Fenotipos clínicos en el síndrome de apnea obstructiva del sueño / Clinical phenotypes in obstructive sleep apnea

El síndrome de apnea e hipopnea obstructiva del sueño se caracteriza por episodios repetitivos de obstrucción de vía aérea superior y es reconocida cada vez más, como un trastorno heterogéneo y complejo, proponiéndose múltiples fenotipos en base a su mecanismo patogénico, alteraciones polisomnográficas y la presentación clínica. El fenotipo clínico se enfoca en identificar características de un paciente basándose en signos, síntomas, antropometría, comorbilidades, medidas fisiológicas, anatómicas o respuesta al tratamiento. Al ser una enfermedad sub diagnosticada, de alta prevalencia y que produce elevada morbi-mortalidad, se debe estar atento a la pesquisa precoz y en las poblaciones de riesgo. Su diagnóstico se basa en el índice de apnea-hipopnea (IAH) y se requiere un IAH •5 eventos/hora para confirmar el diagnóstico. Sin embargo, cada vez hay más evidencia que el IAH por sí solo es insuficiente para comprender la presentación clínica, respuesta al tratamiento, calidad de vida y mortalidad de los pacientes con apnea del sueño. El fenotipo clínico puede servir de este modo, para entender mejor las diferentes formas de presentación teniendo como finalidad la medicina personalizada con el objetivo de favorecer la conducta terapéutica individualizada. El objetivo de esta revisión es abordar los fenotipos clínicos y proponer una huella digital en los pacientes con apnea del sueño

Obstructive sleep apnea and hypopnea syndrome is characterized by repetitive episodes of upper airway obstruction and is increasingly recognized as a heterogeneous and complex disorder, proposing multiple phenotypes based on its pathogenic mechanism, polysomnographic alterations, and clinical presentation. The clinical phenotype focuses on identifying a patient's characteristics based on signs, symptoms, anthropometry, comorbidities, physiological, anatomical measures or response to treatment. As it is an underdiagnosed disease of high prevalence associated to high morbidity and mortality, we must be alert to early screening and risk populations. Diagnosis is based on the apnea-hypopnea index (AHI) AHI •5 events/hour is required to confirm it, however, there is increasing evidence that AHI alone is insufficient to understand the clinical presentation, the response to treatment, the quality of life and the mortality of patients with sleep apnea. In this way, the clinical phenotype can serve to better understand the different forms of presentation and looks for a personalized medicine that favors an individualized therapeutic behavior. The aim of this review is to address clinical phenotypes and propose a fingerprint in patients with sleep apnea

Journey towards a personalised medicine approach for OSA: Can a similar approach to adult OSA be applied to paediatric OSA?

The concept of personalised medicine is likely to revolutionise the treatment of adult obstructive sleep apnoea as a result of recent advances in the understanding of disease heterogeneity by identifying clinical phenotypes, pathophysiological endotypes, biomarkers and treatable traits. Children with the condition show a similar level of heterogeneity and paediatric obstructive sleep apnoea would also benefit from a more targeted approach to diagnosis and management. This review aims to summarise the adult literature on the phenotypes and endotypes of obstructive sleep apnoea and assess whether a similar approach may also be suitable to guide the development of new diagnostic and management approaches for paediatric obstructive sleep apnoea.

Oxidative stress does not contribute to the release of proinflammatory cytokines through activating the Nod-like receptor protein 3 inflammasome in patients with obstructive sleep apnoea.

PURPOSE: The study was conducted to test the hypothesis that oxidative stress leads to the release of proinflammatory cytokines by activating the Nod-like receptor protein (NLRP)3 inflammasome in patients with obstructive sleep apnoea (OSA). METHODS: The study recruited 247 participants who were divided into cases and healthy control groups. OSA patients were subdivided into four subgroups according to sex, blood pressure, body mass index (BMI), and severity of disease. No significant differences were found between cases and controls with respect to age or sex. Peripheral blood samples were collected for analysis after examination, and the serum concentrations of oxidative stress (8-isoprostane), inflammation (interleukin (IL)-18, IL-1ß, IL-6, tumour necrosis factor (TNF)-α), and NLRP3 inflammasome components (NLRP3, caspase-1, and ASC) were detected by enzyme-linked immunosorbent assay. RESULTS: The serum concentrations of both oxidative stress and proinflammatory factors were higher in OSA patients than healthy controls. Subgroup analysis also revealed significant differences according to the apnoea-hypopnea index and BMI. Additionally, correlations were identified between 8-isoprostane and proinflammatory factors (IL-1ß, IL-18, and TNF-α). Multiple regression analysis suggested that sleep parameters and BMI affected inflammation. However, no differences were observed in the serum level of NLRP3 inflammasome components between patients and controls. Furthermore, stratified analysis revealed no additional differences. CONCLUSIONS: The current study suggests that oxidative stress leads to inflammation by mechanisms other than activation of the NLRP3 inflammasome in OSA patients. Furthermore, both sleep apnoea and BMI influenced the serum concentration of inflammatory mediators.

