Effects of mandibular advancement devices on the evolution of obstructive sleep apnea.

PURPOSE: Mandibular advancement devices (MADs) are a treatment for obstructive sleep apnea (OSA). Titration is a necessary component of proper fitting of MADs, yet little is known about what happens at each step of the titration. The objectives of this study were to determine the clinical and paraclinical evolution of OSA at every mm of MAD advancement. METHODS: Volunteers were fitted with MADs set to 50% of maximum advancement. MAD clinical and paraclinical results were recorded at every additional mm-titration, including apnea-hypopnea index (AHI), as well as symptoms of sleepiness and fatigue. RESULTS: In 20 volunteers with OSA, the MAD had a significant effect on every polygraphic parameter at the onset of use. The mean AHI with MAD fell by 15.2/h (p < 0.001). The mean Epworth Sleepiness Score and Pichot Fatigue questionnaire with MAD fell by 2.0 (p = 0.0687) and 2.4 (p = 0.1073) respectively. There was no proportionality between clinical gains (drowsiness and fatigue) and AHI improvements. CONCLUSIONS: MADs led to a significant improvement in AHI and other polygraphic parameters from the onset of use. The decrease of clinical symptoms (drowsiness and fatigue) was more complex to interpret because of the small decreases observed. The absence of concordance between AHI improvement and clinical symptoms was nevertheless objectively quantified and symptoms were alleviated with advancements. The findings suggest that it may be appropriate to use clinical symptoms as a main aim of titration, since the improvement in AHI is reached at the onset of MAD use.

Effect of CPAP vs. mandibular advancement device for excessive daytime sleepiness, fatigue, mood, sustained attention, and quality of life in patients with mild OSA.

OBJECTIVE: This study's objective was to compare the best long-term treatment, mandibular advancement device (MAD) or continuous positive airway pressure (CPAP), for patients with mild obstructive sleep apnea (OSA) in improving excessive daytime sleepiness, fatigue, mood, sustained attention, and quality of life. METHODS: This study was a single-blind, parallel, randomized clinical trial with controls. The sample was composed of individuals between 18 and 65 years of age with a body mass index of < 35 kg/m2 and apnea/hypopnea index above five and less than 15. Participants were submitted to physical examination, polysomnography, and the following questionnaires: Pittsburgh Sleep Quality Index, Berlin Questionnaire, Epworth Sleepiness Scale, Stanford Sleepiness Scale, Karolinska Sleepiness Scale, Modified Fatigue Impact Scale, Functional Outcomes of Sleep Questionnaire, Beck Anxiety Inventory, and Beck Depression Inventory. They were also presented with the following tests: maintenance of wakefulness test and psychomotor vigilance task. RESULTS: Of 79 patients, 25 were in the MAD group, 31 in the CPAP group, and 23 in the control group. Polysomnographic parameters were best normalized with CPAP compared with MAD. Fatigue was improved in the MAD and CPAP groups, with no difference between these treatments. Quality of life was also improved with both treatments, but CPAP was superior to MAD. Daytime sleepiness, mood, and sustained attention showed no difference with the interventions. Greater adherence was obtained with MAD patients than with CPAP measured by hours of use. CONCLUSIONS: Treatment with CPAP was better at normalizing polysomnographic parameters and improving quality of life in patients with mild OSA. Both treatments improved fatigue with no difference between the two treatments. Neither treatment improved daytime sleepiness, mood or sustained attention. CLINICAL TRIALS DATABASE: NTC01461486.

Residual sleepiness in veterans with post-traumatic stress disorder and obstructive sleep apnea.

PURPOSE: The causes of residual excessive sleepiness (RES) in patients with post-traumatic stress disorder (PTSD) and obstructive sleep apnea (OSA) are multifactorial and modulated by comorbid conditions. The aim of the present study was to elucidate clinical and polysomnographic determinants of RES in continuous positive airway pressure (CPAP)-adherent OSA veterans with PTSD. METHODS: The study protocol consisted of a retrospective analysis of consecutive cases of patients with PTSD who presented to the Veterans Affairs sleep clinics with adequately treated OSA between June 1, 2017 and October 15, 2021. Based on the Epworth Sleepiness Scale (ESS), patients were categorized into RES (ESS ≥ 11) and no RES (ESS < 11) groups. Demographic and PSG data were subjected to univariate and multivariate analyses to ascertain predictive factors of RES. RESULTS: Out of 171 veterans with PTSD who were adherent to CPAP, 59 (35%) continued to experience RES. The RES group had a decrease in mean ESS score of 1.2 ± 4.5 after CPAP treatment compared with 4.6 ± 4.9 for the no RES group (< 0.001). A dose-response was observed between CPAP use and RES (p = 0.003). Multivariate regression analysis identified higher baseline ESS (OR 1.30; 95% CI 1.16-1.44), greater percentage of time spent in REM sleep (OR 0.91; 95% CI 0.85-0.96), CPAP use less than 6 h (OR 2.82; 95% CI 1.13-7.01), and a positive screen for depression (OR 1.69; 95% CI 1.03-4.72) as independent predictors of RES in patients with PTSD and OSA. CONCLUSION: RES is highly prevalent in patients with PTSD and OSA despite adherence to CPAP and is independently associated with percentage time spent in REM, duration of CPAP utilization, and symptoms of depression.

