Positive airway pressure therapy for sleep-disordered breathing confers short-term benefits to patients with spinal cord injury despite widely ranging patterns of use.

STUDY DESIGN: Prospective, cohort study. OBJECTIVES: To evaluate the effectiveness of bi-level positive airway pressure (PAP) therapy and the patterns of use for sleep-disordered breathing (SDB) in individuals with spinal cord injury (SCI). SETTING: Academic tertiary care center, USA. METHODS: Overall, 91 adults with C1-T6 SCI for ≥3 months were recruited and 74 remained in the study to be evaluated for SDB and follow-up. Individuals with SDB but no nocturnal hypercapnia (NH) were prescribed auto-titrating PAP. Those with NH were prescribed PAP with volume-assured pressure support. Device downloads and overnight transcutaneous capnography were performed at 3, 6, and 12 months to quantify PAP use and effectiveness. Participants kept daily event logs, and quality of life (QOL) questionnaires were performed after 3, 6, and 12 months. RESULTS: Overall, 45% of 91 participants completed the study. There was great diversity among SCI patients in PAP utilization; after 3 months, 37.8% of participants used PAP for ≥70% nights and ≥240 min per night, whereas 42.2% seldom used PAP and 20% used PAP sporadically or for short periods. PAP therapy was effective in improving OSA in 89% and nocturnal hypercapnia in 77%. Higher PAP pressures predicted higher levels of device use. There were marked reductions in symptoms of autonomic dysreflexia (AD) and orthostatic hypotension as well as some improved indices of QOL. CONCLUSIONS: Despite widely diverse patterns of use, PAP therapy may have short-term benefits with regard to QOL and reducing episodes of dizziness and autonomic dysreflexia.

Simplified Approach to Diagnosing Sleep-Disordered Breathing and Nocturnal Hypercapnia in Individuals With Spinal Cord Injury.

OBJECTIVE: To evaluate a strategy of home-based testing to diagnose sleep-disordered breathing and nocturnal hypercapnia in individuals with spinal cord injury (SCI). DESIGN: Case series. SETTING: Referral center. PARTICIPANTS: Adults with C1-T6 SCI (N=81). Individuals were eligible if ≥ 18 years old, with SCI of ≥ 3 months' duration, living within 100 miles of the study site, and not meeting exclusion criteria. Of the 161 individuals recruited from the SCI Model System database who were not enrolled, reasons were not interested in participating, change of location, prior positive pressure ventilation use, or medical contraindication. Ten individuals did not complete the study. INTERVENTIONS: Performance of an unsupervised home sleep apnea test combined with transcutaneous partial pressure of carbon dioxide/oxygen saturation by pulse oximetry monitoring. MAIN OUTCOME MEASURES: Prevalence of sleep-disordered breathing and nocturnal hypercapnia. Clinical and physiological variables were examined to determine which, if any, correlate with the severity of sleep-disordered breathing. RESULTS: Obstructive sleep apnea (OSA) was found in 81.3% of individuals, central sleep apnea (CSA) was found in 23.8%, and nonspecific hypopnea events, where respiratory effort was too uncertain to classify, were present in 35%. Nonspecific hypopnea events correlated strongly with CSA but weakly with OSA, suggesting that conventional sleep apnea test scoring may underestimate central/neuromuscular hypopneas. Nocturnal hypercapnia was present in 28% and oxygen desaturation in 18.3%. Neck circumference was the primary predictor for OSA, whereas baclofen use and obstructive apnea/hypopnea index weakly predicted CSA. Awake transcutaneous partial pressure of carbon dioxide and CSA were only marginally associated with nocturnal hypercapnia. CONCLUSIONS: Unsupervised home sleep apnea testing with transcutaneous capnography effectively identifies sleep-disordered breathing and nocturnal hypercapnia in individuals with SCI.

Increasing access to evidence-based insomnia care in the United States: findings from an American Academy of Sleep Medicine stakeholder summit.

