A new tool to screen patients with severe obstructive sleep apnea in the primary care setting: a prospective multicenter study.

BACKGROUND: The coordination between different levels of care is essential for the management of obstructive sleep apnea (OSA). The objective of this multicenter project was to develop a screening model for OSA in the primary care setting. METHODS: Anthropometric data, clinical history, and symptoms of OSA were recorded in randomly selected primary care patients, who also underwent a home sleep apnea test (HSAT). Respiratory polygraphy or polysomnography were performed at the sleep unit to establish definite indication for continuous positive airway pressure (CPAP). By means of cross-validation, a logistic regression model (CPAP yes/no) was designed, and with the clinical variables included in the model, a scoring system was established using the ß coefficients (PASHOS Test). In a second stage, results of HSAT were added, and the final accuracy of the model was assessed. RESULTS: 194 patients completed the study. The clinical test included the body mass index, neck circumference and observed apneas during sleep (AUC 0.824, 95% CI 0.763-0.886, P < 0.001). In a second stage, the oxygen desaturation index (ODI) of 3% (ODI3% ≥ 15%) from the HSAT was added (AUC 0.911, 95% CI 0.863-0.960, P < 0.001), with a sensitivity of 85.5% (95% CI 74.7-92.1) and specificity of 67.8% (95% CI 55.1-78.3). CONCLUSIONS: The use of this model would prevent referral to the sleep unit for 55.1% of the patients. The two-stage PASHOS model is a useful and practical screening tool for OSA in primary care for detecting candidates for CPAP treatment. Clinical Trial Registration Registry: ClinicalTrials.gov; Name: PASHOS Project: Advanced Platform for Sleep Apnea Syndrome Assessment; URL: https://clinicaltrials.gov/ct2/show/NCT02591979 ; Identifier: NCT02591979. Date of registration: October 30, 2015.

Predictors of respiratory complications in patients with C5-T5 spinal cord injuries.

STUDY DESIGN: Retrospective chart audit. OBJECTIVES: Describing the respiratory complications and their predictive factors in patients with acute traumatic spinal cord injuries at C5-T5 level during the initial hospitalization. SETTING: Hospital Vall d'Hebron, Barcelona. METHODS: Data from patients admitted in a reference unit with acute traumatic injuries involving levels C5-T5. Respiratory complications were defined as: acute respiratory failure, respiratory infection, atelectasis, non-hemothorax pleural effusion, pulmonary embolism or haemoptysis. Candidate predictors of these complications were demographic data, comorbidity, smoking, history of respiratory disease, the spinal cord injury characteristics (level and ASIA Impairment Scale) and thoracic trauma. A logistic regression model was created to determine associations between potential predictors and respiratory complications. RESULTS: We studied 174 patients with an age of 47.9 (19.7) years, mostly men (87%), with low comorbidity. Coexistent thoracic trauma was found in 24 (19%) patients with cervical and 35 (75%) with thoracic injuries (p < 0.001). Respiratory complications were frequent (53%) and were associated to longer hospital stay: 83.1 (61.3) and 45.3 (28.1) days in patients with and without respiratory complications (p < 0.001). The strongest predictors of respiratory complications were: previous respiratory disease (OR 5.4, 95% CI: 1.5-19.2), complete motor function impairment (AIS A-B) (OR 4.7, 95% CI: 2.4-9.5) and concurrent chest trauma (OR 3.73, 95% CI: 1.8-7.9). CONCLUSIONS: Respiratory complications are common in traumatic spinal cord injuries between C5-T5. We identified previous respiratory disease, complete motor function impairment and the coexistence of thoracic trauma as predictors of respiratory complications. Identification of patients at risk might help clinicians to implement preventive strategies.

Obstructive sleep apnea and silent cerebral infarction in hypertensive individuals.

