1517 Severe REM Behavior Disorder in a Truck Driver Resolved with OSA Treatment

Respiratory-related leg movements (RRLMs) may contribute to the cardiovascular risk associated with obstructive sleep apnea (OSA). Selective serotonin reuptake inhibitors (SSRIs), but not bupropion, increase periodic leg movements in sleep. This study examines whether patients with OSA using SSRIs have more RRLMs than those taking bupropion or no antidepressant. Patients with an apnea-hypopnea index (AHI) of at least 10 events/h during a full-night diagnostic study or split-night study, who were taking bupropion (n = 32), an SSRI (n = 31), or no antidepressant (n = 31), were selected from a database of prestudy questionnaires. RRLMs were scored according to World Association of Sleep Medicine 2016 standards. Patients using SSRIs had significantly greater overall RRLM% (defined as the percentage of respiratory events associated with a leg movement, including apneas, hypopneas, and respiratory effort-related arousals), RRLM index, and periodic limb movement index relative to patients using bupropion and control patients. The difference between the RRLM% in the SSRI and bupropion groups was limited to patients undergoing split-night studies, and that of the SSRI and control groups was limited to patients undergoing full-night diagnostic studies. The greater number of RRLMs and PLMs in the SSRI group may contribute to treatment-emergent insomnia often seen with SSRI use. Fragmented sleep and elevated autonomic nervous system activation associated with increased RRLMs in patients with OSA taking SSRIs might also limit the tolerability of antidepressant treatment, as well as increase the risk for cardiovascular disease.

Obstructive sleep apnea syndrome (OSAS) is associated with impairment of cognitive function, and improvement is often noted with treatment. Golf is a sport that requires a range of cognitive skills. We evaluated the impact of nasal positive airway pressure (PAP) therapy on the handicap index (HI) of golfers with OSAS. Golfers underwent a nocturnal polysomnogram (NPSG) to determine whether they had significant OSAS (respiratory disturbance index > 15). Twelve subjects with a positive NPSG were treated with PAP. HI, an Epworth Sleepiness Scale (ESS), and sleep questionnaire (SQ) were submitted upon study entry. After 20 rounds of golf on PAP treatment, the HI was recalculated, and the questionnaires were repeated. A matched control group composed of non-OSAS subjects was studied to assess the impact of the study construct on HI, ESS, and SQ. Statistical comparisons between pre- and post-PAP treatment were calculated. The control subjects demonstrated no significant change in HI, ESS, or SQ during this study, while the OSAS group demonstrated a significant drop in average HI (11.3%, p = 0.01), ESS, (p = 0.01), and SQ (p = 0.003). Among the more skilled golfers (defined as HI ≤ 12), the average HI dropped by an even greater degree (31.5%). Average utilization of PAP was 91.4% based on data card reporting. Treatment of OSAS with PAP enhanced performance in golfers with this condition. Treatment adherence was unusually high in this study. Non-medical performance improvement may be a strong motivator for selected subjects with OSAS to seek treatment and maximize adherence.

Background:Rapid eye movement (REM) sleep behavior disorder (RBD) and obstructive sleep apnea (OSA) are the most common sleep disorders in Parkinson's disease (PD). The aim of this study was to identify whether RBD could alleviate OSA severity in PD patients and its effect on cognitive impairment.Methods:From February 2014 to May 2017, we recruited 174 PD patients from the Second Affiliated Hospital of Soochow University, all of whom underwent polysomnography (PSG). We collected clinical data, PSG results, and compared information between patients with and without RBD or OSA by analysis of covariance. We also investigated the effect of these sleep disorders on cognitive impairment using linear regression.Results:We grouped participants as follows: PD only (n = 53), PD + OSA (n = 29), PD + RBD (n = 61), and PD + RBD + OSA (n = 31). Minimum oxygen saturation (SaO2) during whole sleep and in REM sleep was higher in PD + RBD + OSA patients than that in PD + OSA patients. PD + RBD patients had worse Mini-Mental Status Examination and Montreal Cognitive Assessment (MoCA) scores than those in the PD group (P < 0.001), especially in visuospatial/executive, attention, and memory functions. The PD + OSA group performed worse than the PD group in the delayed recall domain. After adjusting for age, sex, body mass index, education, disease severity, and other sleep disorders, MoCA was negatively associated with OSA (β = −0.736, P = 0.043) and RBD (β = −2.575,P < 0.001). The severity of RBD (tonic/phasic electromyography activity) and OSA (apnea-hypopnea index/oxygen desaturation index/minimum SaO2) were also associated with MoCA. The adjusted β values of RBD-related parameters were higher than that for OSA.Conclusions:We found that RBD alleviated OSA severity; however, RBD and OSA together exacerbated PD cognitive impairment. Further studies are needed to evaluate whether OSA treatment can improve cognition in PD.