Challenges exist in access to high-quality care for insomnia disorder. After the recent publication of a clinical practice guideline on behavioral and psychological treatments for insomnia in adults, the American Academy of Sleep Medicine (AASM) hosted a 1-day virtual Insomnia Summit in September 2022 to discuss improving care for patients with insomnia disorder. Fifty participants representing a variety of organizations (eg, medical, psychological, and nursing associations; patient advocacy groups; and federal institutions) participated in the event. Videos highlighting patient perspectives on insomnia and an overview of current insomnia disorder treatment guidelines were followed by thematic sessions, each with 3 to 4 brief, topical presentations by content experts. Breakout groups were used to brainstorm and prioritize issues in each thematic area. Top barriers to care for insomnia disorder include limited access, limited awareness of treatment options, low perceived value of insomnia treatment, and an insufficient number of trained clinicians. Top facilitators of high-quality care include education and awareness, novel care models to increase access, expanding the insomnia patient care workforce, incorporating research into practice, and increasing reimbursement for psychotherapies. Priorities for the future include increasing awareness among patients and providers, increasing the number of skilled behavioral sleep medicine providers, increasing advocacy efforts to address insurance issues (eg, billing, reimbursement, and performance measures), and working collaboratively with multidisciplinary organizations to achieve common goals. These priorities highlight that goals set to improve accessible, high-quality care for insomnia disorder will require sustained, coordinated efforts to increase awareness, improve reimbursement, and grow the necessary skilled health care workforce. CITATION: Schotland H, Wickwire E, Aaronson RM, et al. Increasing access to evidence-based insomnia care in the United States: findings from an American Academy of Sleep Medicine stakeholder summit. J Clin Sleep Med. 2024;20(3):455-459.

African American race is associated with worse sleep quality in heavy smokers.

STUDY OBJECTIVES: To examine the association of self-identified race with sleep quality in heavy smokers. METHODS: We studied baseline data from 1965 non-Hispanic White and 462 African American participants from SPIROMICS with ≥ 20 pack-years smoking history. We first examined the Pittsburgh Sleep Quality Index's (PSQI) internal consistency and item-total correlation in a population with chronic obstructive pulmonary disease. We then used staged multivariable regression to investigate the association of race and sleep quality as measured by the PSQI) The first model included demographics, the second added measures of health status, and the third, indicators of socioeconomic status. We next explored the correlation between sleep quality with 6-minute walk distance and St. George's Respiratory Questionnaire score as chronic obstructive pulmonary disease-relevant outcomes. We tested for interactions between self-identified race and the most important determinants of sleep quality in our conceptual model. RESULTS: We found that the PSQI had good internal consistency and item-total correlation in our study population of heavy smokers with and without chronic obstructive pulmonary disease. African American race was associated with increased PSQI in univariable analysis and after adjustment for demographics, health status, and socioenvironmental exposures (P = .02; 0.44 95%CI: .06 to .83). Increased PSQI was associated with higher postbronchodilator forced expiratory volume in 1 second and lower household income, higher depressive symptoms, and female sex. We identified an interaction wherein depressive symptoms had a greater impact on PSQI score for non-Hispanic White than African American participants (P for interaction = .01). CONCLUSIONS: In heavy smokers, self-reported African American race is independently associated with worse sleep quality. CLINICAL TRIAL REGISTRATION: Registry: ClinicalTrials.gov; Name: Study of COPD Subgroups and Biomarkers (SPIROMICS); URL: https://clinicaltrials.gov/ct2/show/NCT01969344; Identifier: NCT01969344. CITATION: Baugh AD, Acho M, Arhin A, et al. African American race is associated with worse sleep quality in heavy smokers. J Clin Sleep Med. 2023;19(8):1523-1532.

Risk of COPD exacerbation is increased by poor sleep quality and modified by social adversity.