Obstructive sleep apnea syndrome is very prevalent in hypertensive subjects. Moreover, obstructive sleep apnea syndrome activates multiple processes that might be associated with silent cerebral infarct independently of established risk factors. Our aim is to estimate the frequency of obstructive sleep apnea syndrome in hypertensive patients with and without silent cerebral infarct, and to determine whether obstructive sleep apnea syndrome is an independent risk factor of silent cerebral infarct and/or lacunar silent cerebral infarct in patients with hypertension. In this matched cross-sectional study performed in hypertensive subjects, each patient with silent cerebral infarct detected by magnetic resonance imaging was matched with two patients without silent cerebral infarct. Polysomnographic studies were performed, and the apnea-hypopnea index was calculated. Severe obstructive sleep apnea syndrome was considered in those with apnea-hypopnea index >30. One-hundred and eighty-three patients, 61 with silent cerebral infarct and 122 without silent cerebral infarct, were evaluated. The mean age was 64.1 ± 4.5 years, and 72.1% were men. The frequency of severe obstructive sleep apnea syndrome was 44.3% in patients with silent cerebral infarct and 38.5% in the control group. An adjusted conditional logistic regression model did not show a significant increased risk of silent cerebral infarct in patients with severe obstructive sleep apnea syndrome (odds ratio 1.362; 95% confidence interval: 0.659-2.813; P = 0.404). Forty-three patients (70.5%) of the silent cerebral infarct were lacunar. The presence of severe obstructive sleep apnea syndrome was significantly higher in lacunar silent cerebral infarct when compared with patients without lacunar infarcts (55.8% versus 35.7%, P = 0.019), being independently associated on an adjusted logistic regression model (odds ratio 2.177; 95% confidence interval: 1.058-4.479; P = 0.035). In conclusion, severe obstructive sleep apnea syndrome is highly prevalent among hypertensive subjects, and is independently associated with lacunar silent cerebral infarct.

Poor sleep quality, COPD severity and survival according to CASIS and Pittsburgh questionnaires.

Poor sleep quality is frequent among COPD patients and it has been related to worse outcomes. The objective of this study was to compare the COPD and Asthma Sleep Impact Scale (CASIS) and the generic Pittsburgh Sleep Quality Index (PSQI) questionnaires as reliable tools for evaluating sleep quality and its relationship with COPD characteristics and survival. Stable COPD patients were prospectively evaluated. Anthropometric, sociodemographic, comorbidity, lung function and treatment data were collected. All patients completed CASIS and PSQI, mMRC dyspnea severity scale, COPD Assessment Test (CAT), sleep apnoea STOP-Bang and Hospital Anxiety and Depression Scale (HADS) questionnaires. Body mass index, airflow Obstruction, Dyspnea and Exacerbations (BODEx) index was calculated. Life status was determined after a mean follow-up of 3.7 (SD 1) years. We included 200 patients, 69.5% male, mean age 65.8 (9) years. Poor sleep was detected in 100 (50%) and 84 patients (42%) according to PSQI and CASIS questionnaires, respectively, with an agreement of 63%. Poor sleep was related to female gender, more severe dyspnea and worse BODEx, HADS and CAT scores according to both questionnaires. PSQI was associated to chronic pain or inferior urinary tract symptoms and CASIS to exacerbations, shorter walked distance in the 6-min walking test and treatment with oral corticosteroids or chronic oxygen. Thirty nine (19.5%) patients died during follow-up. Mortality was not associated to PSQI nor CASIS results. Unlike PSQI, CASIS is more related to COPD severity and its results are not influenced by comorbidities with known impact on sleep quality. In our sample, poor sleep quality was not associated with increased mortality.

Poor sleep is associated with deficits of attention in COPD patients.

