Sleep and Breathing

The use of mandibular advancement devices in obstructive sleep apnea: a proven and effective therapy

The use of mandibular advancement devices in obstructive sleep apnea: a proven and effective therapy

Sleep quality in survivors of critical illness: practical shortcomings unresolved

Long-term adherence to ambulatory initiated continuous positive airway pressure in non-syndromic OSA children Abstract Purpose In children, the usual indications for continuous positive airway pressure (CPAP) are residual OSA after adenotonsillectomy and/or persistent OSA due to obesity. Data concerning adherence (hours/night) following ambulatory CPAP initiation are scarce. Methods An observational cohort of 78 children was followed over 2 years. All exhibited sleep-disordered breathing (SDB) symptoms, were assessed by polysomnography, and prescribed CPAP. CPAP was initiated at hospital for 10 children. Results OSA children, mean age 10.4 ± 3.2 years, were mostly males (75.6%), with a mean body mass index of 21.2 ± 7.3 kg/m2, and mean apnea+hypopnea index of 12.2 ± 10.6 events/hour. Seventy-two children were still on CPAP at 3 months, 63 at 6 months, 55 at 1 year, and 34 at 2 years. CPAP was discontinued thanks to rehabilitation programs, dento-facial orthopedics, and/or weight loss. Mean CPAP adherence at 1, 3, 6, 12, and 24 months was respectively 6.1 ± 2.8, 6.2 ± 2.6, 6.2 ± 2.8, 6.3 ± 2.8, and 7.0 ± 2.7 h/night. There was a trend towards higher CPAP adherence and younger age, primary versus middle/high school attendance, higher baseline apnea+hypopnea index, and neurocognitive disorders. Conclusion In our population, mean CPAP adherence defined in hours per night was high and did not decrease during the 24-month follow-up. These findings support the feasibility of ambulatory CPAP initiation in non-syndromic OSA. The high CPAP adherence is expected to be associated with improvements in neurocognition, and in metabolic and cardiovascular parameters.

Sleep quality in survivors of critical illness: practical shortcomings resolved

Aortic root size is associated with nocturnal blood pressure in a population of hypertensive patients under treatment for obstructive sleep apnea Abstract Background Obstructive sleep apnea (OSA) is associated with an increased aortic root size. This association has never been studied in patients with hypertension undergoing continuous positive airway pressure (CPAP) treatment for OSA. Methods The 24-h blood pressure (BP) monitoring of 142 hypertensive patients undergoing CPAP treatment for OSA was prospectively documented. Aortic root diameter was assessed by echocardiography. Results The population included 33.8% women, with an overall mean age of 60.7 ± 10.5 years. The median body mass index was 32.7 [29. 5–36.3] kg/m2. The median treatment score was 3 [2–4] anti-hypertensive drugs per day. The median 24-h systolic and diastolic BP were 130 [120–144] and 74.5 [69–82] mmHg, respectively. The night-time systolic and diastolic BP were 119.5 [108–136] and 67 [61–74] mmHg, respectively. The mean diameter of the aorta at the level of the Valsalva sinuses was 34.9 ± 4.4 mm and 20.4 ± 2.3 mm/m when adjusted for height. Patients underwent ventilation for a median duration of 3.8 [1. 7–7.5] years, with a median night-time duration of 6.6 [5. 5–7.5] h per night. The median residual apnea-hypopnea index under ventilation was 2 [1–4] events per hour. A multivariate analysis showed that aortic root size was associated with male gender (p < 0.01) and nocturnal diastolic BP (p < 0.01). When normalized for height, aortic root diameter was positively associated with age (p < 0.01) and nocturnal diastolic BP (p < 0.01). Conclusion In OSA patients, the relationship between aortic root diameter and nocturnal BP persists on CPAP therapy. Further studies that evaluate the potential protective effect of OSA treatment on aortic root dilatation should monitor nocturnal diastolic BP.

Prevalence of newly established thyroid disorders in patients with moderate-to-severe obstructive sleep apnea syndrome Abstract Background Hypothyroidism can directly cause obstructive sleep apnea (OSA) but may also contribute to it through its impact on the metabolic syndrome. The purpose of this study was to establish the prevalence of known and newly diagnosed overt and subclinical hypothyroidism (SCH) among patients with OSA. Methods We prospectively included all consecutive moderate or severe OSA patients referred for CPAP therapy. A fasting blood sample was collected to determine thyroid-stimulating hormone (TSH) and free T4 (FT4) levels. Results A total of 280 patients were included (70% male). Mean ± SD body mass index (BMI) and apnea–hypopnea index (AHI) were 33 ± 7 kg/m2 and 49 ± 25, respectively. Median (range) serum TSH levels and mean ± SD FT4 levels were comparable between severe and moderate OSA (1.7 (1.3–2.6) vs 2.1 (1.2–2.8); p = 0.378 and 15.3 ± 2.3 vs 15.3 ± 2.3; p = 0.981). TSH and FT4 levels were not correlated with AHI (p = 0.297 and p = 0.370, respectively), but TSH was correlated with BMI (p = 0.049).Of all patients, 8.9% had increased serum TSH levels (severe and moderate OSA patients had similar levels (p = 0.711)) and 8.2% were newly diagnosed patients (no differences were observed between severe and moderate OSA (p = 0.450)). A total of 16.4% of patients had some type of thyroid disorder. Thyroid function parameters were associated with BMI but not with the severity of OSA. Conclusion In our population of moderate or severe OSA, 16% of patients had a thyroid problem and 8% of these were newly diagnosed with SCH.

