%]) had significantly lower all-cause mortality (hazard ratio [HR], 0.53; 95% CI, 0.52-0.54) and MACE incidence risk (HR, 0.90; 95% CI, 0.89-0.91). Higher quartiles (Q) of annual PAP claims were progressively associated with lower mortality (Q2 HR, 0.84; 95% CI, 0.81-0.87; Q3 HR, 0.76; 95% CI, 0.74-0.79; Q4 HR, 0.74; 95% CI, 0.72-0.77) and MACE incidence risk (Q2 HR, 0.92; 95% CI, 0.89-0.95; Q3 HR, 0.89; 95% CI, 0.86-0.91; Q4 HR, 0.87; 95% CI, 0.85-0.90). In this cohort study of Medicare beneficiaries with OSA, PAP utilization was associated with lower all-cause mortality and MACE incidence. Results might inform trials assessing the importance of OSA therapy toward minimizing cardiovascular risk and mortality in older adults.

Does the number of loops affect the results of barbed pharyngoplasties? A retrospective comparison in two techniques

IntroductionThe use of barbed sutures for pharyngoplasty techniques is a new trend in sleep apnea surgery, but little is known about its short-term results depending on the different techniques. The purpose of this study was to analyze the surgical results in two different centers using barbed sutures with different barbed pharyngoplasty techniques. Material and methodsThis is a multicenter retrospective study of patients with obstructive sleep apnea (OSA) undergoing surgery, all of whom underwent pharyngoplasty with barbed suture using a classic or modified technique, which may or may not be associated with other surgical techniques. A univariate and multivariate statistical analysis were performed to assess the relationship of these surgical techniques with surgical success and with different descriptive variables. ResultsThe final sample size was 126 patients. A surgical success rate of 39.7% was obtained for a postoperative AHI < 10/h and a 51.6% success rate according to Sher's criteria. A greater proportion of success was observed in the modified barbed pharyngoplasty technique that was not maintained after the multivariate analysis, as with other factors such as age, ODI or the presence of nasal surgery. ConclusionNon-resective pharyngoplasty with barbed sutures is an effective technique for the treatment of OSA in selected patients, with both the classic technique and the modified alternatives having good postoperative results, with no differences observed in relation to surgical success between both. More studies are necessary to evaluate the differences between both techniques in more homogeneous groups.

Kairos positive airway pressure (KPAP) equals continuous PAP in effectiveness, and offers superior comfort for obstructive sleep apnea treatment

Kairos positive airway pressure (KPAP) equals continuous PAP in effectiveness, and offers superior comfort for obstructive sleep apnea treatment

Evaluation of a cross-sectoral care model including novel telemedical concepts for diagnosis and treatment of obstructive sleep apnea (SLEEP WELL)

Evaluation of a cross-sectoral care model including novel telemedical concepts for diagnosis and treatment of obstructive sleep apnea (SLEEP WELL)

Clinical efficacy study of position-responding mandibular advancement device in patients with obstructive sleep apnea.

Although mandibular advancement device (MAD) treatment is effective in patients with obstructive sleep apnea (OSA), there are still some concerns about its potential therapeutic and side effects. Thus, we developed a novel MAD that auto-titrates depending on its position in patients with OSA. Therefore, we conducted a clinical trial to determine the efficacy of an auto-titrating mandibular advancement device (AMAD) for treating OSA. Fourteen patients with OSA were enrolled in this study. Polysomnography (PSG) was conducted at the start of the clinical trial, and PSG with AMAD in situ was performed after three months of treatment. The mean Epworth Sleepiness Scale (ESS) and STOP-Bang scores were 8.21 ± 4.21 and 5.00 ± 1.00, respectively. After 3 months of treating AMAD, STOP-Bang scores improved to 3.75 ± 1.06; however, there was no significant change in ESS scores. Additionally, we found statistically significant improvements in several respiratory parameters in the PSG data after AMAD treatment. The AHI (32.85 ± 21.71 to 12.93 ± 10.70), supine AHI (45.91 ± 23.58 to 15.59 ± 12.76), lateral AHI (13.94 ± 10.95 to .49 ± 7.40), lowest O2 saturation (79.71 ± 6.22 to 84.00 ± 5.71), total arousal number (191.14 ± 112.07 to 86.57 ± 48.80), and arousal index (33.76 ± 21.00 to 15.05 ± 8.42) were recorded. However, there were no significant changes in total sleep time, sleep efficiency, or mean oxygen saturation. Additionally, we did not observe any major side effects during treatment, specifically related to tooth or jaw pain. Our clinical trial revealed that AMAD improved PSG parameters and reduced the incidence of common side effects. Therefore, AMAD may be an effective alternative treatment for OSA.