BACKGROUND: Poor sleep and attention deficits are common in COPD. OBJECTIVES: To assess the relationship between self-reported poor sleep and attention deficits in COPD. We also studied the association between self-reported sleep and the attention tests with the objective characteristics of sleep. METHODS: Fifty-nine COPD patients were prospectively studied. Self-reported sleep quality was assessed using the Pittsburgh sleep quality index (PSQI). Objective characteristics of sleep were assessed by actigraphy and polysomnography. Attention was evaluated with the Oxford sleep resistance test (OSLER) and the Psychomotor vigilance test (PVT). RESULTS: 28 (47 %) patients referred poor sleep (PSQI >5). In the OSLER test they showed earlier sleep onset than patients with good sleep, median (Interquartil range): 31.2 min (25.4-40) vs 40 min (28.5-40), p: 0.048. They also spent more time making errors: 4.5 % (0.6-7.6) of total test time vs 0.7 % (0.2-5.3), p: 0.048. In PVT, patients with poor sleep presented a greater dispersion of the reaction time values with a higher value in the slowest 10 % of the reactions, 828 (609-1667) msec. vs 708 (601-993) msec, p: 0.028. No association was found between self-reported poor sleep and objective sleep variables. We found no correlation between OSLER and PVT results and polysomnographic variables except between sleep efficiency and PVT response speed (ß: 0.309, p: 0.018). CONCLUSION: Self-reported poor sleep in COPD is associated with attention deficits. Sleep quality should be included in future studies of this facet of cognition in COPD, as well as to assess its potential usefulness as a therapeutic target.

Impact of home CPAP-treated obstructive sleep apnea on COVID-19 outcomes in hospitalized patients.

STUDY OBJECTIVES: To investigate the association between moderate or severe obstructive sleep apnea treated with home continuous positive airway pressure (CPAP) and severe coronavirus disease 2019 (COVID-19). METHODS: Retrospective study of patients admitted for COVID-19. Patients with obstructive sleep apnea treated with home CPAP were identified and for each of them we selected 5 patients admitted consecutively in the following hours. The main outcome of the study was the development of severe COVID-19, defined as 1) death or 2) a composite outcome of death or the presence of severe hypoxemic respiratory failure at or during admission. The association between CPAP-treated obstructive sleep apnea and these outcomes was estimated by logistic regression analysis after applying inverse probability of treatment weighting using a propensity score-weighting approach. RESULTS: Of the 2,059 patients admitted, 81 (3.9%) were receiving treatment with home CPAP. Among the 486 patients included in the study, 19% died and 39% presented the composite outcome. The logistic regression analysis did not show an association of CPAP treatment either with death (odds ratio [OR]: 0.684; 95% confidence interval [CI]: 0.332-1.409; P = .303) or with the composite outcome (OR: 0.779; 95% CI: 0.418-1.452; P = .432). Death was associated with age (OR: 1.116; 95% CI: 1.08-1.152; P < .001) and number of comorbidities (OR: 1.318; 95% CI: 1.065-1.631; P = .012), and the composite outcome was associated with male sex (OR: 2.067; 95% CI: 1.19-3.589; P = .01) and number of comorbidities (OR: 1.241; 95% CI: 1.039-1.484; P = .018). CONCLUSIONS: In hospitalized patients with COVID-19, prior obstructive sleep apnea treated with home CPAP is not independently associated with worse outcomes. CITATION: Sampol J, Sáez M, Martí S, et al. Impact of home CPAP-treated obstructive sleep apnea on COVID-19 outcomes in hospitalized patients. J Clin Sleep Med. 2022;18(7):1857-1864.

Cluster-derived obstructive sleep apnea phenotypes and outcomes at 5-year follow-up.