Obstructive sleep apnea negatively impacts objectively measured physical activity Abstract Purpose Obesity and obstructive sleep apnea (OSA) are frequent comorbid conditions. The impact of OSA on objectively measured physical activity (PA), independent of obesity, is not clear. The purpose of this study is to examine the effect of OSA on PA measured via accelerometer. Methods Overweight-to-obese individuals were recruited and screened for the presence of OSA via portable diagnostic device and divided into an OSA (n = 35) and control group (n = 24). Daytime sleepiness was assessed with the Epworth Sleepiness Scale. Body composition was assessed with dual-energy X-ray absorptiometry. Subjects wore an accelerometer (Actigraph GT3X+, Actigraph Corp., Pensacola, FL) for a minimum of 4 and maximum of 7 days, including at least one weekend day. Results There were no group differences in body mass index (BMI) or daytime sleepiness. Waist and neck circumference were higher in the OSA group. The OSA group was significantly older than the control group. The OSA group had fewer steps, moderate intensity minutes, moderate-to-vigorous minutes, number of PA bouts per day (≥ moderate intensity PA for ≥ 10 consecutive minutes), and total number of PA bouts. When adjusted for age, the PA bout data was no longer significant. Conclusion Individuals screened as likely possessing OSA were less physically active than individuals without OSA when measured through objective means. We found no group differences in daytime sleepiness, BMI, or percent fat, suggesting other mechanisms than obesity and sleepiness for this difference.

Alterations of the brain network in idiopathic rapid eye movement sleep behavior disorder: structural connectivity analysis Abstract Purpose To evaluate and compare structural connectivity using graph theoretical analysis in patients with idiopathic rapid eye movement sleep behavior disorder (iRBD) and healthy subjects. Methods Ten consecutive patients with iRBD were recruited from a single tertiary hospital. All patients had normal brain magnetic resonance imaging results on visual inspection. They did not have any other neurological disorder. Control subjects were also enrolled. All subjects underwent three-dimensional volumetric T1-weighted imaging. Absolute structural volumes were calculated using FreeSurfer image analysis software. Structural volume and connectivity analyses were performed with Brain Analysis using Graph Theory. Results Compared to healthy controls, patients with iRBD showed significant alterations in cortical and subcortical volumes, showing increased volumes of frontal cortex, thalamus, and caudate nucleus. In addition, patients with iRBD exhibited significantly different structural connectivity compared to healthy controls. In measures of global network, average degree, global efficiency, and local efficiency were decreased whereas characteristic path length was increased in iRBD patients. In measures of local network, there was significant hub reorganization in patients with iRBD. Betweenness centrality of caudate nucleus and frontal cortex was increased in patients with iRBD. Conclusions This is the first study to report that structural volume and connectivity in patients with iRBD are significantly different from those in healthy controls. iRBD patients exhibited disrupted topological disorganization of the global brain network and hub reorganization. These alterations are implicated in the pathogenesis of iRBD. They might be potential biomarkers of iRBD.

Predictors of cognitive behavioral therapy outcomes for insomnia in veterans with post-traumatic stress disorder Abstract Background Insomnia is a well-recognized co-morbid condition in veterans with post-traumatic stress disorder (PTSD) with negative personal and social consequences. Cognitive behavioral therapy (CBT) is considered an efficacious treatment, yet little attention has been devoted to treatment response in this population. The aim of this study was to identify factors that may predict clinical response to CBT for insomnia (CBT-I) in veterans with PTSD. Methods A retrospective chart review of 136 veterans with PTSD-related insomnia was conducted. Epworth Sleepiness Score (ESS), PTSD Checklist (PCL), and Insomnia Severity Index (ISI) were assessed at baseline. We converted prescribed antidepressant and hypnotic dosages before and after CBT-I to dose equivalent of fluoxetine diazepam, respectively. A 6-point reduction or greater in ISI scores at 6-month follow-up visit was defined as CBT-I responsiveness. Results CBT-I responsiveness was observed in 47% of veterans with PTSD. Seventy-seven percent completed treatment. Lack of perceived benefit was the most given reason for failure to return for follow-up. In contrast to hypnotics, antidepressants usage decreased in those who had experienced benefit from CBT-I (p = 0.001). Younger age, non-white race, and use of hypnotics prior to behavioral therapy were independently associated with lack of response to CBT-I. Conclusions While CBT-I ameliorates insomnia in veterans with PTSD, the use of hypnotics prior to instituting behavioral therapy may negatively affect the response rate to CBT-I. Future studies should examine whether racial and cultural influences on the generation of insomnia in veterans with PTSD affects the response to CBT-I.