This guideline establishes clinical practice recommendations for positive airway pressure (PAP) treatment of obstructive sleep apnea (OSA) in adults and is intended for use in conjunction with other American Academy of Sleep Medicine (AASM) guidelines in the evaluation and treatment of sleep-disordered breathing in adults. The AASM commissioned a task force of experts in sleep medicine. A systematic review was conducted to identify studies, and the Grading of Recommendations Assessment, Development and Evaluation (GRADE) process was used to assess the evidence. The task force developed recommendations and assigned strengths based on the quality of evidence, the balance of clinically significant benefits and harms, patient values and preferences, and resource use. In addition, the task force adopted recommendations from prior guidelines as "good practice statements" that establish the basis for appropriate and effective treatment of OSA. The AASM Board of Directors approved the final recommendations. The following good practice statements are based on expert consensus, and their implementation is necessary for appropriate and effective management of patients with OSA treated with positive airway pressure: (1) Treatment of OSA with PAP therapy should be based on a diagnosis of OSA established using objective sleep apnea testing. (2) Adequate follow-up, including troubleshooting and monitoring of objective efficacy and usage data to ensure adequate treatment and adherence, should occur following PAP therapy initiation and during treatment of OSA. The following recommendations are intended as a guide for clinicians using PAP to treat OSA in adults. A STRONG (ie, "We recommend…") recommendation is one that clinicians should follow under most circumstances. A CONDITIONAL recommendation (ie, "We suggest…") reflects a lower degree of certainty regarding the outcome and appropriateness of the patient-care strategy for all patients. The ultimate judgment regarding any specific care must be made by the treating clinician and the patient, taking into consideration the individual circumstances of the patient, available treatment options, and resources. (1) We recommend that clinicians use PAP, compared to no therapy, to treat OSA in adults with excessive sleepiness. (STRONG) (2) We suggest that clinicians use PAP, compared to no therapy, to treat OSA in adults with impaired sleep-related quality of life. (CONDITIONAL) (3) We suggest that clinicians use PAP, compared to no therapy, to treat OSA in adults with comorbid hypertension. (CONDITIONAL) (4) We recommend that PAP therapy be initiated using either APAP at home or in-laboratory PAP titration in adults with OSA and no significant comorbidities. (STRONG) (5) We recommend that clinicians use either CPAP or APAP for ongoing treatment of OSA in adults. (STRONG) (6) We suggest that clinicians use CPAP or APAP over BPAP in the routine treatment of OSA in adults. (CONDITIONAL) (7) We recommend that educational interventions be given with initiation of PAP therapy in adults with OSA. (STRONG) (8) We suggest that behavioral and/or troubleshooting interventions be given during the initial period of PAP therapy in adults with OSA. (CONDITIONAL) (9) We suggest that clinicians use telemonitoring-guided interventions during the initial period of PAP therapy in adults with OSA. (CONDITIONAL).