Varying Hypopnea Definitions Affect Obstructive Sleep Apnea Severity Classification and Association With Cardiovascular Disease.

STUDY OBJECTIVES: To compare clinical features and cardiovascular risks in patients with obstructive sleep apnea (OSA) based on ≥ 3% desaturation or arousal, and ≥ 4% desaturation hypopnea criteria. METHODS: This is a cross-sectional analysis of 1,400 veterans who underwent polysomnography for suspected sleep-disordered breathing. Hypopneas were scored using ≥ 4% desaturation criteria per the American Academy of Sleep Medicine (AASM) 2007 guidelines, then re-scored using ≥ 3% desaturation or arousal criteria per AASM 2012 guidelines. The effect on OSA disease categorization by these two different definitions were compared and correlated with symptoms and cardiovascular associations using unadjusted and adjusted logistic regression. RESULTS: The application of the ≥ 3% desaturation or arousal definition of hypopnea captured an additional 175 OSA diagnoses (12.5%). This newly diagnosed OSA group (OSAnew) was symptomatic with daytime sleepiness similarly to those in whom OSA had been diagnosed based on ≥ 4% desaturation criteria (OSA4%). The OSAnew group was more obese and more likely to be male than those without OSA based on either criterion (No-OSA). However, the OSAnew group was younger, less obese, more likely female, and had a lesser smoking history compared to the OSA4% group. Those with any severity of OSA4% had an increased adjusted odds ratio for arrhythmias (odds ratio = 1.95 [95% confidence interval 1.37-2.78], P = .0155). The more inclusive hypopnea definition (ie, ≥ 3% desaturation or arousal) resulted in recategorization of OSA diagnosis and severity, and attenuated the increased odds ratio for arrhythmias observed in mild and moderate OSA4%. However, severe OSA based on ≥ 3% desaturation or arousals (OSA3%/Ar) remained a significant risk factor for arrhythmias. OSA based on any definition was not associated with ischemic heart disease or heart failure. CONCLUSIONS: The most current AASM criteria for hypopnea identify a unique group of patients who are sleepy, but who are not at increased risk for cardiovascular disease. Though the different hypopnea definitions result in recategorization of OSA severity, severe disease whether defined by ≥ 3% desaturation/arousals or ≥ 4% desaturation remains predictive of cardiac arrhythmias. COMMENTARY: A commentary on this article appears in this issue on page 1971.

Buccinator myomucosal flap for the treatment of velopharyngeal insufficiency in patients with cleft palate and/or lip / Buccinator myomucosal flap for the treatment of velopharyngeal insufficiency in patients with cleft palate and/or lip

Abstract Introduction: The interpretation of the speech results obtained with the buccinator myomucosal flap in the treatment of velopharyngeal insufficiency in patients with cleft palate has been limited by the restriction in the number of patients and the time of postoperative follow-up. Objective: To evaluate the effect of the buccinator myomucosal flap on speech hypernasality in the treatment of patients with cleft palate and velopharyngeal insufficiency. Methods: Patients with repaired cleft palate (± lip) who were submitted to surgical correction of velopharyngeal insufficiency using the bilateral buccinator myomucosal flap were assessed. Hypernasality (scores 0 [absent], 1 [mild], 2 [moderate], or 3 [severe]) was analyzed by three evaluators by measuring the audiovisual records collected in early and late preoperative and postoperative periods (3 and 12 months, respectively). The values were considered significant for a 95% Confidence Interval (p < 0.05). Results: Thirty-seven patients with cleft palate (± lip) showing moderate (16.2%) or severe (83.8%) hypernasality in the preoperative period were included. Analyses of the late postoperative period showed that hypernasality (0.5 ± 0.7) was significantly (p < 0.05) lower than the hypernasality of the preoperative and recent postoperative periods (2.8 ± 0.4 and 1.7 ± 0.9, respectively). Conclusion: The buccinator myomucosal flap is effective in reducing/eliminating hypernasality in patients with cleft palate (± lip) and velopharyngeal insufficiency.

