Obstructive Sleep Apnea.

Clinical Guidelines for the Use of Unattended Portable Monitors in the Diagnosis of Obstructive Sleep Apnea in Adult Patients

To examine the cross-sectional association between obstructive sleep apnea (OSA) risk and atrial fibrillation (AF) in the REasons for Geographic And Racial Differences in Stroke (REGARDS), a cohort of black and white adults. Using REGARDS data from subjects recruited between 2003-2007, we assessed 20,351 participants for OSA status. High OSA risk was determined if the participant met at least two criteria from the Berlin Sleep Questionnaire (persistent snoring, frequent sleepiness, high blood pressure, or obesity). AF was defined as a self-reported history of a previous physician diagnosis or presence of AF on electrocardiogram. Logistic regression was used to determine odds ratio and 95% confidence interval for the association between OSA status and AF with subgroup analysis to examine effect modification by age, race, sex, and geographical region. The prevalence of AF was 7% (n = 1,079/14,992) and 9% (n = 482/5,359) in participants at low and high risk of OSA, respectively (P < .0001). Persons at high risk of OSA had greater prevalence of diabetes and stroke history, and were more likely to be obese and taking sleep medications. In a multivariable analysis adjusted for demographics, cardiovascular risk factors, and potential confounders, high risk for OSA was associated with an increased odds of AF compared to low risk for OSA (odds ratio = 1.27, 95% confidence interval = 1.13, 1.44). This association differed significantly only by race (P for interaction = .0003). For blacks, there was a significant 58% increase in odds of AF in participants at high risk versus low risk of OSA, compared to a nonsignificant 12% increase in odds in whites. We were limited by self-reported variables, inability to adjust for obesity, and the cross-sectional nature of our study. High risk of OSA is associated with prevalent AF among blacks but not whites. A commentary on this article appears in this issue on page 1459.

Background: Prevalence of obstructive sleep apnea (OSA) in hypertrophic cardiomyopathy (HCM) is estimated between 32% and 71%. Individuals with HCM and OSA have increased blood pressure, BMI, , ascending aorta size, left atrial size, left ventricular end diastolic diameter, E/e’ ratio, atrial fibrillation rates and NYHA functional class. It has been suggested that treatment of OSA can decrease the need for septal reduction. However, studies have found no effect of OSA on septal thickness or outflow gradient. It is not known how OSA affects exercise performance or cardiac remodeling assessed by MR. Genetic propensity toward OSA in HCM has not been reported. We propose that OSA predicts decrease exercise tolerance and that cardiac remodeling could be identified using MR. We sought to report on HCM genotype in OSA as well as compare our clinical and echo data with other investigators. Methods: Subjects were identified through our institution’s HCM database. They were surveyed using the STOP-BANG (SB) questionnaire, a validated questionnaire to identify individuals at high risk for OSA. We stratified patients into high risk (HR) and low risk (LR) groups, based on a cut point of greater than or equal to 3 on SB. Demographics and clinical characteristics were extracted from our database. Prevalence and means were compared between the two groups, using Chi-square and t-tests. Differences between the groups were adjusted for age, sex, and BMI using linear mixed models for continuous measures and logistic regression for dichotomous measures. Results: There were 206 respondents, of those 160 (78%) scored high risk for OSA, 60 of which had a history of polysomnogram (PSG) confirming OSA. Having a HR vs. LR SB was associated with a significantly greater likelihood of stroke, CHF hospitalization, NYHA functional class &gt;2, reduced peak VO2, reduced anaerobic threshold and increased LA diameter. Adjusted comparisons for age, gender, and BMI showed that had significantly higher PAWP and LV mass index. Of those with a prior diagnosis of OSA we compared therapy compliant and non-compliant individuals and found they differed on LV mass index (HR=98.7 g/m2 vs. LR=62.0 g/m2, p=0.01). Conclusions: OSA occurs frequently in HCM and is associated with decreased exercise tolerance, worse hemodynamics, poor outcome as well as increased LV mass, which may be attenuated by therapy. OSA is an important and modifiable risk factor in HCM. Prospective evaluation utilizing PSG based diagnosis and positive pressure therapy is warranted.