The relationship among obstructive sleep apnea syndrome (OSAS), type 2 diabetes mellitus (DM2) and obesity is very complex and multi-directional. Obesity and increased visceral fat are important perpetuating factors for DM2 in patients with OSAS. On the other hand, OSAS itself leads to obesity by causing both leptin and insulin resistance as a consequence of activation of the sympathetic nervous system. Risk for developing DM2 further increases in patients with OSAS and obesity. Data regarding effects of positive airway pressure (PAP) therapy, gold standard treatment for OSAS, on glycemic control were inconsistent due to variability in duration of and adherence to PAP therapy. In our cohort study we investigated effects of PAP treatment on glucose metabolism in normal-weighted non-diabetic OSAS patients, in obese non-diabetic OSAS patients, and in OSAS patients with DM2. We prospectively analyzed 67 patients diagnosed with OSAS and documented to be effectively treated with PAP therapy for three months. Apnea-hypopnea index was highest in the diabetic group, being significantly higher than in the normal-weighted group (p=0.021). Mean HOMA values were significantly higher in obese (p=0.002) and diabetic group (p=0.001) than normal-weighted group; the differences were still significant after PAP therapy. HbA1c levels were significantly higher in diabetic group compared to those in normal-weighted (p=0.012) and obese (p=0.001) groups. After PAP treatment, decrease in HbA1c levels were significant in normal-weighted (p=0.008), obese (p=0.034), and diabetic (p=0.011) groups. There was no correlation with the change in HbA1c levels and age (p=0.212), BMI (p=0.322), AHI (p=0.098) or oxygen levels (p=0.122). Our study showed that treatment of OSAS by PAP therapy offers beneficial effect on glucose metabolism, not only in diabetic patients, but also in obese and normal-weighted OSAS patients. Although data regarding overall effects of PAP therapy on glycemic control present contradictory results in the literature, it should be emphasized that duration and adherence to PAP therapy were main determinants for beneficial outcome of treatment.

Impact of positive airway pressure therapy on pulmonary arterial pressures in obstructive sleep apnoea or obesity hypoventilation syndrome: a systematic review and meta-analysis.

Night-to-night variability of obstructive sleep apnea severity is considerable and may depend on the diagnostic modality used. We investigated the night-to-night variability using peripheral arterial tonometry (PAT). Home sleep apnea testing was performed in 51 patients during 3 consecutive nights using PAT. Patients referred to our sleep clinic were screened and prospectively recruited for this study. All recordings were automatically and manually scored according to the PAT scoring guidelines. No systematic differences in PAT-derived apnea-hypopnea index (pAHI) were found between the nights. The night-to-night variability was comparable between manually and automatically scored data. pAHI varied in 35% of patients more than 10 events/h between the nights. The obstructive sleep apnea severity of 24% of patients was misclassified when using 1 night compared to the average of all nights. On average, pAHI varied by 57% from night to night. The variability of pAHI could partially be explained by the variability of time spent in the supine position with more time supine leading to a higher pAHI. On measuring a subsequent night, 12-14% of patients spontaneously fulfilled the commonly accepted criteria for treatment success without any intervention. With repeated recordings of PAT, we found no first night effect. However, there is considerable night-to-night variability similar to values found for polysomnography, which can partially be explained by the variability of time spent in the supine position. Obstructive sleep apnea severity was frequently misclassified due to the night-to-night variability. Our findings make a strong case for multiple testing in the diagnostic work-up of obstructive sleep apnea patients. Tschopp S, Wimmer W, Caversaccio M, Borner U, Tschopp K. Night-to-night variability in obstructive sleep apnea using peripheral arterial tonometry: a case for multiple night testing. J Clin Sleep Med. 2021;17(9):1751-1758.

Objectives: Although rapid eye movement behavior disorder (RBD) and obstructive sleep apnea syndrome (OSA) have different pathophysiology, RBD patients with OSA appeared to have more stable sleep compared to patients with OSA and to verify it by cardiopulmonary coupling (CPC) method. Methods: The polysomnography (PSG) data of 138 subjects with OSA (AHI ≥ 15), RBD with OSA (AHI ≥ 15), RBD, normal control (N=32, 26, 29, 51, respectively) were collected. For conducting case control study between RBD with OSA and patients with OSA only, a total of 32 OSA controls, matched for age, AHI and BMI were recruited. CPC parameters were obtained using CPC analyzer in Rem Logic. Sleep spectrogram by CPC analyses revealed the percentage of stable tidal volume [high-frequency coupling (HFC), 0.1–0.4 Hz] and fluctuation tidal volume [lowfrequency coupling (LFC), 0.01 Hz to 0.1 Hz)] during sleep. Results: Although there was no significant Apnea-Hypopnea index (AHI) difference between RBD with OSA and OSA group (AHI 29.1 ± 15.6/hr vs. 34.1 ± 18.9, p=0.332), there was significant difference in CPC measurements. In RBD-OSA group showed lower LFC (35.9 ± 16.8 vs. 49.7 ± 21.3, p=0.010) than OSA group. Unlike higher AHI in RBD with OSA than RBD group (29.1 ± 15.6/hr vs. 3.2 ± 1.6, p<0.001), there was no significant difference in CPC study. Both OSA group and RBD with OSA group showed higher LFC (OSA vs. normal: 49.7 ± 21.3 vs. 28.4 ± 13.3, p<0.001, RBD with OSA vs. normal: 35.9 ± 16.8 vs. 28.4 ± 13.2 p=0.035) and lower HFC (OSA vs. normal: 37.5 ± 20.0 vs. 56.2 ± 16.2, p<0.001, RBD with OSA vs. normal: 46.8 ± 20.8 vs. 56.2 ± 16.2, p=0.031) when compared with normal control group, respectively. Conclusions: In terms of autonomic-respiratory interaction, RBD with OSA showed similar CPC profile (higher LFC and lower HFC than normal) to OSA group but less severe than pure OSA group. It suggests that RBD may have a protective effect on OSA.