Resumo: Introdução: A interpretação dos resultados de fala obtidos com o retalho miomucoso do músculo bucinador no tratamento da insuficiência velofaríngea em pacientes fissurados tem sido limitada pela restrição do número de pacientes e do tempo de seguimento pós-operatório. Objetivo: Avaliar o efeito do retalho miomucoso do músculo bucinador sobre a hipernasalidade da fala no tratamento de pacientes fissurados com insuficiência velofaríngea. Método: Foram avaliados pacientes com fissura palatina (± lábio) reparada, com retalho miomucoso do músculo bucinador bilateral para a correção cirúrgica da insuficiência velofaríngea. A hipernasalidade (escores 0 [ausente], 1 [leve], 2 [moderada] ou 3 [severa]) foi analisada por três avaliadores por meio da mensuração dos registros audiovisuais coletados nos períodos pré-operatório e pós-operatórios recente e tardio (3 e 12 meses, respectivamente). Os valores foram considerados significativos para um intervalo de confiança de 95% (p < 0,05). Resultado: Foram incluídos 37 pacientes fissurados com hipernasalidade moderada (16,2%) ou severa (83,8%) no período pré-operatório. As análises do período pós-operatório tardio revelaram que a hipernasalidade (0,5 ± 0,7) foi significativamente (p < 0,05) menor do que a hipernasalidade dos períodos pré-operatório e pós-operatório recente (2,8 ± 0,4 e 1,7 ± 0,9; respectivamente). Conclusão: O retalho miomucoso do músculo bucinador é eficaz na redução/eliminação da hipernasalidade nos pacientes fissurados com insuficiência velofaríngea.

Comparisons of measures used to screen for obstructive sleep apnea in patients referred to a sleep clinic.

STUDY OBJECTIVES: Obstructive Sleep Apnea (OSA) contributes to all-cause mortality. An American Academy of Sleep Medicine task force is focusing on improving detection and categorization of OSA symptoms and severity to promote screening, assessment, and diagnosis. The purpose of this study was to psychometrically compare measures used in OSA screening (Berlin, Epworth Sleepiness Scale (ESS), STOP Bang) and a portable sleep monitor (PSM) to apnea-hypopnea index (AHI) and levels from polysomnogram (PSG). METHODS: An observational, cross-sectional design was used. Patients referred to a sleep specialist were enrolled at initial sleep evaluation. Participants completed measures used in OSA screening, then sent home for one night using PSM. PSGs were ordered by the physician and AHI results were obtained from the medical record. RESULTS: Participants (N = 170) were enrolled in the study. Almost all participants completed the OSA measures, approximately half-completed PSM measurement, and the majority completed laboratory PSG. The STOP Bang had the highest levels of sensitivity; the ESS had the lowest. The ESS had the highest specificity and reliability levels; the STOP Bang had the lowest. The PSM measure had the highest positive predictive value (PPV) and the strongest psychometric properties of the screening measures. CONCLUSIONS: The STOP Bang was the preferred self-report OSA screening measure because of high levels of sensitivity. The ESS was the least desirable measure. PSM measurement consistently predicted the presence of OSA but at the expense of low sensitivity at AHI levels ≥30. This expands the knowledge of validity testing of screening measures used for OSA.

Obstructive Sleep Apnea and the Impact on Surgical Outcomes in Gynecology.