STUDY OBJECTIVES: Obstructive sleep apnea (OSA) is a heterogeneous, complex disease. We aimed to identify OSA phenotypes through cluster analysis and to perform a long-term follow-up to validate the phenotypes. METHODS: We applied a partitioning around medioids technique in a cohort of 1,217 participants recently diagnosed with OSA. We performed a 5-year follow-up analyzing the incidence of comorbidities, chronic medication, hospital admissions, mortality, and the influence of continuous positive airway pressure treatment on mortality risk. RESULTS: We identified three phenotypes: two predominantly male clusters, one composed of middle-aged participants with overweight, moderate OSA, and cardiovascular risk factors and the other consisting of older, obese participants with severe OSA, cardiovascular risk factors, ischemic heart disease (18.4%), and atrial fibrillation (9.7%). The third cluster was composed of 77% female participants with moderate OSA; cardiovascular risk factors; the highest prevalence of depression (15.7%); and high prescription of antidepressants (55.1%), anxiolytics (40.0%), hypnotics, sedatives (11.1%), nonsteroidal anti-inflammatory drugs (67.9%), and weak opioids (15.1%). The baseline characteristics of each cluster maintained the same trend over time regarding the incidence of new comorbidities, medication intake, hospitalization rates, and reasons for admission. The absence of continuous positive airway pressure treatment was associated with a significantly higher risk of all-cause mortality (hazard ratio 5.84, confidence interval 2.9-11.8), especially in the older men (hazard ratio 7.7, confidence interval 4.06-14.63) and predominantly female clusters (hazard ratio 2.79, confidence interval 1.34-5.79). CONCLUSIONS: We identified three phenotypes with relevant clinical and prognostic implications in order to improve personalized strategies in OSA management. CITATION: Silveira MG, Sampol G, Mota-Foix M, Ferrer J, Lloberes P. Cluster-derived obstructive sleep apnea phenotypes and outcomes at 5-year follow-up. J Clin Sleep Med. 2022;18(2):597-607.

Sleep increases leaks and asynchronies during home noninvasive ventilation: a polysomnographic study.

STUDY OBJECTIVES: In patients treated with noninvasive ventilation, sleep-related breathing changes can modify patient-ventilator interactions, which could reduce its effectiveness. The aim of this prospective observational study was to determine the impact of sleep/wake state on leaks, upper airway obstructive events, and asynchronies in patients treated by long-term noninvasive ventilation. METHODS: Stable patients adapted to noninvasive ventilation were considered for nocturnal polysomnography. Unintentional leaks, upper airway obstructive events, and asynchronies were compared between sleep and awake periods. RESULTS: Twenty-eight patients were enrolled. Underlying diagnoses were neuromuscular disease (n = 11), chest wall disease (n = 8), and obesity-hypoventilation (n = 9). Leaks were more frequent in sleep than in awake periods, with a median of 10% (interquartile range [IQR], 0%-75%) vs 1% (IQR, 0%-9%) of time (P < .001), respectively. During sleep, asynchronies with and without associated leak affected 27% of breaths (IQR, 16%-39%) compared with non-leak-related asynchronies that were recorded in 8% (IQR, 3%-25%) of breaths (P < .001). Asynchronies affecting more than 10% of total breaths were more frequent in sleep (25 patients, 89%) than in awake time (8 patients, 29%; P = .25). Eleven patients (39%) presented with 5 or more upper airway obstructive events without reduction in ventilatory drive per hour of sleep. CONCLUSIONS: In patients adapted to home noninvasive ventilation, leaks, asynchronies, and upper airway obstructive events are frequent during the night and are concentrated in sleep periods. Asynchronies are often associated with leaks. These findings may have clinical implications considering that in patients with low sleep efficiency respiratory events could be underestimated if sleep is not evaluated. CITATION: Martí S, Ferré A, Sampol G, et al. Sleep increases leaks and asynchronies during home noninvasive ventilation: a polysomnographic study. J Clin Sleep Med. 2022;18(1):225-233.

Nasal cannula use during polysomnography in children aged under three with suspected sleep apnea.