Phenotyping patients treated for obstructive sleep apnea with persistent objective impaired alertness or subjective sleepiness

Background and objectivesSleepiness in patients with obstructive sleep apnea (OSA) is associated with accidental and economic burden, as well as cardiovascular risk. Despite OSA treatment, 10–28 % of patients report residual sleepiness. Its determinants, as well as those of objective impaired alertness remain poorly known. In this study, we investigated factors associated with residual subjective sleepiness and objective impaired alertness in patients treated for OSA. MethodsConsecutive OSA treated patients referred for maintenance of wakefulness tests (MWT) at a tertiary university center were recruited between 2017 and 2020. Clinical data and polysomnography parameters were compared between patients with vs without subjective sleepiness (Epworth Sleepiness Scale, ESS≥11) and those with vs without impaired alertness (at least one trial with sleep onset on MWT). A multivariate logistic model was used to assess explanatory variables of MWT and ESS results. ResultsWe included 141 patients, of whom 12.8 % had both subjective sleepiness and objective impaired alertness, 17.7 % objective impaired alertness only and 9.2 % subjective sleepiness only. Self-reported history of car accident/near miss, smoking history and ESS≥11 were significantly associated with objective impaired alertness whereas residual Apnea-hypopnea Index and CPAP use were not. The only significant variable associated with ESS at the time of MWT evaluation was initial ESS. Patients with objective impaired alertness only were more often smokers (52 % vs 19 %, p = 0.01), had a higher body mass index (BMI) (32 vs 29 kg/m2, p = 0.05), and showed lower initial ESS (11 vs 13, p < 0.01). ConclusionsMore than one third of OSA treated patients referred for MWT have objective impaired alertness and/or subjective sleepiness. Our findings highlight the need for a comprehensive medical assessment including accident history, subjective sleepiness and comorbidities. Particular attention should be paid to smoking patients with high BMI, who are at risk of impaired alertness with no report of subjective sleepiness.

Multidimensional prediction of continuous positive airway pressure adherence

ObjectiveContinuous positive airway pressure (CPAP) is the standard treatment for obstructive sleep apnea (OSA). Unsatisfactory adherence to CPAP is an important clinical issue to resolve. Cluster analysis is a powerful tool to distinguish subgroups in a multidimensional fashion. This study aimed to investigate the use of cluster analysis for predicting CPAP adherence using clinical polysomnographic (PSG) parameters and patient characteristics. Patients/methodsParticipants of this multicenter observational study were 1133 patients with OSA who were newly diagnosed and implemented CPAP. Ward's method of cluster analysis was applied to in-laboratory diagnostic PSG parameters and patient characteristics. CPAP adherence was assessed during 90- and 365-day periods after CPAP initiation in each cluster. We adopted the Centers for Medicare and Medicaid Services criterion for CPAP adherence, i.e., CPAP use ≥4 h per night for 70 % or more of the observation period. Logistic regression analysis was performed to stratify clusters according to CPAP adherence. ResultsFive clusters were identified through cluster analysis. Clustering was significantly associated with CPAP adherence at 90- and 365-day periods after CPAP initiation. Logistic regression revealed that the cluster with features including apnea predominant sleep-disordered breathing, high apnea-hypopnea index, and relatively older age demonstrated the highest CPAP adherence. ConclusionCluster analysis revealed hidden connections using patient characteristics and PSG parameters to successfully identify patients more likely to adhere to CPAP for 90 days and up to 365 days. When prescribing CPAP, it is possible to identify patients with OSA who are more likely to be non-adherent.

Personalized Treatment for Obstructive Sleep Apnea: Beyond CPAP.

Obstructive sleep apnea (OSA) is a sleep disorder characterized by repetitive episodes of partial or complete obstruction of the upper airway during sleep. Continuous positive airway pressure (CPAP) is a method used as a first-line treatment for obstructive sleep apnea (OSA). However, intolerance and resistance to CPAP can limit its long-term effectiveness. Alternative treatments are available, such as Mandibular Advancement Devices (MADs), positional therapy, upper airway surgery, and maxillomandibular osteotomy. However, often less efficient in reducing the apnea-hypopnea index, the higher tolerance of and compliance to alternative treatment has resulted in the adequate treatment of OSA in CPAP-intolerant patients. This paper describes the protocol of a prospective single-center cohort study including adult patients with moderate to severe OSA (15 events/h ≤ apnea-hypopnea index (AHI) < 65 events/h) that failed to comply with CPAP therapy. Selected patients will be invited to the clinic to explore alternative treatment options where DISE will be a first step in further identifying upper airway collapse during sleep. By exploring alternative treatment options in CPAP-intolerant patients and systematically documenting their treatment paths, an algorithm can be defined to better guide patients towards personalized treatment for OSA. The follow-up is aimed at 5 years with an inclusion of 170 patients per year, including a drop-out rate of 15%. By leveraging a real-world database, this study aims to bridge the gap between research and clinical practice, facilitating the development of evidence-based guidelines and personalized treatment algorithms for CPAP-intolerant patients.