IMPORTANCE: Obstructive sleep apnea syndrome (OSAS) is a common medical condition in the United States and affects gynecologic surgical outcomes. OBJECTIVE: The aim of this review was to improve perioperative diagnosis and management of OSAS in patients presenting for gynecologic surgery and ultimately improve perioperative outcomes. The role of preoperative evaluation and screening is also addressed. EVIDENCE ACQUISITION: Medical databases were queried for publications pertaining to OSAS complications, risk factors, screening, and perioperative management. Pertinent articles were reviewed by the study authors. RESULTS: Obstructive sleep apnea syndrome is underdiagnosed in the preoperative surgical population. Obesity and other risk factors for OSAS are prevalent in patients with gynecologic issues but are not fully assessed with screening prior to surgery. Effective treatment modalities, such as continuous positive airway pressure, and perioperative management strategies are available to improve patient outcomes. CONCLUSIONS AND RELEVANCE: Increased diagnosis and treatment for OSAS in the perioperative period can improve perioperative outcomes, surgical outcomes, and long-term patient outcomes. Strategies to increase effective management in patients presenting for gynecologic surgery are needed.

Interobserver Consistency of Drug-Induced Sleep Endoscopy in Diagnosing Obstructive Sleep Apnea Using a VOTE Classification System.

OBJECTIVES: To explore the interobserver consistency of drug-induced sleep endoscopy (DISE) for patients with obstructive sleep apnea syndrome (OSAS) and review the current literature. METHODS: In total, 55 patients with an apnea-hypopnea index >5, as determined by on overnight sleep study, were included in this study, 45 males and 10 females, with an average age of 46.87 ±â€Š10.06 years old (range, 19-71). For all OSAS patients, DISE was performed by the same surgeon, which was recorded digitally. The video recordings of DISE were evaluated independently by 3 experienced surgeons who were asked to note his or her decisions as the pattern, site, and degree of upper airway collapse using a VOTE (velum, oropharynx lateral wall, tongue base, and the epiglottis) classification system. RESULTS: Interobserver consistency in the diagnosis of velum-related obstruction in anteroposterior, lateral, and concentric configurations ranged from poor to good. Only significant interobserver consistency among observers A and B was obtained in the diagnosis of oropharynx-related obstruction in the lateral configuration (concordance 60.0%, kappa: 0.365, P < 0.05). Interobserver consistency in the diagnosis of the tongue-related collapse in an anteroposterior configuration, the epiglottis-related collapse in an anteroposterior and lateral configuration ranged from fair to moderate (all kappa values >0.20, all P values < 0.05). CONCLUSION: Our data suggested that the interobserver consistency of DISE ranged from poor to good. Therefore, further studies with larger numbers of patients are needed to standardize DISE procedures, training, and interpretation.

Systematic Review of Drug-Induced Sleep Endoscopy Scoring Systems.

Objective To systematically review the scoring systems used to report findings during drug-induced sleep endoscopy (DISE) for adults and children with obstructive sleep apnea. Data Sources PubMed, CINAHL, EBM Reviews, Embase, and Scopus databases. Review Methods This is a systematic review of all indexed years of publications referring to scoring of DISE for children and adults with obstructive sleep apnea. The type of DISE scoring system utilized was the primary outcome. PRISMA guidelines were followed to carry out this review; articles were independently reviewed by 2 investigators. All pediatric and adult studies that utilized ≥1 DISE grading systems were included. Results Of 492 identified abstracts, 44 articles (combined population, N = 5784) were ultimately included; 6 reported on children, 35 on adults, and 1 on children and adults. Twenty-one reporting methods were used in these studies, with the most common being the VOTE system (velum, oropharynx, tongue base, and epiglottis; 38.6%) and the Pringle and Croft classification (15.9%). The sites of obstruction most commonly included in a scoring system were the tongue base (62%), lateral pharynx/oropharynx (57%), palate (57%), epiglottis/supraglottis (38%), and hypopharynx (38%). Less commonly included sites were the larynx (29%), velum (23%), nose (23%), tongue (14%), adenoids (10%), and nasopharynx (10%). Conclusion There is no consensus regarding which scoring system should be utilized to report findings during DISE. The VOTE system and the Pringle and Croft classification were the most frequent scoring systems reported for patients undergoing DISE. Standardization of the reporting of DISE findings would improve comparability among studies.

The Effect of Midface Advancement Surgery on Obstructive Sleep Apnoea in Syndromic Craniosynostosis.