OBJECTIVE: Early diagnosis of obstructive sleep apnea (OSA) in children is important. The use of a nasal cannula as an airflow sensor during polysomnography has not been evaluated in younger children. The study aims to evaluate the use of nasal cannula in detecting respiratory events in children under three with suspected OSA during daytime nap studies. METHODS: A total of 185 patients were prospectively included. Respiratory events were scored using nasal cannula alone, thermistor alone, and both methods simultaneously as the airflow sensor. Agreement and diagnostic accuracy were assessed. RESULTS: One hundred and seventy-two children were finally analyzed and 110 (64.0%) presented OSA. Total sleep time with an uninterpretable signal was longer with the nasal cannula than with the thermistor (17.8% vs 1.9%; p < 0.001), and was associated with poor sensor tolerance and adenotonsillar hypertrophy. In the estimation of the apnea-hypopnea index, the nasal cannula showed lower agreement than the thermistor with the joint use of the two sensors (intraclass correlation coefficient: 0.79 vs 0.996 with thermistor). Compared with the thermistor, the nasal cannula presented lower sensitivity for detecting OSA (82.7% vs 95.5%) and a lower negative predictive value (76.5% vs 92.4%). Overall, fewer children were diagnosed with severe OSA with the nasal cannula (19.8% vs 30.8% with the thermistor, and 32.6% with both). CONCLUSIONS: In children under the age of three, the ability of the nasal cannula to detect obstructive events was relatively low. Therefore, other non-invasive measurements for identifying respiratory events during sleep may be of additional value.

Circadian Patterns of Patients with Type 2 Diabetes and Obstructive Sleep Apnea.

Sleep apnea, a condition that modifies sleep and circadian rhythms, is highly prevalent in patients with diabetes. However, it is not known if there is an association between sleep apnea, circadian alterations and glycemic regulation in this type of patient. Here, a polysomnographic study was carried out on 21 women and 25 men (mean age = 64.3 ± 1.46 years) with diagnoses of type 2 diabetes to detect the presence of sleep apnea. Moreover, patients wore an actigraph and a temperature sensor on the wrist for one week, to study the manifestation of the circadian rhythms. The correlations of circadian and polysomnographic variables with the severity of apnea, measured by the apnea-hypopnea index, and with glycemic dysregulation, measured by the percentage of glycated hemoglobin, were analyzed. The mean apnea-hypoapnea index of all the participants was 39.6 ± 4.3. Apnea-hypoapnea index correlated with % N1, negatively with % N3, and also the stability of the active circadian rhythm. However, no significant correlation was found between the apnea-hypopnea index and wrist temperature rhythm and glycated hemoglobin. Glycated hemoglobin levels were negatively associated with the percentage of variance explained by the wrist temperature circadian rhythm (calculated via 24 and 12 h rhythms). This association was independent of body mass index and was strongest in patients with severe apnea. In conclusion, patients with diabetes showed altered circadian rhythms associated with a poor glycemic control and this association could partially be related to the coexistence of sleep apnea.

Insulin resistance is related to impaired lung function in morbidly obese women: a case-control study.

BACKGROUND: There is growing evidence suggesting an association between type 2 diabetes and impaired pulmonary function. However, the role of insulin resistance itself remains to be elucidated. The aim of the study is to determine whether obese patients with insulin resistance without diabetes have reduced pulmonary function in comparison with non-diabetic obese subjects without insulin resistance. METHODS: Seventy-five morbidly obese non-diabetic women [50 with an insulin resistance index (homeostasis model assessment, HOMA-IR) ≥ 3.8-cases-and 25 with HOMA-IR < 3.8-controls-] with a history of not smoking and without prior cardiovascular or respiratory disease were prospectively recruited in the outpatient Obesity Unit of a university hospital. Both groups were closely matched by age, body mass index and waist circumference. Pulmonary function test included a forced spirometry and static pulmonary volume measurements. RESULTS: Patients with HOMA-IR ≥ 3.8 showed lower forced expiratory volume at 1 s [mean difference - 7.6% of predicted (95% confidence interval - 14.2 to - 0.9); p = 0.025], and also a lower maximum midexpiratory flow [mean difference - 16.4% of predicted (95% confidence interval - 30.9 to - 2.0); p = 0.026] in comparison with those with HOMA-IR < 3.8. Significant negative correlations between HOMA-IR and forced expiratory volume at 1 s, maximum midexpiratory flow and forced vital capacity were detected. Multiple linear regression analysis showed that HOMA-IR (ß = - 0.323, p = 0.002) and total lung capacity (ß = 0.468, p < 0.001) were independently associated with forced expiratory volume at 1 s (r(2) = 0.358). CONCLUSIONS: Insulin resistance is related to respiratory function impairment in morbidly obese women. Our results strongly suggest that the metabolic pathways related to insulin resistance are crucial in initiating lung abnormalities previously described in type 2 diabetic patients. Copyright © 2010 John Wiley & Sons, Ltd.