ObjectivesTo study the prevalence of high-risk obstructive sleep apnea (OSA) in attention deficit hyperactivity disorder (ADHD) children in a child and adolescent psychiatry clinic using the Thai version of the Pediatric Obstructive Sleep Apnea Screening Tool (POSAST) questionnaire. The secondary objective was to evaluate the quality of life and identify associated factors for high-risk OSA in ADHD children.Study designProspective cross-sectional study.Material and methodCaregivers of pediatric patients aged 5–18 years old and diagnosed with ADHD by child and adolescent psychiatrists were surveyed about their child's sleeping habits.ResultsTwo hundred and seventy-four subjects were included. The patients' mean age was 10.4 ± 2.6 years, and 82.8% were males. There were 30 children (10.9%) diagnosed with obesity, 46 (16.8%) with chronic rhinitis, and 9 (3.3%) with asthma. The median duration of ADHD symptoms was 22.1 months. The prevalence of high-risk OSA was 18.2% and was associated with significantly reduced quality of life (adjusted OR = 4.46, 95% CI: 2.26–8.81, P < 0.001). A significant association between high-risk OSA and obesity also emerged (adjusted OR = 2.84, 95% CI: 1.17–6.88, P = 0.021).ConclusionAn elevated prevalence of high-risk OSA is present among Thai children with ADHD, and significantly impacts quality of life. A significant association between high-risk OSA and obesity is also detected in patients with ADHD. Therefore, screening for high-risk OSA in ADHD patients may likely facilitate early detection and treatment of OSA, and potentially prevent adverse consequences.

Background: Recent studies have found a high prevalence of obstructive sleep apnea (OSA) among responders of the World Trade Center (WTC) disaster. Exposure to particulate matter (PM) causing upper airway inflammation is considered a significant contributing factor in the pathogenesis of OSA. The Berlin Questionnaire (BQ) is a widely used questionnaire to screen for OSA with published sensitivity up to 86% and specificity of 87% for OSA risk. We aim to investigate whether a relationship exists between OSA risk using the BQ and exposure to PM using the Wisnevsky exposure score. Methodology: We evaluated 808 participants in the WTC-CHEST Program from January 2011 to September 2013. High risk for OSA was identified as 2 or more positive categories in the BQ. The subjects were categorized into four exposure groups: very high, high, intermediate and low (Wisnevsky exposure score). Chi-square and Binary Logistic Regression analyses were performed to determine if there was a significant relationship between OSA risk and PM exposure. Results: High risk for OSA is associated with PM exposure in the study population (p=0.002). Using a binary logistic regression adjusting for gender and age, high risk for OSA was still found to be significantly associated with PM exposure (p = 0.022). Conclusion: Prior investigations have demonstrated a link between PM exposure and pulmonary disease, digestive disorders and PTSD. These results provide strong evidence for the association of PM exposure and OSA. In fact, PM exposure in this cohort of WTC first responders is one of the most significant contributors to increased OSA risk. Assessment of both OSA risk and exposure to PM are important as both have been linked to an increase in cardiovascular risk.

World Trade Center (WTC)-exposed rescue/recovery workers continue to have high rates of gastroesophageal reflux disease (GERD), chronic rhinosinusitis, and posttraumatic stress disorder (PTSD) symptoms. This study examines the relationship between these WTC-related conditions and being at high risk for obstructive sleep apnea (OSA). The Fire Department of the City of New York (FDNY) performs periodic health evaluations on FDNY members every 12 to 18 months. Evaluations consist of physician examinations and self-administered health questionnaires, which, since 2005, have incorporated questions about sleep problems that were adapted from the Berlin Questionnaire. The study population consisted of 11,701 male firefighters and emergency medical service personnel. Incidence analyses were limited to a cohort (n = 4,576) who did not meet the criterion for being at high risk for OSA at baseline (between September 12, 2005 and September 8, 2006) and had at least one follow-up assessment, on average, 1.4 (±0.5) years later. The baseline prevalence of high risk for OSA was 36.5%. By follow-up, 16.9% of those not at high risk initially became at high risk for OSA. In multivariable logistic regression models predicting incident high risk for OSA, independent predictors included: earlier time of arrival at the WTC site, GERD, chronic rhinosinusitis, PTSD symptoms, self-assessed fair/poor health, low body mass index (BMI < 18.5 kg/m(2)), and, as expected, BMI > 30 kg/m(2) and weight gain of ≥10 lb (4.5 kg). We found significant associations between being at high risk for OSA and common WTC-related conditions, although the responsible causative mechanisms remain unknown. Since the etiology of OSA is likely multifactorial, improvement may require successful treatment of both OSA and its comorbid conditions.