BACKGROUND: Children with syndromic craniosynostosis frequently suffer from obstructive sleep apnoea (OSA). The aim of the authors' study was to investigate if midface advancement surgery for patients with SC improved the severity of OSA by examining the results of sleep studies before and after surgery. METHODS: A retrospective comparison of the pre and postoperative sleep study data of children undergoing midface advancement surgery at Great Ormond Street Hospital between 2007 and 2016. RESULTS: A total of 65 children underwent midface advancement surgery between 2007 and 2016 at Great Ormond Street Hospital and had recorded pre- and postoperative sleep studies. Thirteen patients were excluded from the analysis as their sleep study techniques before and after surgery were not comparable (e.g., different conditions with prong/continuous positive airway pressure use). Fifty-six percent of the patients were treated by monobloc surgery and the remainder with bipartition surgery. A greater proportion of patients had a normal OSA grading following midface advancement (42.3% postoperatively vs. 23.1% preoperatively, P = 0.059) although no statistically significant categorical changes in OSA grade were observed. Seventy-one percent of the patients had a decrease in Apnoea-Hypopnoea Index after surgery (21 patients 2011 onward). Similarly, there was no significant change in median oxygen desaturation index or in oxygen saturation nadir following surgery. CONCLUSION: The authors report one of the largest reviews of the effects of midface advancement surgery on sleep study parameters. Most patients showed improvements in Apnoea-Hypopnoea Index and OSA grading, although measures of oxygenation showed no consistent change.

Buccinator myomucosal flap for the treatment of velopharyngeal insufficiency in patients with cleft palate and/or lip.

INTRODUCTION: The interpretation of the speech results obtained with the buccinator myomucosal flap in the treatment of velopharyngeal insufficiency in patients with cleft palate has been limited by the restriction in the number of patients and the time of postoperative follow-up. OBJECTIVE: To evaluate the effect of the buccinator myomucosal flap on speech hypernasality in the treatment of patients with cleft palate and velopharyngeal insufficiency. METHODS: Patients with repaired cleft palate (± lip) who were submitted to surgical correction of velopharyngeal insufficiency using the bilateral buccinator myomucosal flap were assessed. Hypernasality (scores 0 [absent], 1 [mild], 2 [moderate], or 3 [severe]) was analyzed by three evaluators by measuring the audiovisual records collected in early and late preoperative and postoperative periods (3 and 12 months, respectively). The values were considered significant for a 95% Confidence Interval (p<0.05). RESULTS: Thirty-seven patients with cleft palate (± lip) showing moderate (16.2%) or severe (83.8%) hypernasality in the preoperative period were included. Analyses of the late postoperative period showed that hypernasality (0.5±0.7) was significantly (p<0.05) lower than the hypernasality of the preoperative and recent postoperative periods (2.8±0.4 and 1.7±0.9, respectively). CONCLUSION: The buccinator myomucosal flap is effective in reducing/eliminating hypernasality in patients with cleft palate (± lip) and velopharyngeal insufficiency.

Asociación entre índices antropométricos y presencia de apnea obstructiva del sueño en adultos / Association Between Anthropometric Indexes and Obstructive Sleep Apnea in Adults

Antecedentes: La apnea obstructiva del sueño (AOS) es un trastorno del sueño altamente prevalente producido por una obstrucción anatómica o neuromuscular de la vía aérea superior. Propósito: Identificar la asociación entre los índices antropométricos: circunferencia de cuello (CC), perímetro abdominal e índice de masa corporal (IMC), con la presencia de AOS en adultos. Métodos: Se realizó un estudio observacional retrospectivo de casos y controles en 353 individuos entre 18 y 82 años de edad con diagnóstico polisomnográfico de AOS. Se correlacionó el índice apnea hipoapnea con los índices antropométricos y los datos demográficos. El grupo control estuvo conformado por 105 adultos sin AOS y el de estudio por 248 pacientes con diagnóstico de AOS. Para determinar la asociación entre las variables se utilizaron las pruebas de Chi cuadrado de Pearson y odds ratio. Resultados Se encontró una asociación estadísticamente significativa entre el IMC y la CC, que estaban aumentados con la presencia de AOS en adultos. La presencia de AOS fue mayor en mujeres y hombres entre 56 y 82 años. Conclusiones: Las medidas antropométricas IMC y CC son factores de riesgo de AOS en adultos.

