Predominant obstructive or central sleep apnea in patients with atrial fibrillation: influence of characterizing apneas versus apneas and hypopneas.

OBJECTIVE/BACKGROUND: Sleep-disordered breathing (SDB) is common in patients with atrial fibrillation (Afib). Although a high proportion of respiratory events are hypopneas, previous studies have only used apneas to differentiate obstructive (OSA) from central (CSA) sleep apnea. This study investigated the impact of using apneas and hypopneas versus apneas only to define the predominant type of SDB in Afib patients with preserved ejection fraction. PATIENTS/METHODS: This retrospective analysis was based on high-quality cardiorespiratory polygraphy (PG) recordings (07/2007-03/2016) that were re-analyzed using 2012 American Academy of Sleep Medicine criteria, with differentiation of apneas and hypopneas as obstructive or central. Classification of predominant (>50% of events) OSA and CSA was defined based on apneas only (OSAAI and CSAAI) or apneas and hypopneas (OSAAHI and CSAAHI). SDB was defined as an apnea-hypopnea index ≥5/h. RESULTS: A total of 211 patients were included (146 male, age 68.7 ± 8.5 y). Hypopneas accounted for >50% of all respiratory events. Based on apneas only, 46% of patients had predominant OSA and 44% had predominant CSA. Based on apneas and hypopneas, the proportion of patients with OSA was higher (56%) and that with CSA was lower (36%). In the subgroup of patients with moderate to severe SDB (AHI ≥ 15/h), the proportion with predominant CSA was 55.2% based on apneas only versus 42.1% with apneas and hypopneas. CONCLUSIONS: In hospitalized patients with Afib and SDB, use of apneas and hypopneas versus apneas alone had an important influence on the proportion of patients classified as having predominant OSA or CSA.

[Guidelines in Practice: The New S3 Guideline "Sleeping Disorders - Sleep-Related Abnormal Breathing"]. / Leitlinien in der Praxis: Die neue S3-Leitlinie "Nicht erholsamer Schlaf/Schlafstörungen" ­ Kapitel "Schlafbezogene Atmungsstörungen".

Sleep related breathing disorders include central sleep apnea (CSA), obstructive sleep apnea (OSA), sleep-related hypoventilation, and sleep-related hypoxia. These disorders are frequent and growing in clinical relevance. The related chapter of the S3 guideline "Non-restorative sleep/Sleep disorders", published by the German Sleep Society (DGSM), has recently been updated in November 2016. Epidemiology, diagnostics, therapeutic procedures, and classification of sleep related disorders have been revised. Concerning epidemiology, a considerably higher mortality rate among pregnant women with OSA has been emphasized. With regards to diagnostics, the authors point out that respiratory polygraphy may be sufficient in diagnosing OSA, if a typical clinical condition is given. For CSA, recommendations were changed to diagnose CSA with low apnea rates present. Significant changes for treating CSA in patients with left ventricular dysfunction have been introduced. In addition, there is now to be differentiated between sleep-related hypoventilation and sleep-related hypoxaemia. Obesity hypoventilation syndrome is discussed in more detail. This article sums up and comments on the published changes.

Comparison of American Academy of Sleep Medicine (AASM) versus Center for Medicare and Medicaid Services (CMS) polysomnography (PSG) scoring rules on AHI and eligibility for continuous positive airway pressure (CPAP) treatment.

BACKGROUND: Obstructive sleep apnea (OSA) is an important clinical condition. Eligibility for treatment usually depends on disease severity, measured as the apnea-hypopnea index (AHI), equal to the sum of apneas plus hypopneas per hour of sleep. There is divergence on scoring rules for hypopneas between the recommendations of the American Academy of Sleep Medicine (AASM) and the Center for Medicare Services (CMS), the latter being more restrictive. Thus, patients could be eligible for treatment under AASM rules, but not under CMS rules. METHODS: Sleep laboratory records of 112 consecutive patients were reviewed (85 < 65, 27 ≥ 65 years old). AHI was calculated both by AASM and by CMS criteria. Information on demographics, and important comorbidities, was also reviewed. RESULTS: AHI was lower in younger patients using CMS criteria. However, differences in AHI using the two sets of criteria were not significantly different in the older patients. Incorporating all criteria for eligibility (severity, presence of certain comorbid conditions) for treatment, we found that fewer younger patients would be eligible using CMS criteria, but among the older patients, eligibility for treatment was the same whether AASM or CMS criteria were used. CONCLUSIONS: Use of CMS criteria for scoring hypopneas results in lower estimates of OSA severity, with fewer younger patients eligible for treatment. However, among Medicare age patients, the rate of treatment eligibility was the same whether AASM or CMS scoring rules were used.