STUDY OBJECTIVES: Sleep is an important dimension in the care of chronic obstructive pulmonary disease (COPD), but its relevance to exacerbations is unclear. We wanted to assess whether sleep quality as measured by the Pittsburgh Sleep Quality Index (PSQI) is associated with an increased risk of COPD exacerbations and does this differ by socio-environmental exposures. METHODS: We included 1647 current and former smokers with spirometrically confirmed COPD from the SPIROMICS cohort. We assessed incidence rate ratios for exacerbation using zero-inflated negative binomial regression adjusting for demographics, medical comorbidities, and multiple metrics of disease severity, including respiratory medications, airflow obstruction, and symptom burden. Our final model adjusted for socio-environmental exposures using the Area Deprivation Index, a composite measure of contemporary neighborhood quality, and Adversity-Opportunity Index, a composite measure of individual-level historic and current socioeconomic indicators. We used a pre-determined threshold of 20% missingness to undertake multiple imputation by chained equations. As sensitivity analyses, we repeated models in those with complete data and after controlling for prior exacerbations. As an exploratory analysis, we considered an interaction between socio-environmental condition and sleep quality. RESULTS: After adjustment for all co-variates, increasing PSQI scores (range 0-21) were associated with a 5% increased risk for exacerbation per point (p = .001) in the imputed dataset. Sensitivity analyses using complete cases and after controlling for prior exacerbation history were similar. Exploratory analysis suggested less effect among those who lived in poor-quality neighborhoods (p-for-interaction = .035). CONCLUSIONS: Poor sleep quality may contribute to future exacerbations among patients with COPD. This represents one target for improving disease control. CLINICAL TRIAL REGISTRATION: Subpopulations and Intermediate Outcome Measures in COPD Study (SPIROMICS). ClinicalTrials.gov Identifier# NCT01969344. Registry URL: https://clinicaltrials.gov/ct2/show/.

Sleep disruption as a predictor of quality of life among patients in the subpopulations and intermediate outcome measures in COPD study (SPIROMICS).

Study Objectives: Sleep quality is poor among patients with chronic obstructive pulmonary disease (COPD), and studies show that sleep disturbance is associated with low overall quality of life in this population. We evaluated the impact of patient-reported sleep quality and sleep apnea risk on disease-specific and overall quality of life within patients with COPD enrolled in the SPIROMICS study, after accounting for demographics and COPD disease severity. Methods: Baseline data from 1341 participants [892 mild/moderate COPD (FEV1 ≥ 50% predicted); 449 severe COPD (FEV1 < 50%)] were used to perform three nested (blocks) regression models to predict quality of life (Short Form-12 mental and physical components and St. George's Respiratory Questionnaire). Dependent measures used for the nested regressions included the following: Block1: demographics and smoking history; Block 2: disease severity (forced expiratory volume 1 s; 6 min walk test); Block 3: risk for obstructive sleep apnea (OSA; Berlin questionnaire); and Block 4: sleep quality (Pittsburgh Sleep Quality Index [PSQI]). Results: Over half of participants with COPD reported poor sleep quality (Mean PSQI 6.4 ± 3.9; 50% with high risk score on the Berlin questionnaire). In all three nested regression models, sleep quality (Block 4) was a significant predictor of poor quality of life, over and above variables included in blocks 1-3. Conclusions: Poor sleep quality represents a potentially modifiable risk factor for poor quality of life in patients with COPD, over and above demographics and smoking history, disease severity, and risk for OSA. Improving sleep quality may be an important target for clinical interventions. Clinical Trial: SPIROMICS. Clinical Trial URL: http://www2.cscc.unc.edu/spiromics/. Clinical Trial Registration: ClinicalTrials.gov NCT01969344.

Development of a measure of knowledge and attitudes about obstructive sleep apnea in children (OSAKA-KIDS).

