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Concept: Hypopnea

177

Obstructive sleep apnea (OSA) has been reported to be a risk factor for cardiovascular (CV) disease. Although the apnea-hypopnea index (AHI) is the most commonly used measure of OSA, other less well studied OSA-related variables may be more pathophysiologically relevant and offer better prediction. The objective of this study was to evaluate the relationship between OSA-related variables and risk of CV events.

Concepts: Epidemiology, Actuarial science, Sleep apnea, Obstructive sleep apnea, Cultural studies, Hypopnea, Abnormal respiration, Medical conditions related to obesity

172

OBJECTIVE We tested the hypothesis of an independent cross-sectional association between obstructive sleep apnea (OSA) severity and glycated hemoglobin (HbA(1c)) in adults without known diabetes. RESEARCH DESIGN AND METHODS HbA(1c) was measured in whole-blood samples from 2,139 patients undergoing nocturnal recording for suspected OSA. Participants with self-reported diabetes, use of diabetes medication, or HbA(1c) value ≥6.5% were excluded from this study. Our final sample size comprised 1,599 patients. RESULTS A dose-response relationship was observed between apnea-hypopnea index (AHI) and the percentage of patients with HbA(1c) >6.0%, ranging from 10.8% for AHI <5 to 34.2% for AHI ≥50. After adjustment for age, sex, smoking habits, BMI, waist circumference, cardiovascular morbidity, daytime sleepiness, depression, insomnia, sleep duration, and study site, odds ratios (95% CIs) for HbA(1c) >6.0% were 1 (reference), 1.40 (0.84-2.32), 1.80 (1.19-2.72), 2.02 (1.31-3.14), and 2.96 (1.58-5.54) for AHI values <5, 5 to <15, 15 to <30, 30 to <50, and ≥50, respectively. Increasing hypoxemia during sleep was also independently associated with the odds of HbA(1c) >6.0%. CONCLUSIONS Among adults without known diabetes, increasing OSA severity is independently associated with impaired glucose metabolism, as assessed by higher HbA(1c) values, which may expose them to higher risks of diabetes and cardiovascular disease.

Concepts: Diabetes mellitus, Blood sugar, Sleep, Sleep apnea, Obstructive sleep apnea, Glycated hemoglobin, Hypopnea, Medical conditions related to obesity

170

PURPOSE: To directly compare the clinical effectiveness of maxillomandibular advancement (MMA) and uvulopalatopharyngoplasty (UPPP)-performed alone and in combination-for the treatment of moderate to severe obstructive sleep apnea (OSA). PATIENTS AND METHODS: The investigators designed and implemented a retrospective cohort study composed of patients with moderate to severe OSA (baseline AHI >15). The predictor variable was operative treatment and included MMA, UPPP, and MMA followed by UPPP (UPPP/MMA). The primary outcome variable was the apnea-hypopnea index (AHI) measured preoperatively and 3 months to 6 months postoperatively. Other variables were grouped into the following categories: demographic, respiratory, and sleep parameters. Descriptive and bivariate statistics were computed. RESULTS: The sample was composed of 106 patients grouped as follows: MMA (n = 37), UPPP (n = 34), and UPPP/MMA (n = 35) for treatment of OSA. There were no significant differences between the 3 groups for the study variables at baseline, except for AHI. Surgical treatment resulted in a significant decrease in AHI in each group: MMA (baseline AHI, 56.3 ± 22.6 vs AHI after MMA, 11.4 ± 9.8; P < .0001), UPPP/MMA (baseline AHI, 55.7 ± 49.2 vs AHI after UPPP/MMA, 11.6 ± 10.7; P < .0001), and UPPP (baseline AHI, 41.8 ± 28.0 vs AHI after UPPP, 30.1 ± 27.5; P = .0057). After adjusting for differences in baseline AHI, the estimated mean change in AHI was significantly larger for MMA compared with UPPP (MMA AHI, -40.5 vs UPPP AHI, -19.4; P = < .0001). UPPP/MMA was no more effective than MMA (P = .684). CONCLUSION: The results of this study suggest that MMA should be the surgical treatment option of choice for most patients with moderate to severe OSA who are unable to adequately adhere to CPAP.

Concepts: Cohort study, Clinical trial, Sleep apnea, Obstructive sleep apnea, Hypopnea, Uvulopalatopharyngoplasty

168

OBJETIVE: To evaluate the effectiveness of adenotonsillectomy for the treatment of obstructive sleep apnea hypopnea syndrome (OSAHS) in children by respiratory polygraphy (RP). MATERIAL AND METHODS: Prospective study was conducted on children referred with clinical suspicion of OSAHS. A clinical history was taken and a general physical and ENT examination was performed on all patients. RP was performed before adenotonsillectomy and six months afterwards. Patients with craniofacial syndromes, neuromuscular disorders, and severe concomitant disease were excluded. RESULTS: We studied 150 children (67. 8% male), with a mean age of 3.74±1.80 years and a BMI of 41.70±31.75. A diagnosis of OSAHS was made if the total number of respiratory events, apneas and hypopneas, divided by the total study time (RDI) was > 4.6, using RP before undergoing adenotonsillectomy. The mean respiratory disturbance index (RDI) was 15.18±11.11, with 58.7% (88) of with severe OSAHS (RDI>10). There was a significant improvement in all clinical and polygraphic variables six months after adenotonsillectomy. The residual OSAHS was 14%. The preoperative RDI was significantly associated with persistent disease (P=.042). CONCLUSIONS: Respiratory polygraphy is useful for monitoring the efficacy of surgical treatment by adenotonsillectomy in children with OSAHS.