Parameters affecting improvement of excessive daytime sleepiness in obstructive sleep apnea patients.

OBJECTIVES: Obstructive sleep apnea (OSA) is a sleep-related breathing disorder caused by repetitive obstruction of the upper airway; this impairs gaseous exchange, resulting in hypoxia, hypercapnia, and frequent arousals. Excessive daytime sleepiness (EDS) is a common daytime symptom of OSA. EDS manifests as fatigue and impaired attention, leading to poor performance at work and falling asleep while driving, which is a major socioeconomic problem. Therefore, it is important to properly treat EDS and accurately predict the response to treatment. However, few studies have compared OSA patients showing and not showing improvement in EDS. Therefore, this study aimed to objectively analyze and compare EDS improvement and non-improvement groups. SUBJECTS AND METHODS: We retrospectively reviewed the medical records of 57 OSA patients with EDS. Patients were divided into two groups according to the improvement in EDS after positive airway pressure (PAP) device treatment. We analyzed differences in clinical records including patients' age, sex, history of smoking, hypertension, diabetes, myocardial infarction, and cerebrovascular disease between the two groups. Systolic, diastolic blood pressure, blood test including blood glucose, total cholesterol, high- and low-density lipoprotein cholesterol, and triglyceride levels were also analyzed. Polysomnography (PSG) data, PAP device treatment compliance and scores of questionnaires related to various psychiatric symptoms, subjective sleep quality between the two groups were also analyzed. RESULTS: There was no statistically significant difference in age, gender, or past medical history between the two groups. Systolic and diastolic blood pressure, and blood test results, were also not significantly different. Among the questionnaires related to various psychiatric symptoms, the groups showed statistically significant differences in Social Avoidance and Distress Scale (SADS) and Fear of Negative Evaluation (FNE) scores (P = 0.001 and 0.020, respectively). The group differences in the scores on the other questionnaires were not significantly different. Among the PSG items, significant group differences were observed in the percentage of stage 2 non-REM sleep (N2%, P = 0.023), apnea index (AI, P = 0.005), apnea-hypopnea index (AHI, P = 0.023), and frequency of 3 % oxygen desaturation (ODI3, P = 0.001). No obesity-related parameters showed significant group differences. The percentage of days on which a PAP device was used (out of 90 days; PAP%) and percentage of days on which a PAP device was used for >4 h (Time4%) did not differ significantly. CONCLUSIONS: The SADS, FNE, AI, AHI, N2%, and ODI3 parameters differed significantly between the EDS improvement and non-improvement groups. These parameters may help clinicians treat and predict the prognosis of patients suffering with EDS.

Different components of excessive daytime sleepiness and the change with positive airway pressure treatment in patients with obstructive sleep apnea: Results from the Icelandic Sleep Apnea Cohort (ISAC).

Excessive daytime sleepiness includes both an inability to stay awake during the day and a general feeling of sleepiness. We describe different dimensions of daytime sleepiness in adults with moderate-severe obstructive sleep apnea (OSA) before and after 2 years of positive airway pressure (PAP) treatment. Using the Epworth Sleepiness Scale (score >10 defined as "risk of dozing") and Basic Nordic Sleep Questionnaire (feeling sleepy ≥3 times/week defined as "feeling sleepy"), participants were categorised into sleepiness phenotypes labelled non-sleepy, risk of dozing only, feeling sleepy only, or both symptoms. Participants repeated baseline assessments and PAP adherence was evaluated after 2 years. PAP-adherent subjects with sleepiness symptoms at both baseline and follow-up were considered persistently sleepy. Of the 810 participants, 722 (89%) returned for follow-up. At baseline, 17.7% were non-sleepy, 7.7% were at risk of dozing only, 24.7% were feeling sleepy only, and 49.9% had both symptoms. PAP adherence did not differ by baseline sleepiness phenotype. Patients with risk of dozing demonstrated greater PAP benefits for sleepiness symptoms than non-sleepy and feeling sleepy only phenotypes. Using these phenotypes, 42.3% of PAP users had persistent sleepiness; they had less severe OSA (p < 0.001), more persistent OSA symptoms and more often had symptoms of insomnia than patients in whom sleepiness resolved. Our present results, therefore, suggest that measuring the risk of dozing and the feeling of sleepiness reflect different sleepiness components and may respond differently to PAP. Patients feeling sleepy without risk of dozing may need more thorough evaluation for factors contributing to sleepiness before initiating treatment.