Obstructive sleep apnoea and 24-h blood pressure in patients with resistant hypertension.

Obstructive sleep apnoea (OSA) is common in patients with resistant hypertension, but understanding of the pathogenic mechanisms linking both conditions is limited. This study assessed the prevalence of OSA and the relationships between OSA and 24-h blood pressure (BP) in 62 consecutive patients with resistant hypertension, defined as clinic BP values ≥ 140/90 despite the prescription of at least three drugs at adequate doses, including a diuretic. In order to exclude a 'white coat effect', only patients with ambulatory 24-h BP values ≥ 125/80 were recruited. Patients underwent polysomnography, 24-h ambulatory BP monitoring and completed the Epworth sleepiness scale (ESS). OSA was defined as an apnoea-hypopnoea index (AHI) ≥ 5 and excessive daytime sleepiness (EDS) by an ESS ≥ 10. A multiple linear regression analysis was used to assess the association of anthropometric data, OSA severity measures and ESS with 24-h systolic and diastolic BP. Mean 24-h BP values were 139.14/80.98 mmHg. Ninety per cent of patients had an AHI ≥ 5 and 70% had an AHI ≥ 30. Only the ESS was associated with 24-h diastolic BP [slope 0.775, 95% confidence interval (CI) 0.120-1.390, P < 0.02); age was associated negatively with 24-h diastolic BP (slope -0.64, 95% CI -0.874 to -0.411, P < 0.001). Compared with those without EDS, patients with EDS showed a significantly higher frequency of diastolic non-dipping pattern (69.2% versus 34.7%, P < 0.032). Our results demonstrate a high prevalence of severe OSA in patients with resistant hypertension and suggest that EDS could be a marker of a pathogenetic mechanism linking OSA and hypertension.

Primary care and sleep unit agreement in management decisions for sleep apnea: a prospective study in Spain.

STUDY OBJECTIVES: Involvement of primary care teams in the care of patients with OSA is a focus of interest. The study objective was to compare diagnostic and therapeutic agreement between decisions taken by primary care professionals and sleep unit specialists. METHODS: This was a prospective multicenter study conducted at primary care and specialized care centers in the urban area of Barcelona, Spain. Men and women aged 18-75 years who visited the participating primary care centers for any reason were recruited. Both primary care physicians and sleep specialists made a diagnostic and therapeutic decision with clinical data and results of a home sleep apnea test. All patients were finally assessed with respiratory polygraphy or polysomnography as a gold-standard test. RESULTS: A total of 229 patients underwent a home sleep apnea test and were evaluated at the primary care centers and the sleep units. Diagnostic agreement using the same tools and excluding indeterminate decisions was 69.8% (Cohen's kappa = 0.64; 95% confidence interval, 0.56-0.72). Agreement for therapeutic decisions (PAP vs conservative treatment) was obtained in 82.5% of patients (Cohen's kappa = 0.62; 95% confidence interval, 0.51-0.73), increasing to 92.5% (Cohen's kappa = 0.49, 95% confidence interval, 0.40-0.58) when indeterminate options were excluded. As compared with the final therapeutic decisions made at the sleep unit with respiratory polygraphy/polysomnography, primary care physicians agreed regarding 83.3% (Cohen's kappa = 0.62; 95% confidence interval, 0.49-0.74) of patients. CONCLUSIONS: Primary care professionals may assume an important role in the management of OSA in coordination with sleep centers, identifying patients who require specific treatment and should be referred to specialized care. CLINICAL TRIAL REGISTRATION: Registry: ClinicalTrials.gov; Name: PASHOS Project: Advanced Platform for Sleep Apnea Syndrome Assessment; URL: https://clinicaltrials.gov/ct2/show/NCT02591979; Identifier: NCT02591979.

