Long term effects of continuous positive airway pressure treatment of obstructive sleep apnea-hypopnea syndrome in multiple sclerosis patients.

BACKGROUND: Obstructive sleep apnea-hypopnea (OSAH) is common in MS patients and is associated with fatigue. We recently published a randomized, controlled trial (RCT) of active vs sham continuous positive airway pressure (CPAP) treatment in MS patients with fatigue, poor sleep quality, and (OSAH) (Mult Scl J 2022;28:82-92). Our aim was to evaluate the long-term effects of CPAP treatment on fatigue (Fatigue Severity Scale, FSS, primary outcome) and other clinical outcomes in MS patients with OSAH. METHODS: Following the RCT, participants were offered treatment with CPAP and participation in an open label study. Patients were re-evaluated with RCT outcome measures at least 6 months after completion of the RCT. RESULTS: Twenty-eight of 34 (82 %) RCT-completers participated in this study a mean of 2.7 years after the RCT. Sixteen (57 %) patients were treated with CPAP (mean use 5.4 ± 1.0 h/night during the 6 months prior to follow-up visit), while the other 12 patients declined CPAP use and received no other OSAH treatments. Baseline clinical characteristics, including MS related disability and sleep outcomes, were not significantly different between CPAP-treated vs non-CPAP treated patients. Patients using CPAP at follow-up (n = 16) demonstrated significant improvements from RCT baseline in FSS (p = 0.005), Fatigue Scale for Motor and Cognitive Functions (p = 0.008, p = 0.012), Pittsburgh Sleep Quality Index (p = 0.016), Center of Epidemiological Studies-Depression Scale (p = 0.05), and Multiple Sclerosis Quality of Life-54 (MSQOL-54) physical and mental component scores (p = 0.012, p = 0.023), but no improvements in Epworth Sleepiness Scale, Pain Visual Analog Scale, or Expanded Disability Status Scale. Patients not using CPAP (n = 12) had no significant improvements in outcome measures. Using a linear mixed model, FSS (p = 0.03), morning fatigue (p = 0.048), and MSQOL-54 physical component score (p = 0.02) improved significantly in CPAP treated patients compared with non-CPAP treated patients from RCT baseline. CONCLUSION: In this post-RCT open label study, long-term CPAP use was associated with improved fatigue (FSS, our primary outcome) and physical quality of life in MS patients with OSAH.

Scoring heart rate increases as a surrogate arousal marker on portable monitor studies for obstructive sleep apnea: Impact on diagnostic accuracy and clinical decision-making.

Cortical arousal-related hypopneas are not scored on type 3 home devices, which therefore limits their diagnostic accuracy for obstructive sleep apnea. The objective of this study was to evaluate whether scoring heart rate accelerations as surrogate markers of arousal improves type 3 portable monitor diagnostic agreement compared with polysomnography and improves therapeutic decision-making. We prospectively recruited patients evaluated for obstructive sleep apnea to undergo in-laboratory simultaneous full polysomnography + type 3 portable monitoring. Hypopnea events were scored on portable monitor studies with and without autonomic scoring, which was defined as an associated increase in pulse oximetry-derived heart rate ≥6 beats per min (autonomic hypopnea). Portable monitor diagnostic agreement compared with polysomnography with and without autonomic hypopnea scoring was assessed. We also evaluated whether reporting autonomic hypopnea scoring improves portable monitor clinical treatment decision agreement after four physicians reviewed clinical data and sleep study results (polysomnography, portable monitor with autonomic hypopnea, portable monitor without autonomic hypopnea). Eighty-two participants completed simultaneous polysomnography and in-laboratory portable monitor studies. Scoring autonomic hypopnea resulted in a decreased mean difference between in-laboratory portable monitor respiratory event index and polysomnography apnea-hypopnea index in Bland-Altman analysis (mean difference 14.6 per hr without versus 6.1 per hr with autonomic hypopnea scoring [p ˂ 0.01]), and increased intraclass correlation from 0.769 to 0.844. Inclusion of autonomic hypopnea scoring resulted in better accuracy between portable monitor and polysomnography expert's treatment decisions, and ultimately resulted in 24% fewer additional polysomnographies requested. The addition of pulse oximetry heart rate increases for autonomic hypopnea scoring during portable monitor resulted in better diagnostic agreement, improved clinical decision-making and reduced additional polysomnography testing.

Effect of continuous positive airway pressure treatment of obstructive sleep apnea-hypopnea in multiple sclerosis: A randomized, double-blind, placebo-controlled trial (SAMS-PAP study).

OBJECTIVE: The aim of this study was to evaluate the effect of continuous positive airway pressure (CPAP) treatment on the Fatigue Severity Scale (FSS, preplanned primary outcome), another fatigue measure, sleep quality, somnolence, pain, disability, and quality of life in multiple sclerosis (MS) patients with obstructive sleep apnea-hypopnea (OSAH). METHODS: In a randomized, double-blind trial (NCT01746342), MS patients with fatigue, poor subjective sleep quality, and OSAH (apnea-hypopnea index of ⩾ 15 events per hour/sleep), but without severe OSAH (apnea-hypopnea index > 30, and 4% oxygen desaturation index > 15 events/hour or severe somnolence), were randomized to fixed CPAP or sham CPAP for 6 months. Outcome assessments were performed at 3 and 6 months. RESULTS: Of 49 randomized patients, 34 completed the protocol. Among completers, FSS did not improve with CPAP compared to sham at 6 months. FSS tended to improve (p = 0.09), and sleepiness (Epworth Sleepiness Scale) improved significantly (p = 0.03) at 3 months with CPAP compared to sham, but there were no other improvements with CPAP at either study evaluation. CONCLUSION: In non-severe OSAH patients, CPAP did not significantly improve the primary outcome of FSS change at 6 months. In secondary analyses, we found a trend to improved FSS, and a significant reduction in somnolence with CPAP at 3 months.