Patient preferences in obstructive sleep apnea-a discrete choice experiment.

BACKGROUND: Obstructive sleep apnea (OSA) is one of the most common chronic sleep disorders, which can be treated by different interventions. It is known that acceptance and adherence to these therapies is influenced by a variety of factors. However, there is a limited understanding of patient preferences and decision-making in the context of OSA treatment. METHODS: A discrete choice experiment was conducted on patients with OSA recruited from a tertiary sleep center to evaluate preferences for different treatment attributes. Participants received four different choice tasks with three hypothetical treatments, each defined by seven attributes. A random-effects logit model was used to estimate the influence of the different attributes on the choice decisions. Multivariate logistic regression analysis was carried out to evaluate interactions with medical variables. RESULTS: In a cohort of 241 subjects with OSA, preferences for treatment attributes and utilities derived from them differed. Most relevant attributes were Reduction in risk of comorbidities, Improvements of daytime sleepiness, Requirement for surgery, and Occurrence of treatment-related side effects. Demographic or medical variables, such as age, gender, or apnea-hypopnea index, did not influence the choice decision. Multivariate logistic regression revealed significant differences in preferences depending on OSA disease history (p = .025) and presence of OSA symptoms (p = .033). CONCLUSIONS: The study identified preferences for attributes of OSA and their utilities from a patient perspective. Relevant differences of preferences in subgroups of patients with OSA were identified, which may be important to consider in selecting appropriate treatments that lead to high rates of acceptance and adherence.

The effect of tongue elevation muscle training in patients with obstructive sleep apnea: A randomised controlled trial.

BACKGROUND: Oropharyngeal myofunctional therapy is a multi-component therapy effective to reduce the severity of obstructive sleep apnoea (OSA). However, existing protocols are difficult to replicate in the clinical setting. There is a need to isolate the specific effectiveness of each component of the therapy. OBJECTIVE: To assess the effects of a 6 weeks tongue elevation training programme in patients with OSA. METHODS: We conducted a multicentre randomised controlled trial. Eligible participants were adults diagnosed with moderate OSA who presented low adherence to continuous positive airway pressure therapy (mean use <4 h per night). The intervention group completed a 6 weeks tongue elevation training protocol that consisted in anterior tongue elevation strength and endurance tasks with the Iowa Oral Performance Instrument. The control group completed a 6 weeks sham training protocol that involved expiratory muscle training at very low intensity. Polygraphy data, tongue force and endurance, and OSA symptoms were evaluated pre- and post-intervention. The primary outcome was apneoa-hypopnea index (AHI). RESULTS: Twenty-seven patients (55 ± 11 years) were recruited. According to modified intention-to-treat analysis (n = 25), changes in AHI and c did not significantly differ between groups. Daytime sleepiness (Epworth Sleepiness Scale) and tongue endurance significantly improved in the intervention group compared to the control group (p = .015 and .022, respectively). In the intervention group, 75% of participants had a decrease in daytime sleepiness that exceeded the minimal clinically important difference. CONCLUSION: Six weeks of tongue elevation muscle training had no effect on OSA severity.

Acceptance of virtual agents in a homecare context: Evaluation of excessive daytime sleepiness in apneic patients during interventions by continuous positive airway pressure (CPAP) providers.

Sleep apnea syndrome treatment relies primarily on continuous positive airway pressure, which requires a homecare follow-up. Excessive daytime sleepiness is a key symptom to be measured during follow-up, and there is a need for more easy-to-administer, ecological and engaging tools to assess it. Virtual agents have shown their effectiveness in performing clinical evaluation in a medical environment. A virtual agent assessing excessive daytime sleepiness via the Epworth Sleepiness Scale has been tested at home by 102 patients treated by continuous positive airway pressure (CPAP) and their homecare providers. Acceptance and trustworthiness of the agent, as well as the influence of demographics and clinical characteristics of patients, were investigated. Results showed that both patients and homecare providers reported a positive attitude towards the virtual agent, which was found to be usable, satisfactory, credible and benevolent. Homecare providers reported that it was not a burden to their working routine. Positive regression coefficients were found between patients' and homecare providers' attitudes towards the virtual agent. We found no influence of patients' demographics and clinical characteristics on their acceptance of the virtual agent. This shows that virtual agents are well accepted by patients and homecare providers, independently of their demographics and clinical characteristics. Positive regression coefficients observed between patients' and homecare providers' perceptions of the agent indicate that the opinions of both influence acceptance of the virtual agent in a homecare context. Virtual agents are new innovative digital solutions to be considered in homecare follow-up of apneic patients treated by CPAP.