Metabolic Syndrome, Obstructive Sleep Apnea, and Continuous Positive Airway Pressure: A Weighty Issue

Objective: To test the hypothesis that risk status for obstructive sleep apnea (OSA) is associated with time of onset in intracerebral hemorrhage. Background: OSA can affect 30-70% of patients with ischemic strokes, intracerebral hemorrhage and transient ischemic attacks. In normal sleep, blood pressure and heart rate decrease due to increased parasympathetic activity. In OSA, increased sympathetic activity during sleep can lead to a absence of this blood pressure fall. This non-dipping nocturnal blood pressure pattern has been associated with a shift in the timing of sudden cardiac death, from 7am-noon in those without OSA to 12am-6am in those with OSA. Whether this diurnal shift exists in intracerebral hemorrhage cases at high risk for OSA has not been studied. Method: A nested case control study within the interviewed case cohort from the Ethnic/Racial Variations of Intracerebral Hemorrhage (ERICH) study was performed. OSA risk status was categorized as “high-risk” based on a positive score in 2 out of 3 categories on the Berlin questionnaire, which ascertains snoring, daytime fatigue, body mass index and hypertension. Timing of intracerebral hemorrhage was categorized as “Nocturnal” based on a known time of stroke onset from 22:00pm to 06:00am and “Awake” based on a known time of stroke onset from 06:01am to 21:59pm. Results: Time of stroke onset was known in 434 subjects. The Berlin questionnaire categorized 54.2% of cases as high-risk for OSA. In comparison with low-risk subjects, high-risk cases tended to be younger (59.1±13.7 vs. 61.8±15.7, p=0.05), male (48% vs 58%, p=0.03), have coronary disease (6% vs 11%, p=0.09), have diabetes (27% vs 18%, p=0.02), and have dyslipidemia (43% vs 30%, p=0.006). There were no ethnic differences in the prevalence of high risk for OSA (P=0.60). Nocturnal strokes were seen in 17% of high- and low-risk OSA cases. There was no statistically significant difference in OSA status and timing of stroke (p=0.98). Conclusions: OSA risk status was not associated with timing of hemorrhagic stroke. This finding suggests that a non-dipping nocturnal blood pressure pattern is not seen in intracerebral hemorrhage cases at high-risk for OSA.

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).

Sedation during endoscopy for patients at risk of obstructive sleep apnea

Introduction Racial and ethnic disparities exist in the prevalence of obstructive sleep apnea (OSA); however, research on racial and ethnic differences in the diagnosis and treatment of OSA in older populations is limited. We examined whether the likelihood of being undiagnosed or untreated for OSA differed by race/ethnicity among middle-aged and older adults with probable OSA or self-reported OSA diagnosis. Methods Data came from the 2016 wave of the Health and Retirement Study (HRS), a nationally representative study of middle-aged and older adults in the United States. We categorized participants as: “probable OSA” based on a modified STOP-Bang measure; self-reported diagnosis of OSA; or self-reported OSA treatment (i.e., CPAP, oral appliance, surgery). We further classified participants as probable-undiagnosed OSA, diagnosed-untreated OSA, or diagnosed-treated OSA. Participants without a self-reported diagnosis who had a total score of ≥4 on the modified STOP-Bang measure or who had a score ≥3 and endorsed 2 items from the STOP portion of the scale were considered probable-undiagnosed OSA. Results Among 5,007 participants (mean 63.5 ± 9.16 years; 46.2% female), 39% of non-Hispanic White (NHW), 53% of non-Hispanic Black (NHB), and 66% of Hispanic participants had undiagnosed OSA. After adjustment for factors related to demographics, health, and insurance, compared to NHWs, NHBs had 42% higher odds of probable-undiagnosed OSA (AOR=1.42, 95% CI [1.15, 1.74], p&amp;lt; 0.001) and Hispanics had 95% higher odds of probable-undiagnosed OSA (AOR=1.95, 95% CI [1.50, 2.54], p&amp;lt; 0.001). Among those reporting OSA diagnosis, compared to NHWs, Hispanic participants had 50% higher odds of being untreated (AOR=1.50, 95% CI [1.02, 2.19], p=0.038); odds of treatment did not differ between NHBs and NHWs. Conclusion Among middle-aged and older adults, Hispanics are markedly more likely to be undiagnosed than NHWs and NHBs. Moreover, when diagnosed, Hispanics are the most likely to be untreated. If replicated, these findings indicate a critical sleep health disparity. Support (if any) This work was supported by the National Institute on Aging (R01AG079391, K01AG061239).

Objectives. We determined the prevalence of patients at risk for obstructive sleep apnea (OSA) with uncontrolled type 2 diabetes mellitus (T2DM) at the out-patient department (OPD) of the University of the Philippines-Philippine General Hospital (UP-PGH) from December 1, 2018 - February 28, 2019. We described the demographic characteristics of patients with uncontrolled T2DM and compared them with high and low OSA risk, its association, and correlation with the quality of sleep.&#x0D; Methods. This is a prospective cross-sectional study among uncontrolled T2DM. The questionnaires were Berlin Questionnaire (screen OSA-HR) and Epworth Sleepiness Score (level of sleepiness). Clinicodemographic profile and significant laboratory data were obtained. Descriptive statistics utilized. Chi-square test was used to compare categorical variables between patients with high vs low OSA risk and to determine if an association exists between OSA-HR and sleep quality.&#x0D; Results. A total of 240 participants, 88 males and 151 females, were included in the study. The overall prevalence of OSA-HR among patients with uncontrolled type 2DM is 58.33%. The majority of the OSA–HR patients (105 /140) was 46 years old and above. There is a significant association of tonsillar grade, Mallampati score, BMI, HbA1c, hypercholesterolonemia, and Epworth sleepiness on OSA High risk. There is also a substantial association with age, BMI, Mallampati score, tonsillar grade, hypertension, asthma, HbA1c, and hypercholesterelonemia on the level of sleepiness of OSA-HR.&#x0D; Conclusion. There is a high prevalence of high OSA-risk among patients with uncontrolled DM. Factors associated with high OSA-risk among uncontrolled diabetes mellitus include HbA1c, dyslipidemia, BMI, Mallampati score, tonsillar grade, and Epworth score.