Duration of positive airway pressure adherence: how much PAP is enough?

232 USE OF NASAL CANNULA COMPARED TO THERMISTOR IN CHILDREN WITH FACIAL SYNDROMES AND RELEVANCE OF END-TIDAL PCO2 EXPIRED

Validation of semiautomatic scoring of REM sleep without atonia in patients with RBD

Background: The initial phase of positive airway pressure (PAP) therapy in patients with obstructive sleep apnea (OSA) can significantly influence sleep and treatment compliance. Objective: To assess clinical sleep parameters using actigraphy, the Epworth Sleepiness Scale (ESS), and the Pittsburgh Sleep Quality Index (PSQI) in OSA patients comparing before and after a one-week PAP therapy period. Materials and Methods: The present study was a prospective observational study conducted at the Central Chest Institute of Thailand (CCIT). Adult OSA patients diagnosed using standard criteria following the International Classification of Sleep Disorders, third ed., text revision (ICSD-3-TR) and achieving optimal PAP titration from split-night polysomnography (PSG) were recruited. Participants wore actigraphy devices for one week before and after PAP therapy. Clinical sleep parameters, including time in bed (TIB), total sleep time (TST), sleep efficiency (SE), wake after sleep onset (WASO), the number of wake bouts (NWB), sleep latency (SL), ESS, and PSQI were collected and analyzed. Results: Twenty OSA patients participated in the present study. The majority were male at 55%, and 45% had comorbidities, including hypertension and dyslipidemia. The median age, body mass index (BMI), ESS, PSQI, apnea-hypopnea index (AHI), and nadir SpO₂ were 42.5 years, 27.9 kg/m², 10.5, 8, 37.8 events/hour, and 86%, respectively. Sleep assessment by actigraphy comparing before and after one week of PAP treatment revealed a significant reduction in NWB at 45.4 versus 37.6 events (p=0.002) and SL of 29.6 versus 19.4 minutes (p=0.017) after PAP therapy. Additionally, ESS was at 10.5 versus 7.5 (p=0.003) and PSQI at 8 versus 4 (p=0.001) scores improved significantly, days used PAP for four hours or more was 100% and achieving good PAP compliance in 80%. Conclusion: Short-term use of PAP therapy in newly treated severe OSA patients resulted in meaningful improvement in sleep continuity, daytime sleepiness, and sleep quality, within one week, with good PAP adherence.