Nighttime hypoxia affects global cognition, memory, and executive function in community-dwelling individuals with hypertension.

STUDY OBJECTIVES: The objective of this study was to determine which respiratory and architectural sleep parameters are related to cognitive function and cognitive status (mild cognitive impairment [MCI] versus normal cognitive aging [NCA]) in community-dwelling individuals with hypertension. Additionally, it aimed to determine whether the results changed in the presence or absence of vascular brain lesions (silent brain infarcts and extensive white matter hyperintensities [WMHs]). METHODS: In a cohort of individuals with hypertension and without previous stroke or dementia, we conducted in-hospital polysomnography including electroencephalography, electro-oculography, electromyography, and magnetic resonance imaging to assess silent brain infarcts and WMHs. Cognitive testing was carried out with a screening test (Dementia Rating Scale version 2 [DRS-2]) and a complete cognitive visit. RESULTS: This study included 158 participants with a median age of 65.0 years; 32.3% were females, and the median apnea-hypopnea index was 22.3 events/h. MCI was diagnosed in 24 study participants, and the rest had NCA. Regarding respiratory parameters, total DRS-2 scores (ß; 95% CI) 0.121; 0.026, 0.215 were positively associated with mean O2 saturation, whereas total (-0.022; -0.036, -0.009), executive function (-0.016; -0.026, -0.006) and memory (-0.017; -0.029, -0.004) DRS-2 scores were all negatively associated with the percent of time with oxygen saturation < 90% after correcting for education, vascular risk factors, and magnetic resonance imaging lesions. Regarding sleep architecture, Attention DRS-2 scores (0.0153; 0.001, 0.306) were independently associated with total sleep time. Similar results were obtained in the absence of silent brain infarcts or WMHs in the stratified analysis. None of the sleep parameters were associated with cognitive status. CONCLUSIONS: Low oxygen saturation contributes to cognitive performance, and this effect appears even in the absence of vascular brain lesions in individuals with hypertension.

Clinical Practice Guideline recommendations on examination of the upper airway for adults with suspected obstructive sleep apnoea-hypopnoea syndrome. / Recomendaciones de la Guía de Práctica Clínica de la exploración de la vía aérea superior para pacientes adultos con sospecha de síndrome de apnea-hipoapnea obstructiva del sueño (versión reducida).

In November 2014 the Spanish Society of Otolaryngology, the Spanish Sleep Society and the Spanish Society of Maxillofacial Surgery proposed and endorsed the development of a Clinical Practice Guideline on the physical examination of the upper airway in patients with obstructive sleep apnoea. The Guideline strictly followed the recommendations of the manual for the preparation of clinical practice guidelines of the National Health System 2007 and 2009 and the manual of the Scottish Intercollegiate Guidelines Network (SIGN) 2015. The final document could be highly useful for the purposes that were originally proposed: to act as a reference to unify the regions that should be explored in patients with obstructive sleep apnoea-hypopnoea syndrome, the type of examination and how to grade it, and specific to all the care areas to which these patients have access. The conclusions and recommendations are based on a thorough and up-to-date review of the literature with a high level of evidence, as well as the experience and knowledge demonstrated by all the members of the drafting group. This group was formed bearing in mind at all times the transversality of the project, and, therefore, specialists from all the involved areas participated (maxillofacial surgery, family medicine, pneumology, clinical neurophysiology, odontology and otolaryngology). The external reviewers of the final text were selected along the same lines.

A Conditional Inference Tree Model for Predicting Sleep-Related Breathing Disorders in Patients With Chiari Malformation Type 1: Description and External Validation.