The Swiss Primary Hypersomnolence and Narcolepsy Cohort study (SPHYNCS): Study protocol for a prospective, multicentre cohort observational study.

Narcolepsy type 1 (NT1) is a disorder with well-established markers and a suspected autoimmune aetiology. Conversely, the narcoleptic borderland (NBL) disorders, including narcolepsy type 2, idiopathic hypersomnia, insufficient sleep syndrome and hypersomnia associated with a psychiatric disorder, lack well-defined markers and remain controversial in terms of aetiology, diagnosis and management. The Swiss Primary Hypersomnolence and Narcolepsy Cohort Study (SPHYNCS) is a comprehensive multicentre cohort study, which will investigate the clinical picture, pathophysiology and long-term course of NT1 and the NBL. The primary aim is to validate new and reappraise well-known markers for the characterization of the NBL, facilitating the diagnostic process. Seven Swiss sleep centres, belonging to the Swiss Narcolepsy Network (SNaNe), joined the study and will prospectively enrol over 500 patients with recent onset of excessive daytime sleepiness (EDS), hypersomnia or a suspected central disorder of hypersomnolence (CDH) during a 3-year recruitment phase. Healthy controls and patients with EDS due to severe sleep-disordered breathing, improving after therapy, will represent two control groups of over 50 patients each. Clinical and electrophysiological (polysomnography, multiple sleep latency test, maintenance of wakefulness test) information, and information on psychomotor vigilance and a sustained attention to response task, actigraphy and wearable devices (long-term monitoring), and responses to questionnaires will be collected at baseline and after 6, 12, 24 and 36 months. Potential disease markers will be searched for in blood, cerebrospinal fluid and stool. Analyses will include quantitative hypocretin measurements, proteomics/peptidomics, and immunological, genetic and microbiota studies. SPHYNCS will increase our understanding of CDH and the relationship between NT1 and the NBL. The identification of new disease markers is expected to lead to better and earlier diagnosis, better prognosis and personalized management of CDH.

The Effectiveness of Nasal Airway Stent Therapy for the Treatment of Mild-to-Moderate Obstructive Sleep Apnea Syndrome.

BACKGROUND: Patients with obstructive sleep apnea syndrome (OSAS) experience excessive daytime sleepiness and insomnia and they are at risk of developing cardiovascular disease and stroke. Continuous positive airway pressure therapy could improve symptoms and decrease these risks; however, adherence is problematic. Although the oral appliance is another therapeutic option, patient satisfaction is limited and the effect of the nasal airway stent - a new device - remains unclear. OBJECTIVES: The aim of this study was to evaluate the effect of NAS therapy in patients with mild-to-moderate OSAS in a prospective, single-arm, interventional pilot study. METHOD: Patients with mild/moderate sleep apnea (n = 71; Apnea-Hypopnea Index [AHI], 5-20 events/h on polysomnography) were recruited. Sleep-associated events were measured using a portable device (WatchPAT200) pre- and immediately post-treatment and at 1 month follow-up. AHI (including supine and non-supine AHI), Oxygen Desaturation Index (ODI), Respiratory Disturbance Index (RDI), percutaneous oxygen saturation, heart rate, and snore volume were evaluated. Symptoms were assessed using the Epworth Sleepiness Scale, Pittsburgh Sleep Quality Index, and Hospital Anxiety and Depression Scale. RESULTS: NAS use significantly improved AHI, supine AHI, RD, ODI, and snore volume compared to pre-intervention (r = 0.44, 0.48, 0.3, 0.42, and 0.34; p < 0.001, p < 0.001, p = 0.011, p < 0.001, and p = 0.048, respectively). Additionally, 25 and 10% of patients showed complete and partial response for AHI, respectively; these improvements remained significant 1 month later. Pittsburgh Sleep Quality Index scores improved from 6.0 to 5.3 (r = 0.46, p = 0.022). CONCLUSIONS: NAS therapy reduced severity and snoring in patients with mild-to-moderate OSAS. Approximately 30% of patients did not tolerate NAS due to side effects.

A Guide to Management of Sleepiness in ESKD.

Daytime sleepiness, also known as hypersomnolence, is common among patients receiving maintenance dialysis and following successful kidney transplantation. Sleepiness may be secondary to medical comorbid conditions, medication side effect, insufficient sleep syndrome, and sleep-disordered breathing or the result of a primary central disorder of hypersomnolence, such as narcolepsy. Unrecognized and untreated sleep disorders are associated with substantial morbidity and mortality among patients with end-stage kidney disease. Effective management of hypersomnolence can improve quality of life in patients with kidney disease. This review focuses on the principal causes of sleepiness in patients with end-stage kidney disease. Awareness of these disorders by treating nephrologists is crucial. This review provides a systematic approach to guide providers through the recognition, early diagnosis, and treatment of hypersomnolence, which is commonly encountered in this patient population. Areas of future research are also suggested.