Background: Obstructive sleep apnea (OSA) is a highly prevalent sleep disorder caused by anatomic or neuromuscular obstructions. Purpose: To identify the association between anthropometric indexes: neck circumference (NC), abdominal perimeter, and Body Mass Index (BMI), and the presence of OSA in adults. Methods: A retrospective observational case-control study was carried out in 353 individuals between the ages of 18 and 82 years with a polysomnographic diagnosis of OSA. The Apnea-Hypopnea Index was correlated with the anthropometric indexes and demographic data. The control group consisted of 105 adults without OSA and the case group were 248 patients diagnosed with OSA. Pearson Chi-square and Odds Ratio (OR) tests were used for statistical analysis. Results: Statistically significant associations between increased BMI and NC with the presence of OSA in adults were found. The presence of OSA was greater in 56-to-82-year-old women and men. Conclusions: Anthropometric measures BMI and NC are OSA risk factors in adults.

Drug-induced sleep endoscopy in the obstructive sleep apnea: comparison between NOHL and VOTE classifications.

Obstructive sleep apnea (OSA) is characterized by recurrent episodes of partial or complete collapse of the pharynx that result in a decrease in oxyhemoglobin saturation. Nasofibrolaryngoscopy under induced sleep is a promising alternative for identifying sites of upper airway obstruction in patients with OSA. This study aimed to compare the obstruction sites screened by drug-induced sleep endoscopy (DISE) using the Nose oropharynx hypopharynx and larynx (NOHL) and Velum oropharynx tongue base epiglottis (VOTE) classifications. We also determined the relationship between OSA severity and the number of obstruction sites and compared the minimum SaO2 levels between DISE and polysomnography (PSG). This was a prospective study in 45 patients with moderate and severe OSA using DISE with target-controlled infusion of propofol bispectral index (BIS) monitoring. The retropalatal region was the most frequent obstruction site, followed by the retrolingual region. Forty-two percent of patients had obstruction in the epiglottis. Concentrically shaped obstructions were more prevalent in both ratings. The relationship between OSA severity and number of obstruction sites was significant for the VOTE classification. Similar minimum SaO2 values were observed in DISE and PSG. The VOTE classification was more comprehensive in the analysis of the epiglottis and pharynx by DISE and the relationship between OSA severity and number of affected sites was also established by VOTE. The use of BIS associated with DISE is a reliable tool for the assessment of OSA patients.

[The relationship between oxygen saturation and related respiratory events in patients with obstructive sleep apnea-hypopnea syndrome].

Objective:To explore the relationship between variation of hemoglobin saturation and related respiratory events in patients with obstructive sleep apnea and hypopnea syndrome (OSAHS).Method:According to the SaO2, the respiratory events were divided into two groups, followed or not followed the second events (SRE and N-SRE). Four features were extracted from SaO2 and compared within groups under SRE versus N-SRE, and comparisons were also developed between moderate patients and severe patients.Result:ΔSaO2, max, the duration and Dvmax was significantly higher in SRE than N-SRE (P< 0.01), while Nadir was significantly lower in SRE than N-SRE (P< 0.01). There was also significant difference in the blood oxygen index between moderate and severe patients. The change of SaO2 is correlated with the ventilation restoration. The results also suggest that the severity of the patient's condition will affect the change of SaO2 related indicators. Conclusion:This study provides information on the further study of ventilation restoration. Moreover, this study may provide a possible solution for the treatment of OSAHS.

Severity of individual obstruction events is gender dependent in sleep apnea.

PURPOSE: In obstructive sleep apnea (OSA), severity of individual obstruction events is connected to increased mortality rate and it can be significantly different in patients with similar apnea-hypopnea index (AHI). However, possible gender-dependent variation in severity of obstruction events in different OSA categories is unknown. We investigated whether the severity of obstruction events differs between genders with similar AHI and if this difference varies between OSA categories. METHODS: Polygraphic recordings of 2057 consecutive patients with suspected OSA were reanalyzed and those with AHI ≥5/h were included for further analysis (n male = 893 and n female = 197). Statistical significance of differences in AHI, apnea index, hypopnea index, oxygen desaturation index, obstruction severity parameter, and severity of individual obstruction events between genders were evaluated using the Mann-Whitney U (MWU) test as well as the general linear model (GLM) univariate analysis adjusted for age, BMI, smoking, daytime sleepiness, snoring, and heart failure. RESULTS: Apneas were 16.9 and 19.6% longer (MWU p ≤ 0.015, GLM p ≤ 0.036) and desaturation areas were 15.4 and 23.7% larger (MWU p ≤ 0.024, GLM p ≤ 0.053) in males compared to females with moderate and severe OSA, respectively. In contrast, hypopneas were 9.1% shorter (MWU p = 0.001, GLM p ≤ 0.001) and desaturation areas were 6.0% smaller (MWU p = 0.114, GLM p = 0.025) in men with mild OSA. The apnea index was 433.3 and 313.1% higher (MWU p ≤ 0.001, GLM p ≤ 0.043) and the hypopnea index was 12.2 and 17.8% lower (MWU p ≤ 0.001, GLM p = 0.002, p = 0.083) in males with mild and moderate OSA, respectively. CONCLUSION: As severity of individual obstruction events was significantly different in males and females, the overall severity of OSA may not be similar despite the similarity in AHI.