STUDY OBJECTIVES: The aim of this study is to generate and validate supervised machine learning algorithms to detect patients with Chiari malformation (CM) 1 or 1.5 at high risk of the development of sleep-related breathing disorders (SRBD) using clinical and neuroradiological parameters. METHODS: We prospectively included two independent datasets. A training dataset (n = 90) was used to obtain the best model, whereas a second dataset was used to validate it (n = 74). In both cohorts, the same clinical, neuroradiological, and sleep studies were carried out. We used two supervised machine learning approaches, multiple logistic regression (MLR) and the unbiased recursive partitioning technique conditional inference tree (URP-CTREE), to detect patients at high risk of SRBD. We then compared the accuracy, sensitivity, and specificity of the two prediction models. RESULTS: Age (odds ratio [OR] 1.1 95% confidence interval [CI] 1.05-1.17), sex (OR 0.19 95% CI 0.05-0.67), CM type (OR 4.36 95% CI 1.14-18.5), and clivus length (OR 1.14 95% CI 1.01-1.31) were the significant predictor variables for a respiratory disturbance index (RDI) cutoff that was ≥ 10 events/h using MLR. The URP-CTREE model predicted that patients with CM-1 who were age 52 years or older and males with CM-1 who were older than 29 years had a high risk of SRBD. The accuracy of predicting patients with an RDI ≥ 10 events/h was similar in the two cohorts but in the URP-CTREE model, specificity was significantly greater when compared to MLR in both study groups. CONCLUSIONS: Both MLR and URP-CTREE predictive models are useful for the diagnosis of SRBD in patients with CM. However, URP-CTREE is easier to apply and interpret in clinical practice.

Coordinated program between primary care and sleep unit for the management of obstructive sleep apnea.

The purpose of this study is to develop and validate a work model in the primary health-care setting for identifying patients with obstructive sleep apnea-hypopnea syndrome (OSAHS) based on clinical variables and an ambulatory sleep monitoring study. After screening, patients with mild-moderate OSAHS could be managed by primary care physicians, whereas those identified with severe OSAHS would be referred to specialists from sleep units for starting specific treatment. The proposed model does not move the entire health-care process to a generally overburdened primary care level and favors the coordinated work and the necessary flexibility to adapt the model to challenges and perspectives of OSAHS.

[Cost-effectiveness analysis of automatic titration of continuous positive airway pressure at home in 1 night versus 2 nights]. / Análisis de coste-eficacia de la graduación automática de la presión positiva continua de la vía aérea en el domicilio: eurouna o 2 noches?

OBJECTIVE: To assess the cost-effectiveness of automatic continuous positive airway pressure (CPAP) titration at home on 1 night or 2 consecutive nights in patients with the sleep apnea-hypopnea syndrome (SAHS). PATIENTS AND METHODS: A home titration study was performed using automatic CPAP for 2 consecutive nights on 100 patients with SAHS and an indication for CPAP. The number of successful studies and the costs of the first night and both nights were analyzed. The pressure requirements on each night and the agreement between the pressures selected visually by 2 different observers were compared. RESULTS: CPAP titration was successful in 85% and 80% of patients on the first night and second night, respectively, and in 88% of patients after both nights. No significant differences between the 2 nights were found for the following parameters: 95th percentile pressure (mean [SD], 10.2 [1.8] cm H(2)O and 10.2 [1.6] cm H(2)O on the first and second nights, respectively), mean pressure (7.8 [1.7] cm H(2)O and 7.7 [1.7] cm H(2)O), or the pressure selected visually (9.4 [1.5] cm H(2)O and 9.4 [1.4] cm H(2)O). Interobserver agreement on the pressure selected was good: the k statistics were 0.956 for the first night and 0.91 for the second night. The 1-night study cost euro232.63 and the 2-night study cost euro227.93. CONCLUSIONS: Automatic CPAP titration at home for 1 night enables a substantially greater number of patients to be studied at a similar cost than is possible when titration is accomplished in 2 consecutive nights.