Racial/ethnic differences have been documented in the relationship between obstructive sleep apnea (OSA) and stroke incidence, yet racial differences in OSA symptoms or treatment and their relationship with stroke incidence are underexplored and may contribute to stroke disparities. We comprehensively examined OSA symptoms and their relationships to stroke incidence by race/ethnicity. Data were collected from the REasons for Geographic and Racial Differences in Stroke (REGARDS) study, a population-based cohort of Black and White individuals in the United States. Participants free from a stroke diagnosis at baseline were included. Participants self-reported the following: (1) snoring; (2) daytime sleepiness; (3) provider-diagnosed sleep apnea (PDSA); and (4) treatment for PDSA using positive airway pressure (PAP). OSA risk was categorized as high or low based on the Berlin Sleep Questionnaire. Incident stroke was defined as first occurrence of stroke over an average of 12 (SD 3.9) years of follow-up. We report the relationships between snoring, OSA risk, PDSA, PAP therapy use, and incident stroke by race/ethnicity using Cox proportional hazards models after adjusting for demographic and socioeconomic factors and stroke risk factors. Among the 22,192 participants (mean age [SD] 64.2[9.1] years), 38.1% identified as Black. Overall, snoring was not associated with incident stroke (hazard ratio [HR] 0.98, 95% CI 0.85-1.13). However, among White individuals but not Black individuals, high OSA risk and PDSA were associated with incident stroke (HR 1.22, 95% CI 1.01-1.47; HR 1.33, 95% CI 1.04-1.70, respectively). PAP therapy use among those with PDSA (compared with non-PDSA) was associated with incident stroke in White individuals (HR 1.38, 95% CI 1.05-1.80). PAP therapy use among those with PDSA (compared with those with PDSA without PAP therapy use) was associated with reduced risk of incident stroke in Black (HR 0.39, 95% CI 0.17-0.91) but not White (HR 0.63, 95% CI 0.37-1.10) individuals. White individuals with high OSA risk and those with PDSA with or without PAP therapy use were at increased incident stroke risk, whereas Black individuals reporting PDSA and PAP had reduced incident stroke risk relative to those not using PAP. Future research is needed to understand the mechanisms underlying racial differences in OSA and stroke such as differences in assessment modes and treatment.

To estimate the rate of obstructive sleep apnea (OSA) and associated factors among Lebanese adults. A cross-sectional study was conducted in February-April 2022; 1,202 Lebanese adults were enrolled. The sample was collected among several Lebanese governorates through an anonymous online self-reported questionnaire. The STOP-BANG questionnaire was used as a screening tool to estimate the OSA risk. "Low OSA risk" is established with 0-2 positive answers, "Intermediate OSA risk" is established by 3-4 positive answers while "High OSA risk" is established by 5-8 positive answers. This study showed that 743 (62.4%) of the sample had low risk for OSA, 357 (30.0%) had moderate, and 90 (7.6%) had high risk for OSA. Older age (aOR = 1.05) and having hypertension (aOR = 7.80) were associated with higher odds of moderate OSA. Female sex (aOR = 0.04) was significantly associated with lower odds of moderate OSA compared to males. Older age (OR = 1.17), higher BMI (OR = 1.14), hypertension (OR = 18.55), and having severe COVID-19 infection compared to mild (OR = 4.30) were significantly associated with higher odds of high OSA, whereas female sex (OR = 0.002) and being married compared to single (aOR = 0.23) were associated with lower odds of high OSA. This study showed that most Lebanese adults have low risk for OSA. It also confirmed that sex, age, obesity, hypertension, and severe COVID-19 were associated with high OSA risk. These associated factors call for future research exploring the causes including the potential effect of social, economic, and political instability, local customs, and environmental factors. Moreover, future health campaigns should be assigned to increase awareness among Lebanese population regarding the prevention of OSA through lifestyle modifications.

From Resistant Airway to Resistant Hypertension.