Implications of revised AASM rules on scoring apneic and hypopneic respiratory events in patients with heart failure with nocturnal Cheyne-Stokes respiration.

STUDY OBJECTIVES: This study investigated the implications of the revised scoring rules of the American Academy of Sleep Medicine (AASM) in patients with heart failure (HF) with Cheyne-Stokes respiration (CSR). METHODS: Ninety-one patients (NYHA ≥II, LVEF ≤45 %; age 73.6 ± 11.3 years old; 81 male subjects) with documented CSR underwent 8 h of cardiorespiratory polygraphy recordings. Those were analyzed by a single scorer strictly applying the 2007 recommended, 2007 alternative, and the 2012 scoring rules. RESULTS: Compared with the AASM 2007 recommended rules, apnea-hypopnea index (AHI) and hypopnea index (HI) increased significantly when the 2007 alternative and 2012 rules were applied (AHI 34.1 ± 13.5/h vs 37.6 ± 13.2/h vs 38.3 ± 13.2/h, respectively; HI 10.2 ± 9.4/h vs 13.7 ± 10.7/h vs 14.4 ± 11.0/h, respectively; all p < 0.001). Duration of CSR increased significantly with the alternate versus recommended 2007 rules (182.2 ± 117.0 vs 170.1 ± 115.0 min; p ≤ 0.001); there was a significant decrease in CSR duration for the 2012 versus 2007 alternative rules (182.2 ± 117.0 vs 166.7 ± 115.4 min; p ≤ 0.001). CONCLUSION: AHI was higher using the AASM 2012 scoring rules due to a less strict definition of hypopnea. Data on the prognostic effects of CSR in patients with HF and the benefits of treatment are mostly based on the AASM 2007 recommended rules, so differences between these and the newer version need to be taken into account.

The effect of respiratory scoring on the diagnosis and classification of sleep disordered breathing in chronic heart failure.

STUDY OBJECTIVES: To evaluate the effect of respiratory scoring criteria on diagnosis and classification of sleep disordered breathing (SDB) in chronic heart failure (CHF). DESIGN: Cross-sectional observational study. SETTING: Heart failure and general cardiology clinics at two London hospitals. PATIENTS OR PARTICIPANTS: One hundred eighty stable patients with CHF and a median age of 69.6 y, 86% male. INTERVENTIONS: SDB was diagnosed by polysomnography. The apnea-hypopnea index (AHI) was initially scored using a conservative hypopnea definition of a ≥ 50% decrease in nasal airflow with a ≥ 4% oxygen desaturation. The AHI was rescored with hypopnea defined according to the American Academy of Sleep Medicine (AASM) alternative scoring rule, requiring an associated ≥ 3% oxygen desaturation or arousal. SDB was defined as AHI ≥ 15/h. Diagnosis and classification of SDB as obstructive sleep apnea (OSA) or central sleep apnea (CSA) with each rule were compared. The effect of mixed apneas on classification of SDB as CSA or OSA was also investigated. MEASUREMENTS AND RESULTS: Median AHI increased from 9.3/h to 13.8/h (median difference 4.6/h) when the AASM alternative rule was used to score hypopneas. SDB prevalence increased from 29% to 46% with the alternative scoring rule (P < 0.001). Classification of SDB as OSA or CSA was not significantly altered by hypopnea scoring rules or the categorization of mixed apneas. CONCLUSION: Hypopnea scoring rules can significantly influence the apnea-hypopnea index and diagnosis of sleep disordered breathing in chronic heart failure but do not alter the classification as obstructive sleep apnea or central sleep apnea. Standardization of hypopnea scoring rules is important to ensure consistency in diagnosis of sleep disordered breathing in chronic heart failure patients.

Does central sleep apnea occur in children with syndromic craniosynostosis?

AIM: To evaluate the prevalence and cause of central sleep apnea (CSA) and central sleep apnea syndrome (CAS) in patients with syndromic craniosynostosis. MATERIALS AND METHODS: This prospective study included ambulant sleep study data to assess, central apneas and obstructive apneas. Data on hindbrain herniation were obtained using cerebral magnetic resonance imaging. RESULTS: One-hundred and thirty-eight syndromic craniosynostosis patients with a median (range) age of 7.8 (1.0-18.0) were included. Central apneas decreased significantly with increasing age (R=-0.25, p=0.003). An increased central apnea index according to the AASM was present in 5 of 138 patients (3.6%; median central apnea index 2.38 (1.12-3.04)). The prevalence of OSAS was 34%, but the median central apnea index in OSAS patients was not pathologically increased. Patients with hindbrain herniation did not have more central apneas compared to patients without hindbrain herniation (F=1.38, p=0.24). CONCLUSION: There is no CSA syndrome in children with syndromic craniosynostosis despite white matter abnormalities, OSAS and hindbrain herniation.