Targeting Arousal and Sleep through Noninvasive Brain Stimulation to Improve Mental Health.

Arousal and sleep represent fundamental physiological domains, and alterations in the form of insomnia (difficulty falling or staying asleep) or hypersomnia (increased propensity for falling asleep or increased sleep duration) are prevalent clinical problems. Current first-line treatments include psychotherapy and pharmacotherapy. Despite significant success, a number of patients do not benefit sufficiently. Progress is limited by an incomplete understanding of the -neurobiology of insomnia and hypersomnia. This work summarizes current concepts of the regulation of arousal and sleep and its modulation through noninvasive brain stimulation (NIBS), including transcranial magnetic, current, and auditory stimulation. Particularly, we suggest: (1) characterization of patients with sleep problems - across diagnostic entities of mental disorders - based on specific alterations of sleep, including alterations of sleep slow waves, sleep spindles, cross-frequency coupling of brain oscillations, local sleep-wake regulation, and REM sleep and (2) targeting these with specific NIBS techniques. While evidence is accumulating that the modulation of specific alterations of sleep through NIBS is feasible, it remains to be tested whether this translates to clinically relevant effects and new treatment developments.

Myofunctional therapy (oropharyngeal exercises) for obstructive sleep apnoea.

BACKGROUND: Obstructive sleep apnoea (OSA) is a syndrome characterised by episodes of apnoea (complete cessation of breathing) or hypopnoea (insufficient breathing) during sleep. Classical symptoms of the disease - such as snoring, unsatisfactory rest and daytime sleepiness - are experienced mainly by men; women report more unspecific symptoms such as low energy or fatigue, tiredness, initial insomnia and morning headaches. OSA is associated with an increased risk of occupational injuries, metabolic diseases, cardiovascular diseases, mortality, and being involved in traffic accidents. Continuous positive airway pressure (CPAP) - delivered by a machine which uses a hose and mask or nosepiece to deliver constant and steady air pressure- is considered the first treatment option for most people with OSA. However, adherence to treatment is often suboptimal. Myofunctional therapy could be an alternative for many patients. Myofunctional therapy consists of combinations of oropharyngeal exercises - i.e. mouth and throat exercises. These combinations typically include both isotonic and isometric exercises involving several muscles and areas of the mouth, pharynx and upper respiratory tract, to work on functions such as speaking, breathing, blowing, sucking, chewing and swallowing. OBJECTIVES: To evaluate the benefits and harms of myofunctional therapy (oropharyngeal exercises) for the treatment of obstructive sleep apnoea. SEARCH METHODS: We identified randomised controlled trials (RCTs) from the Cochrane Airways Trials Register (date of last search 1 May 2020). We found other trials at web-based clinical trials registers. SELECTION CRITERIA: We included RCTs that recruited adults and children with a diagnosis of OSA. DATA COLLECTION AND ANALYSIS: We used standard methodological procedures expected by Cochrane. We assessed our confidence in the evidence by using GRADE recommendations. Primary outcomes were daytime sleepiness, morbidity and mortality. MAIN RESULTS: We found nine studies eligible for inclusion in this review and nine ongoing studies. The nine included RCTs analysed a total of 347 participants, 69 of them women and 13 children. The adults' mean ages ranged from 46 to 51, daytime sleepiness scores from eight to 14, and severity of the condition from mild to severe OSA. The studies' duration ranged from two to four months. None of the studies assessed accidents, cardiovascular diseases or mortality outcomes. We sought data about adverse events, but none of the included studies reported these. In adults, compared to sham therapy, myofunctional therapy: probably reduces daytime sleepiness (Epworth Sleepiness Scale (ESS), MD (mean difference) -4.52 points, 95% Confidence Interval (CI) -6.67 to -2.36; two studies, 82 participants; moderate-certainty evidence); may increase sleep quality (MD -3.90 points, 95% CI -6.31 to -1.49; one study, 31 participants; low-certainty evidence); may result in a large reduction in Apnoea-Hypopnoea Index (AHI, MD -13.20 points, 95% CI -18.48 to -7.93; two studies, 82 participants; low-certainty evidence); may have little to no effect in reduction of snoring frequency but the evidence is very uncertain (Standardised Mean Difference (SMD) -0.53 points, 95% CI -1.03 to -0.03; two studies, 67 participants; very low-certainty evidence); and probably reduces subjective snoring intensity slightly (MD -1.9 points, 95% CI -3.69 to -0.11 one study, 51 participants; moderate-certainty evidence). Compared to waiting list, myofunctional therapy may: reduce daytime sleepiness (ESS, change from baseline MD -3.00 points, 95% CI -5.47 to -0.53; one study, 25 participants; low-certainty evidence); result in little to no difference in sleep quality (MD -0.70 points, 95% CI -2.01 to 0.61; one study, 25 participants; low-certainty evidence); and reduce AHI (MD -6.20 points, 95% CI -11.94 to -0.46; one study, 25 participants; low-certainty evidence). Compared to CPAP, myofunctional therapy may result in little to no difference in daytime sleepiness (MD 0.30 points, 95% CI -1.65 to 2.25; one study, 54 participants; low-certainty evidence); and may increase AHI (MD 9.60 points, 95% CI 2.46 to 16.74; one study, 54 participants; low-certainty evidence). Compared to CPAP plus myofunctional therapy, myofunctional therapy alone may result in little to no difference in daytime sleepiness (MD 0.20 points, 95% CI -2.56 to 2.96; one study, 49 participants; low-certainty evidence) and may increase AHI (MD 10.50 points, 95% CI 3.43 to 17.57; one study, 49 participants; low-certainty evidence). Compared to respiratory exercises plus nasal dilator strip, myofunctional therapy may result in little to no difference in daytime sleepiness (MD 0.20 points, 95% CI -2.46 to 2.86; one study, 58 participants; low-certainty evidence); probably increases sleep quality slightly (-1.94 points, 95% CI -3.17 to -0.72; two studies, 97 participants; moderate-certainty evidence); and may result in little to no difference in AHI (MD -3.80 points, 95% CI -9.05 to 1.45; one study, 58 participants; low-certainty evidence). Compared to standard medical treatment, myofunctional therapy may reduce daytime sleepiness (MD -6.40 points, 95% CI -9.82 to -2.98; one study, 26 participants; low-certainty evidence) and may increase sleep quality (MD -3.10 points, 95% CI -5.12 to -1.08; one study, 26 participants; low-certainty evidence). In children, compared to nasal washing alone, myofunctional therapy and nasal washing may result in little to no difference in AHI (MD 3.00, 95% CI -0.26 to 6.26; one study, 13 participants; low-certainty evidence). AUTHORS' CONCLUSIONS: Compared to sham therapy, myofunctional therapy probably reduces daytime sleepiness and may increase sleep quality in the short term. The certainty of the evidence for all comparisons ranges from moderate to very low, mainly due to lack of blinding of the assessors of subjective outcomes, incomplete outcome data and imprecision. More studies are needed. In future studies, outcome assessors should be blinded. New trials should recruit more participants, including more women and children, and have longer treatment and follow-up periods.