BACKGROUND: Primary care physicians play an important role in screening for childhood obstructive sleep apnea syndrome (OSAS) that, if untreated, can result in serious complications. OBJECTIVE: To describe the development of the Obstructive Sleep Apnea Knowledge and Attitudes in Children (OSAKA-KIDS) questionnaire for use in measuring physicians' knowledge and attitudes about childhood OSAS and its treatment. DESIGN: Cross-sectional survey to pilot administration of the 23-item OSAKA-KIDS questionnaire, mailed to 1195 community- and academic-based physicians in Louisville, Ky; Philadelphia, Pa; and St Louis, Mo. MAIN OUTCOME MEASURES: Analysis of variance measured differences in knowledge and attitudes between academic- and community-based physicians and between pediatricians and family practitioners. Using stepwise multiple linear regression, we analyzed the associations between various predictors (including specialty, practice setting, and years since medical school graduation) and each item of knowledge and attitudes. All tests were 2-tailed. RESULTS: Questionnaires for 497 respondents (44% female; mean [SD] age, 45.7 [10.5] years; and mean [SD] number of years since medical school graduation, 18.7 [11.0] years) were analyzed. The mean (SD) knowledge score (percentage of 18 possible) was 69.6% (14.6%). In regression analyses, more knowledge was associated with more positive attitudes overall and more recent graduation from medical school; having a more positive attitude was associated with having completed a pediatrics residency and more knowledge about OSAS. CONCLUSIONS: Deficits in basic knowledge about childhood OSAS were observed regardless of physician practice setting and specialty training. More education focusing on the diagnosis and treatment of childhood OSAS and identifying children at risk for OSAS is recommended.

Night-to-Night Variability in Sleep Disordered Breathing and the Utility of Esophageal Pressure Monitoring in Suspected Obstructive Sleep Apnea.

STUDY OBJECTIVE: Esophageal manometry (Pes) is the gold standard to detect repetitive episodes of increased respiratory effort followed by arousal (RERAs). Because RERAs are not included in the apnea-hypopnea index (AHI), we often refer patients with symptoms of sleep disordered breathing (SDB) and AHI < 5 for a second polysomnogram (PSG) with Pes. Often, the second PSG will demonstrate AHI > 5, confirming a diagnosis of OSA. We speculate that in most cases of suspected SDB, Pes does not add further diagnostic data and that night-to-night variability in OSA severity results in a first false-negative study. METHODS: We conducted a retrospective review of PSGs between 2008 and 2012 in adults with initial PSG negative for OSA followed by a second study (with or without Pes) within 6 mo. RESULTS: Of 125 studies that met inclusion criteria, a second study was completed with Pes in 105 subjects. SDB was diagnosed in 73 subjects (68.5%) completing a second PSG with Pes: 49 (46.7%) received a diagnosis based on AHI, and 24 (22.8%) received a diagnosis based on Pes (p = 0.003). There were no statistically significant differences in the mean AHI change between the two PSGs in subjects who completed the second study with or without Pes. CONCLUSIONS: In patients with symptoms of SDB and initial PSG with AHI < 5, the majority met criteria for OSA on second PSG by AHI without additional information added by Pes. Because Pes is not widely available and is somewhat invasive, a repeat study without Pes may be sufficient to diagnose SDB.

Development of the obstructive sleep apnea knowledge and attitudes (OSAKA) questionnaire.

STUDY OBJECTIVES: To develop and validate a questionnaire that assesses physicians' knowledge and attitudes about obstructive sleep apnea (OSA): the Obstructive Sleep Apnea Knowledge and Attitudes (OSAKA) questionnaire. DESIGN: Questionnaire study. SETTING: Physicians associated with the Washington University Physicians Network. PARTICIPANTS: Twenty physicians in the pilot testing and 115 physicians in the final testing of the instrument. INTERVENTIONS: Physicians completed the OSAKA questionnaire containing sections regarding knowledge about OSA (18 items), attitudes about OSA (five items), and demographics of the study participants. MEASUREMENTS AND RESULTS: Knowledge scores ranged from 0 to 18 (mean+/-SD=13.3+/-2.8). Individual knowledge items did not differ significantly by gender or by whether or not respondents had completed subspecialty training. The five attitude items were significantly correlated with one another. Knowledge scores correlated with the 5-item attitude scale. There was a negative correlation between age and knowledge (r=-0.368, P<0.001) and between age and the single attitude item pertaining to physicians' confidence in managing patients with OSA (r=-0.198, P=0.036); thus, the older the respondent, the lower the knowledge score and the less confident they were in managing patients with OSA. CONCLUSIONS: The OSAKA appears to be a useful instrument to measure physicians' knowledge about OSA, their views on its importance as a clinical disorder, and their confidence in identifying and managing patients with this disorder.