Screening for obstructive sleep apnea syndrome in patients with type 2 diabetes mellitus: a prospective study on sensitivity of Berlin and STOP-Bang questionnaires.

BACKGROUND: Obstructive sleep apnea (OSA) is highly prevalent in patients with Type 2 diabetes mellitus representing an additional risk factor for already increased cardiovascular mortality. As cardiovascular diseases are the main cause of death in this population, there is a need to identify patients with moderate to severe OSA indicated for treatment. We aimed to evaluate the performance of the Berlin, STOP, and STOP-Bang screening questionnaires in a population of patients with Type 2 diabetes mellitus. METHODS: 294 consecutive patients with Type 2 diabetes mellitus filled in the questionnaires and underwent overnight home sleep monitoring using a type IV sleep monitor. RESULTS: Severe, moderate, and mild OSA was found in 31 (10%), 61 (21%), and 121 (41%) patients, respectively. The questionnaires showed a similar sensitivity and specificity for AHI ≥ 15: 0.69 and 0.50 for Berlin, 0.65 and 0.49 for STOP, and 0.59 and 0.68 for STOP-Bang. However, the performance of the STOP-Bang questionnaire was different in men vs. women, sensitivity being 0.74 vs. 0.29 (p < 0.05) and specificity 0.56 vs. 0.82 (p < 0.05). CONCLUSIONS: Even the best-performing Berlin questionnaire failed to identify 31% of patients with moderate to severe OSA as being at high risk of OSA, thus preventing them from receiving a correct diagnosis and treatment. Considering that patients with Type 2 diabetes mellitus are at high risk of cardiovascular mortality and also have a high prevalence of moderate to severe OSA, we find screening based on the questionnaires suboptimal and suggest that OSA screening should be performed using home sleep monitoring devices.

The Effect of Upper Airway Surgery on Continuous Positive Airway Pressure Levels and Adherence: A Systematic Review and Meta-Analysis.

UNLABELLED: Background /Aims: The aim of this study was to determine the effect of upper airway surgery (UAS) on continuous positive airway pressure (CPAP). A secondary objective was to determine if a decrease in CPAP from UAS increases CPAP adherence. METHODS: Studies were eligible for inclusion if a CPAP titration was performed both prior and following UAS in patients with obstructive sleep apnea (OSA). Studies that compared adherence to CPAP before and after UAS were included to evaluate the secondary objective. RESULTS: A total of 11 articles involving 323 patients were included in the review. The results show that there was a mean reduction in CPAP of 1.40 cm H2O (95% CI -2.08 to -0.73). Four of the 11 papers, with a total of 80 patients, evaluated CPAP adherence and found a significant 0.62-hour improvement on average (95% CI 0.22-1.01). CONCLUSION: Due to high levels of nonadherence, surgical intervention will play a role even in patients who are unlikely to be fully cured by surgery. UAS decreases the apnea-hypopnea index and modestly reduces CPAP while improving CPAP adherence in the majority of patients. The evidence suggests that UAS may have an adjunctive role in the management of OSA.

Addressing the Retrolingual Space in Obstructive Sleep Apnea: Outcomes Stratified by Friedman Stage in Patients Undergoing Transoral Robotic Surgery.