Novel advances in assessment and treatment of obstructive sleep apnea

The current indicators for assessing obstructive sleep apnea are sleep apnea-hypopnea index (AHI) and the lowest nocturnal oxygen saturation, but they do not comprehensively reflect the severity of the disease. The main treatments for OSA are continuous positive airway pressure, mandibular advancement devices and surgery, which have poor compliance and limited effectiveness. Therefore, there is a need to explore novel methods to assess and treat OSA. This article systematically summarized recent advances in this field.

Accuracy of respiratory event indices downloaded from positive airway pressure devices: can they be relied upon when making treatment decisions?

The gold standard for diagnosis and treatment of obstructive sleep apnea (OSA) is attended overnight polysomnography (PSG) in a sleep laboratory. Alternative diagnostic techniques are urgently needed for both diagnosis and treatment control when initiating positive airway pressure (PAP) in the home setting. Current PAP devices compute data such as residual AHI (apnea-hypopnea index) using their proprietary algorithms to provide an automatic event detection (AED). It was suggested that these should be labeled AHIFLOW. The current study situation shows an acceptable agreement with the tendency of mildly overestimating the AHI by the PAP devices. But, the literature is still limited in terms of accuracy, especially when considering the lack of standardization and different detection algorithms. A validation of PAP devices regarding the agreement of AHIFLOW compared to AHIPSG is extremely important, given that the device analysis is exclusively based on the measured flow. There are considerable concerns about assessing the PAP effectiveness in higher risk groups based on the AED function alone. Given these reservations, the use of PAP event detection can be an important addition to the diagnostic spectrum and, in combination with telemonitoring, offers promising potential.

Overnutrition in persons with cystic fibrosis on modulator therapy and the relationship to obstructive sleep apnea.

Cystic fibrosis (CF) care is evolving with the ubiquitous use of modulator therapy and resultant increase in lifespan. It is important for CF clinicians to monitor the pathologic weight gain that is concomitantly being seen as obesity is a known risk factor for multiple other diseases. In this review we focus on obesity in CF, discuss screening and lifestyle considerations, outline CF-specific concerns with weight loss medications, and describe the vicious cycle of obesity and obstructive sleep apnea (OSA). We discuss screening and treatment for OSA, as it directly correlates with weight fluctuation. We offer interim recommendations for CF teams as they continue to care for this population.

Nocturnal hypoxia and age-related macular degeneration.

Nocturnal hypoxia is common, under-diagnosed and is found in the same demographic at risk of age-related macular degeneration (AMD). The objective of this study was to determine any association between nocturnal hypoxia and AMD, its severity, and the high-risk sub-phenotype of reticular pseudodrusen (RPD). This cross-sectional study included participants aged ≥50 years with AMD, or normal controls, exclusive of those on treatment for obstructive sleep apnoea. All participants had at home, overnight (up to 3 nights) pulse oximetry recordings and multimodal imaging to classify AMD. Classification of Obstructive Sleep Apnea (OSA) was determined based on oxygen desaturation index [ODI] with mild having values of 5-15 and moderate-to-severe >15. A total of 225 participants were included with 76% having AMD, of which 42% had coexistent RPD. Of the AMD participants, 53% had early/intermediate AMD, 30% had geographic atrophy (GA) and 17% had neovascular AMD (nAMD). Overall, mild or moderate-to-severe OSAwas not associated with an increased odds of having AMD nor AMD with RPD (p ≥ 0.180). However, moderate-to-severe OSA was associated with increased odds of having nAMD (odds ratio = 6.35; 95% confidence interval = 1.18 to 34.28; p = 0.032), but not early/intermediate AMD or GA, compared to controls (p ≥ 0.130). Mild OSA was not associated with differences in odds of having AMD of any severity (p ≥ 0.277). There was an association between nocturnal hypoxia as measured by the ODI and nAMD. Hence, nocturnal hypoxia may be an under-appreciated important modifiable risk factor for nAMD.