Consensus-Based Care Recommendations for Pulmonologists Treating Adults with Myotonic Dystrophy Type 1.

PURPOSE OF REVIEW: Myotonic dystrophy type 1 (DM1) is a severe, progressive genetic disease that affects approximately 1 in 2,500 individuals globally [Ashizawa et al.: Neurol Clin Pract 2018;8(6):507-20]. In patients with DM1, respiratory muscle weakness frequently evolves, leading to respiratory failure as the main cause of death in this patient population, followed by cardiac complications [de Die-Smulders et al.: Brain 1998;121(Pt 8):1557-63], [Mathieu et al.: Neurology 1999;52(8):1658-62], [Groh et al.: Muscle Nerve 2011;43(5):648-51]. This paper provides a more detailed outline on the diagnostic and management protocols, which can guide pulmonologists who may not have experience with DM1 or who are not part of a neuromuscular multidisciplinary clinic. A group of neuromuscular experts in DM1 including pulmonologists, respiratory physiotherapists and sleep specialists discussed respiratory testing and management at baseline and during follow-up visits, based on their clinical experience with patients with DM1. The details are presented in this report. RECENT FINDINGS: Myotonic recruited 66 international clinicians experienced in the treatment of people living with DM1 to develop and publish consensus-based care recommendations targeting all body systems affected by this disease [Ashizawa et al.: Neurol Clin Pract. 2018;8(6):507-20]. Myotonic then worked with 12 international respiratory therapists, pulmonologists and neurologists with long-standing experience in DM respiratory care to develop consensus-based care recommendations for pulmonologists using a methodology called the Single Text Procedure. This process generated a 7-page document that provides detailed respiratory care recommendations for the management of patients living with DM1. This consensus is completely based on expert opinion and not backed up by empirical evidence due to limited clinical care data available for respiratory care management in DM patients. Nevertheless, we believe it is of relevance for professionals treating adults with myotonic dystrophy because it addresses practical issues related to respiratory management and care, which have been adapted to meet the specific issues in patients with DM1. SUMMARY: The resulting recommendations are intended to improve respiratory care for the most vulnerable of DM1 patients and lower the risk of untoward respiratory complications and mortality by providing pulmonologist who are less experienced with DM1 with practical indications on which tests and when to perform them, adapting the general respiratory knowledge to specific issues related to this multiorgan disease.