BACKGROUND/AIMS: To stratify outcomes in patients with moderate to severe obstructive sleep apnea-hypopnea syndrome (OSAHS) undergoing transoral robotic surgery (TORS) ± multilevel procedures according to Friedman stage. METHODS: A total of 118 patients with moderate to severe OSAHS between 2010 and 2013 were stratified preoperatively by Friedman stage. All patients had TORS-assisted lingual tonsillectomy, either stand-alone or in combination with palatal surgery. Apnea-hypopnea index (AHI) was measured preoperatively and 3 months postoperatively. Success was defined as a decrease in AHI by 50% and AHI <20. RESULTS: The average pre- and postoperative AHI was 43.0 and 22.6, respectively, and the overall success rate was 63%. When stratifying by Friedman stage, success was seen in 75% of stage I, 70% of stage II, 66% of stage III, and 10% of stage IV patients. When stratifying by preoperative BMI, success was seen in 75% of stage II and 72% of stage III patients with BMI <30, compared to 58% of stage II and 56% of stage III patients with BMI >30. CONCLUSIONS: TORS-assisted lingual tonsillectomy ± multilevel procedures can be successful in treating patients with moderate to severe OSAHS with Friedman stage I-III anatomy. Success rates are even greater if patients are stratified according to preoperative BMI, as those with BMI <30 are more likely to achieve success even with Friedman stage II-III anatomy.

Impact of Perioperative Fluid Administration on Postoperative Morbidity and Length of Hospital Stay Following Maxillomandibular Advancement for Obstructive Sleep Apnea.

PURPOSE: The purpose of this study was to evaluate whether the volume of perioperative fluids administered to patients undergoing maxillomandibular advancement (MMA) for treatment of obstructive sleep apnea (OSA) is associated with an increased incidence of postoperative complications and prolonged length of hospital stay. MATERIALS AND METHODS: A retrospective cohort study design was implemented and patients undergoing MMA for OSA at the Mayo Clinic were identified from 2001 through 2014. The primary predictor variable was the total volume of intravenous fluids administered during MMA. The primary outcome variable was length of hospital stay in hours. Secondary outcome variables included the presence of complications incurred during postoperative hospitalization. Additional covariates abstracted included basic demographic data, preoperative body mass index, preoperative apnea-hypopnea index, preoperative Charlson comorbidity index, preoperative American Society of Anesthesiologists score, type of intravenous fluid administered, surgical complexity score, duration of anesthesia, duration of surgery, and the use of planned intensive care unit admission. Univariate and multivariable models were developed to assess associations between the primary predictor variable and covariates relative to the primary and secondary outcome variables. RESULTS: Eighty-eight patients undergoing MMA for OSA were identified. Total fluid volume was significantly associated with increased length of stay (odds ratio [OR] = 1.34, 95% confidence interval [CI], 1.05-1.71; P = .020) in univariate analysis. Total fluid volume did not remain significantly associated with increased length of hospital stay in stepwise multivariable modeling. Total fluid volume was significantly associated with the presence of postoperative complications (OR = 1.69; 95% CI, 1.08-2.63; P = .021) in univariate logistic regression. CONCLUSION: Fluid administration was not found to be significantly associated with increased length of hospital stay after MMA for OSA. Increased fluid administration might be associated with the presence of postoperative complications after MMA; however, future large multicenter studies will be required to more comprehensively assess this association.

The impact of obstructive sleep apnea on high-sensitivity C-reactive protein in subjects with or without metabolic syndrome.

BACKGROUND: It is unclear whether obstructive sleep apnea (OSA) is independently associated with increased levels of the acute-phase reactant C-reactive protein (CRP). The purpose of this study was to evaluate the relationship between OSA and high-sensitivity CRP (hs-CRP) levels according to the presence or absence of metabolic syndrome (MetS). METHODS: This study recruited 245 male bus drivers from one transportation company in Taiwan. Each participant was evaluated by a polysomnography (PSG) test, blood lipids examination, and hs-CRP. Severity of OSA was categorized according to the apnea-hypopnea index (AHI). RESULTS: Subjects were categorized into severe OSA group (n = 44; 17.9 %), moderate and mild OSA group (n = 117; 47.8 %), and non-OSA group (n = 84; 34.3 %). AHI had a significant association with hs-CRP (ß = 0.125, p = 0.009) adjusting for age, smoking, drinking, and MetS status. Hs-CRP was elevated with severe OSA (ß = 0.533, p = 0.005) even adjusting for BMI and MetS. Moreover, there was an independent effect for adjusted odds ratios (AORs) between the stratification of the severity for OSA and MetS. CONCLUSION: Elevated hs-CRP level is associated with severe OSA, independent of known confounders. The effect of OSA in CRP is independent of MetS was identified.