Classification of sleep apnea types using wavelet packet analysis of short-term ECG signals.

OBJECTIVE: Obstructive sleep apnea (OSA) causes a pause in airflow with reduced breathing effort. In contrast, central sleep apnea (CSA) event is not accompanied with breathing effort. The aim of this study is to differentiate CSA and OSA events using wavelet packet analysis and support vector machines of ECG signals over 5 s period. METHODS: Eight level wavelet packet analysis was performed on each 5 s clip using Daubechies (DB3) mother wavelet and for comparison discrete wavelet analysis was performed using Symlet (SYM3) wavelets. The choice of wavelet basis function was based on a grid search using Daubechies, Symlet and biorthogonal wavelets with decomposition levels varying between 2 and 5. Support vector machine is used for two-class classification. Out of 29 overnight polysomnographic studies, 23 of them were used in the training phase and 6 patients were used for independent testing. RESULTS: The proposed algorithm is shown to perform better in classifying CSA and OSA with wavelet packet features (accuracy-91%, sensitivity-88.14% and specificity-91.11%) than with the traditional wavelet decomposition based features (accuracy-83.79%, sensitivity-89.18% and specificity-83.59%). The independent test resulted in overall classification accuracy, sensitivity and specificity of 91.08, 91.02 and 91.09% respectively using wavelet packet analysis. CONCLUSIONS: The classification result indicates the possibility of non-invasively classifying CSA and OSA events based on shorter segments of ECG signals.

[Sleep-related breathing disorders--a second edition of the International Classification of Sleep Disorders (ICSD-2) of the American Academy of Sleep Medicine (AASM)]. / Schlafbezogene Atmungsstörungen--Neuauflage der Internationalen Klassifikation von Schlafstörungen (ICSD-2) der American Academy of Sleep Medicine (AASM).

In 2005 the American Academy of Sleep Medicine (AASM) published a revised form of the International Classification of Sleep Disorders (ICSD-2). Goals of the ICSD-2 are: A) To describe all currently recognized sleep and arousal disorders, and to base the descriptions on scientific and clinical evidence. B) To present the sleep and arousal disorders in an overall structure that is rational and scientifically valid. C) To render the sleep and arousal disorders as compatible with ICD-9 and ICD-10 as possible. In this article, sleep-disordered breathing disorders, as classified in the ICSD-2 are presented.

Reference values for nocturnal home polysomnography in primary schoolchildren.

Abbreviated home polysomnography may be an alternative to laboratory polysomnography in children but is not yet generally accepted, partly due to a lack of reference values. Also, there are no normative data on respiratory events obtained using nasal prongs. We determined the prevalence and frequency of central, obstructive, and mixed apneas and hypopneas in a population-based sample of 50 children (mean age 10.1 years) using abbreviated home polysomnography and nasal prongs. We also determined the frequency of movements/arousals and body position changes. All children had central apneas. Obstructive apneas, mixed apneas, and hypopneas were found in 36%, 6%, and 14% of children, respectively. Average number of central, obstructive, and mixed apneas; hypopneas; movement/arousals; and body position changes per hour of sleep was 1.5, 0.1, 0.01, 0.02, 8.2, and 3.7, respectively. The corresponding cutoff values (mean plus 2 standard deviations or 95th centile) were 3.7, 0.7, 0.1, 0.2, 13.4, and 9.1, respectively. We did not find significant gender differences regarding any sleep variable under study. The presented reference values may help clinicians and researchers to improve the interpretation of abbreviated home polysomnography in school-age children.

XIV Reunión Anual de la Asociación Ibérica de Patología del Sueño. Los síndromes de apnea central del sueño. La respiración de Cheyne Stokes / No disponible

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Sleep-related breathing disorders in patients who are critically ill.

This descriptive study describes the frequency and severity of sleep-related breathing disorders in men who are hemodynamically stable who have an acute cardiovascular illness and are hospitalized in a critical care unit. Sixty-four males, aged 55-79 years, with an acute cardiovascular illness, stable hemodynamics, and no ongoing chest pain or history of sleep apnea were studied for 1 night in the critical care unit using polysomnography. Forty-seven percent of the sample had an apnea-hypopnea index > or = 5, with events of both obstructive and central etiologies, including Cheyne-Stokes respiration. Oxygen desaturation to < or = 90% occurred in 61% of the sample. There were no episodes of chest pain, ventricular tachycardia, or heart block associated with apneic or hypopneic events; however, dysrhythmias, including sinus bradycardia, supraventricular tachycardia, and premature ventricular beats, were associated with apneic and hypopneic events.