Managing daytime sleepiness with the help of sleepcoaching, a non-pharmacological treatment of non-restorative sleep.

PURPOSE: To measure the effect of a 2-day sleepcoaching seminar on daytime sleepiness and sleep-related variables of shift workers employed in an Austrian railway company (ÖBB: Österreichische Bundesbahnen). METHOD: Participants filled in pre- and post-intervention questionnaires, containing items of the PSQI and the ESS, questions about chronotype, personality factors and possible burnout risk factors. About 30 shift workers, working in shifts for more than 300 months on average (28 male; mean age = 24 ± 45.90, age range 24-56 years) voluntarily took part in the investigation twice. Sleep coaching by Holzinger and Kloesch™ (SC) is a new holistic approach for non-pharmacological treatment of non-restorative sleep and is based on Gestalt therapy. It includes psychotherapeutic aspects, which enable clients to improve their sleep quality by developing one's own coping strategies which can be implemented in daily routine. Dream work and relaxation techniques are also part of the programme. RESULTS: The 2-day SC seminar was beneficial by focusing on the sleep problems related to shift work. A significant improvement of the global PSQI score and the PSQI variables subjective sleep quality, diurnal fatigue, and sleep latency was achieved, with a medium effect size. However, the programme did not result in the reduction of daytime sleepiness (ESS). Six more variables did not change significantly. CONCLUSION: While some sleep problems related to shift work were successfully addressed by SC, daytime sleepiness (ESS) could not be reduced contrary to our expectations. More research with a greater sample and a longitudinal design is needed to examine the long-term effects of SC.

The effects of threshold inspiratory muscle training in patients with obstructive sleep apnea: a randomized experimental study.

OBJECTIVES: Patients with obstructive sleep apnea (OSA) (an obstructed airway and intermittent hypoxia) negatively affect their respiratory muscles. We evaluated the effects of a 12-week threshold inspiratory muscle training (TIMT) program on OSA severity, daytime sleepiness, and pulmonary function in newly diagnosed OSA. METHODS: Sixteen patients with moderate-to-severe OSA were randomly assigned to a TIMT group and 6 to a control group. The home-based TIMT program was 30-45 min/day, 5 days/week, for 12 weeks using a TIMT training device. Their apnea-hypopnea index (AHI), Epworth sleepiness scale (ESS), and forced vital capacity (FVC) scores were evaluated pre- and post-treatment. Polysomnographic (PSG) analysis showed that 9 TIMT-group patients had positively responded (TIMT-responder group: post-treatment AHI < pre-treatment) and that 7 had not (TIMT non-responder group: post-treatment AHI > pre-treatment). RESULTS: Post-treatment AHI and ESS scores were significantly (both P < 0.05) lower 6% and 20.2%, respectively. A baseline AHI ≤ 29.0/h predicted TIMT-responder group patients (sensitivity 77.8%; specificity 85.7%). FVC was also significantly (P < 0.05) higher 7.2%. Baseline AHI and FEV6.0 were significant predictors of successful TIMT-responder group intervention. OSA severity and daytime sleepiness were also significantly attenuated. CONCLUSIONS: Home-based TIMT training is simple, efficacious, and cost-effective.

Residual excessive daytime sleepiness in patients with obstructive sleep apnea treated with positive airway pressure therapy.

PURPOSE: Patients with obstructive sleep apnea (OSA) commonly report residual excessive daytime sleepiness (EDS) despite treatment with positive airway pressure (PAP). The present study aimed to determine whether patients presenting with subjective sleepiness after treatment with PAP therapy had objective evidence of residual sleepiness. METHODS: We conducted a retrospective analysis of 29 adults with OSA on PAP therapy who underwent a standardized evaluation for EDS. Patients were evaluated with the Epworth Sleepiness Scale (ESS) and attend an in-lab polysomnogram (PSG) with PAP followed by a multiple sleep latency test (MSLT). RESULTS: Our cohort consisted of 23 men (79%) and 6 women (21%) with a mean age of 40.7 years. All patients were subjectively sleepy with an ESS score of > 10 and met minimal PAP usage of 4 h a night for at least 70% of nights with a residual apnea-hypopnea index (AHI) ≤ 10. On MSLT, 31% of patients had an average sleep onset latency (SOL) < 8 min, 35% had a SOL between 8 and 11 min, and 35% had SOL > 11 min. CONCLUSION: After optimizing PAP therapy and sleep in patients with OSA and residual EDS, the majority were found to have objective findings of an abnormally short SOL on MSLT. This is further evidence that there is a distinct OSA phenotype that will have persistent EDS despite appropriate treatment of their sleep-disordered breathing. Objective testing to quantify the degree of sleepiness is recommended for OSA patients with residual EDS.