Concepts: Pulmonology, Sleep disorder, Sleep apnea, Obstructive sleep apnea, Hypopnea, Abnormal respiration, Apnea, Sleep disorders

162

macronutrient intake has been found to affect sleep parameters including obstructive sleep apnoea (OSA) in experimental studies, but there is uncertainty at the population level in adults.

Concepts: Sleep, Sleep apnea, Obstructive sleep apnea, Hypopnea, Abnormal respiration, Sudden infant death syndrome

29

The purpose of this study was to test the hypothesis that severity of sleep apnea (SA), assessed by frequency of apneas and hypopneas per hour of sleep (apnea-hypopnea index [AHI]), is related to sodium intake in patients with heart failure (HF).

Concepts: Sleep apnea, Hypopnea

28

OBJECTIVES: Sleep disturbances can impair alertness and neurocognitive performance and increase the risk of falling asleep at the wheel. We investigated the prevalence of sleep disorders among public transport operators (PTOs) and assessed the interventional effects on hypersomnolence and neurocognitive function in those diagnosed with obstructive sleep apnea (OSA). METHODS: Overnight polygraphy and questionnaire data from 101 volunteers (72 males, median age 48 range [22-64] years, 87 PTOs) employed at the Gothenburg Public Transportation Company were assessed. Treatment was offered in cases with newly detected OSA. Daytime sleep episodes and neurocognitive function were assessed before and after intervention. RESULTS: At baseline, symptoms of daytime hypersomnolence, insomnia, restless legs syndrome as well as objectively assessed OSA (apnea hypopnea index (AHI, determined by polygraphic recording)=17[5-46]n/h) were highly present in 26, 24, 10 and 22%, respectively. A history of work related traffic accident was more prevalent in patients with OSA (59%) compared to those without (37%, p<0.08). In the intervention group (n=12) OSA treatment reduced AHI by -23 [-81 to -5]n/h (p=0.002), determined by polysomnography. Reduction of OSA was associated with a significant reduction of subjective sleepiness and blood pressure. Measures of daytime sleep propensity (microsleep episodes from 9 [0-20.5] to 0 [0-12.5], p<0.01) and missed responses during performance tests were greatly reduced, indices of sustained attention improved. CONCLUSIONS: PTOs had a high prevalence of sleep disorders, particularly OSA, which demonstrated a higher prevalence of work related accidents. Elimination of OSA led to significant subjective and objective improvements in daytime function. Our findings argue for greater awareness of sleep disorders and associated impacts on daytime function in public transport drivers.

Concepts: Sleep, Sleep deprivation, Sleep disorder, Sleep apnea, Polysomnography, Obstructive sleep apnea, Hypopnea, Sleep disorders

27

OBJECTIVE: To investigate diagnostic test accuracy (DTA) of different tests for obstructive sleep apnea (OSA) compared to polysomnography (PSG) in children. METHODS: We performed a systematic review according to DTA criteria published by the Cochrane Collaboration. Studies that compared any possible diagnostic test with PSG for diagnosing OSA were considered. Study quality assessment was conducted in each selected study and DTA measures recalculated by hand whenever possible. Excellent DTA was defined as positive likelihood ratio (PLR) > 10 and negative likelihood ratio (NLR) < 0.1. RESULTS: We identified 1064 potentially relevant studies, of which 33 met inclusion criteria. Study quality was generally low; 5 studies fulfilled all quality criteria and 11 studies included >100 subjects. Included studies compared 40 different tests to PSG. Only 13 studies used the currently accepted definition for OSA (i.e., apnea hypopnea index ≥1). In these studies, PLR ranged from 1.017 to ∞, NLR from 0 to 1.089. Sleep lab-based polygraphy, urinary biomarkers, and rhinomanometry (one study each) showed excellent DTA. CONCLUSION: There is limited evidence concerning diagnostic alternatives to PSG for identifying OSA in children. However, polygraphy, urinary biomarkers, and rhinomanometry may be valid tests if their apparently high DTA is confirmed by subsequent studies.

Concepts: Diagnosis, Evidence-based medicine, Systematic review, Sleep disorder, Sleep apnea, Obstructive sleep apnea, Hypopnea, Likelihood-ratio test

26

The purpose of this study was to compare the therapeutic pressure determined by an automated CPAP device (AutoCPAP) during the titration period, between nasal and oronasal mask and the residual apnea-hypopnea index (AHI) on a subsequent poligraphy performed with the established therapeutic CPAP.

Concepts: Pulmonology, Sleep, Sleep apnea, Polysomnography, Obstructive sleep apnea, Positive airway pressure, Hypopnea, Abnormal respiration

24

Autotitrating continuous positive airway pressure (CPAP) devices adjust pressure in response to changes in airflow and are an alternative to attended in-laboratory titration polysomnography (PSG) to determine optimal pressure levels. The aim of this study was to compare the performance of the System One RemStar Auto A-Flex (Philips Respironics, Murrysville, PA, USA) automatically adjusted positive airway pressure (APAP) mode to manually titrated, fixed pressure CPAP and to validate the device’s breathing event detection capabilities against attended in-laboratory PSG.

Concepts: Pulmonology, Sleep, Sleep disorder, Sleep apnea, Polysomnography, Obstructive sleep apnea, Positive airway pressure, Hypopnea