ObjectiveCognitive impairment is a rapidly growing global public health problem in China and worldwide. In the recent decades, emerging studies have explored the associations between sleep disturbances and cognitive impairment. However, the variety of the results imply us that further studies should be conducted for the associations.MethodsThis is a cross-sectional study conducted between August and October 2018 in five cities in Hebei province, China. Subjects were 21,376 community residents. Cognitive impairment was screened by the Chinese version of the Mini-Mental State Examination (MMSE). Scales of Athens Insomnia Scale (AIS), Berlin Questionnaire (BQ), REM (rapid eye movement) Sleep Behavior Disorder Questionnaire (RBDQ-HK), Ullanlinna Narcolepsy Scale (CUNS), and Cambridge-Hopkins Restless Legs Syndrome Questionnaire (CH-RLSq) were used to access insomnia, sleep apnea, REM sleep behavior disorder, narcolepsy, and restless leg syndrome.ResultsThe mean ± SD (standard error) of MMSE, AIS, RBDQ-HK, and CUNS were 27.95 ± 4.79, 2.16 ± 3.39, 5.55 ± 7.75, and 3.76 ± 2.31, respectively. Among the participants, 10.6% and 1.5% of the participants were identified as having a high risk of sleep apnea and restless leg syndrome, respectively. The results of multiple linear regression showed that cognitive impairment was associated with insomnia (β = −0.037, p < 0.001) and narcolepsy (β = −0.023, p < 0.001). The association between sleep apnea (β = −0.002, p > 0.05), REM sleep behavior disorder (β = 0.006, p > 0.05), restless leg syndrome (β = −0.007, p > 0.05), and cognitive impairment were not supported. Other factors associated with cognitive impairment were gender, age, education level, married status, and region.ConclusionThis study provides some epidemiological evidence for the association between sleep disturbances and cognitive impairment among community residents in central China. In this study, the associations between insomnia, narcolepsy, and cognitive impairment were identified, but the associations between sleep apnea, REM sleep behavior disorder, narcolepsy, restless leg syndrome, and cognitive impairment were not supported among community residents.

The use of positive airway pressure (PAP) in children is a complex process determined by multiple factors. There are limited data on the response of the pediatric population to PAP therapy at home. The goal of the study was to examine real-world responses using PAP home monitoring in children with obstructive sleep apnea. The study included PAP therapy data for 195 children aged between 1 month and 18 years with obstructive sleep apnea and polysomnogram baseline study. We collected demographics, clinical variables, and polysomnogram parameters in all study participants. The individual response to PAP therapy was calculated comparing the apnea-hypopnea index (AHI) in the initial polysomnogram with the mean AHI provided by the download of PAP devices. Multivariate models (logistic regression) were used to examine the predictors of positive PAP response defined as a reduction in AHI ≥ 75%. We found excellent responses to PAP therapy in children (median 85% AHI reduction). However, there was substantial heterogeneity in AHI reductions while on PAP therapy. The best PAP responses were linked to more severe obstructive sleep apnea and higher PAP levels. We also identified that the response to PAP was higher in obese children and lower in males. The best predictive model for individual PAP response was biological sex, obesity, and obstructive AHI ≥ 20 events/h (area under the receiver operating characteristic curve of 0.791). Real-world data show that PAP is overall an effective therapy in children but the response is heterogeneous. Obstructive sleep apnea parameters and individual factors can be used to predict individual AHI reductions while on PAP and optimize PAP responses at home. Aguilar H, Kahanowitch R, Weiss M, etal. Real-world data evaluation of PAP responsiveness in pediatric obstructive sleep apnea. J Clin Sleep Med. 2023;19(7):1313-1319.

<b>Introduction:</b> Obstructive sleep apnea (OSA) is commonly found in patients with REM sleep behavior disorder (RBD). Both OSA and RBD can present with similar symptoms and are associated with REM sleep. <b>Objectives:</b> We aimed to compare the polysomnographic features between idiopathic RBD patients with OSA (RBD-OSA), RBD patients without OSA (RBD-non-OSA) and OSA without RBD (OSA-non-RBD) <b>Methods:</b> The polysomnographic data of 35 patients who visited Chungnam national university hospital sleep clinic because of abnormal behavior during sleep were analyzed retrospectively. We compared polysomnographic sleep architecture related parameters, sleep apnea related parameters among group. <b>Results:</b> Of the 35 patients (26 males and 9 females), 16 were RBD-OSA, 12 were RBD-non-OSA and 7 were OSA without RBD (OSA-non-RBD). In sleep architecture analysis, the proportion of stage N3 was higher in RBD-non-OSA than OSA-non-RBD. (27.07±5.90% vs 17.60±7.21%, P=0.040) In respiratory parameter analysis, our data showed that RBD-OSA had lower tendency of apnea-hypopnea index(AHI) (16.49±13.99 vs 23.29±15.61%, p=0.187) and oxygen desaturation index(ODI) (16.72±16.68 vs 24.75±14.21%, p=0.060) compared to OSA-non-RBD. Notably, nadir SpO2 was higher in RBD-OSA than OSA-non-RBD, which was statistically significant. (88.19±2.43% vs 83.00±4.73%, p=0.000) <b>Conclusion:</b> Our study suggests that RBD might reduce the severity of OSA.