Excessive daytime sleepiness in narcolepsy and central nervous system hypersomnias.

PURPOSE: Excessive daytime sleepiness (EDS) is the core complaint of central nervous system (CNS) hypersomnias. In this mini-review, we summarized EDS features in CNS hypersomnias to provide a guide for differential diagnosis purposes. METHODS: A review of recent literature was performed to provide an update in CNS hypersomnias. RESULTS: At clinical evaluation, narcolepsy patients report a good restorative potential of sleep together with the frequent occurrence of dreaming even during short-lasting naps. These features are mirrored by the neurophysiological evidence of REM sleep at sleep onset (SOREMP) during the Multiple Sleep Latency Test (MSLT), a specific marker. Conversely, patients with idiopathic hypersomnia (IH) complain sleep inertia and prolonged nocturnal sleep. Polysomnographic studies show high sleep propensity on the MSLT or high 24-h total sleep time during continuous monitoring. Patients with insufficient sleep syndrome (ISS) can present with variable clinical EDS features in between narcolepsy and IH. ISS diagnosis is based on the clinical evidence of nocturnal sleep curtailment (weekdays versus vacations) associated with the disappearance of EDS complaint after sleep extension. Polysomnographic data are not required, but when the MSLT is performed, ISS patients can present with SOREMP arising from non-REM stage 2 sleep (vs narcolepsy patients entering into SOREM most frequently from wakefulness). Kleine-Levin Syndrome is characterized by recurrent episodes of enormously prolonged sleep time lasting days associated with abnormal cognition and behavior intermixed by asymptomatic periods, a sleep pattern that can be well documented by actigraphy. CONCLUSIONS: Different CNS hypersomnias present with specific features of EDS are useful to guide the clinician to apply and interpret appropriate neurophysiological investigations.

Daily Morning Blue Light Therapy Improves Daytime Sleepiness, Sleep Quality, and Quality of Life Following a Mild Traumatic Brain Injury.

OBJECTIVE: Identify the treatment effects of 6 weeks of daily 30-minute sessions of morning blue light therapy compared with placebo amber light therapy in the treatment of sleep disruption following mild traumatic brain injury. DESIGN: Placebo-controlled randomized trial. PARTICIPANTS: Adults aged 18 to 45 years with a mild traumatic brain injury within the past 18 months (n = 35). MAIN OUTCOME MEASURES: Epworth Sleepiness Scale, Pittsburgh Sleep Quality Index, Beck Depression Inventory II, Rivermead Post-concussion Symptom Questionnaire, Functional Outcomes of Sleep Questionnaire, and actigraphy-derived sleep measures. RESULTS: Following treatment, moderate to large improvements were observed with individuals in the blue light therapy group reporting lower Epworth Sleepiness Scale (Hedges' g = 0.882), Beck Depression Inventory II (g = 0.684), Rivermead Post-concussion Symptom Questionnaire chronic (g = 0.611), and somatic (g = 0.597) symptoms, and experiencing lower normalized wake after sleep onset (g = 0.667) than those in the amber light therapy group. In addition, individuals in the blue light therapy group experienced greater total sleep time (g = 0.529) and reported improved Functional Outcomes of Sleep Questionnaire scores (g = 0.929) than those in the amber light therapy group. CONCLUSION: Daytime sleepiness, fatigue, and sleep disruption are common following a mild traumatic brain injury. These findings further substantiate blue light therapy as a promising nonpharmacological approach to improve these sleep-related complaints with the added benefit of improved postconcussion symptoms and depression severity.

[Insomnia and Hypersomnia among Children and Adolescents with Psychiatric Disorders]. / Insomnie und Hypersomnie bei Kindern und Jugendlichen mit psychiatrischen Störungen.

Insomnia and Hypersomnia among Children and Adolescents with Psychiatric Disorders The common symptom of sleep disorders is non-restorative sleep, which results in daytime sleepiness. Therefore in clinical practice simultaneous complaints of "not enough" and "too much" sleep are very frequent. For the investigation and treatment of organic sleep disorders, available instruments, guidelines and specialised institutions (sleep centres or sleep laboratories) are more advanced than for non-organic sleep disorders. Especially in the child and adolescent psychiatric and psychotherapeutic field this complicates an appropriate treatment. In addition multiple psychiatric, neurological and other somatic diseases can disrupt nighttime sleep and cause impairments during the day too. There are various instruments and methods to cover disturbed nocturnal sleep, some of which have already found widespread use in clinical practice (e. g. sleep diaries or specific questionnaires and interviews). For the examination of daytime sleepiness instruments and methods are available too, which by now seem to be less widely used. Against this background an overview of definitions, distinctive features and clinical instruments as well as guidelines for dealing with "too much and too little sleep" during the day or at night shall be presented.