The role of upper airway and facial skeleton anatomy in the evolution of obstructive sleep apnea: an 8-year follow-up.

PURPOSE: To evaluate the role of anatomic alterations of the upper airway and facial skeleton in the evolution of obstructive sleep apnea (OSA) in a prospective population-based study with an 8-year follow-up. METHODS: This was a population-based, longitudinal, prospective study, which took place from 2007 to 2015 at the Instituto do Sono, Sao Paulo, Brazil. In 2007, type I polysomnography (PSG), otorhinolaryngological examination, and collection of anthropometric measurements of all volunteers were performed. Volunteers were classified according to their anatomical features of the upper airway and facial skeleton. After 8 years, volunteers were invited for reevaluation. The relationship between anatomical characteristics and polysomnographic evolution was evaluated. RESULTS: The study included 554 patients. After 8 years of follow-up, there was an increase in neck circumference and body mass index of the participants. There was a worsening in all polysomnographic parameters analyzed, with an increase in the apnea-hypopnea index, a decrease in minimum saturation values, and an increase in the percentage of sleep time with peripheral oxyhemoglobin saturation <90%. There was no statistical relationship between the anatomical findings considered unfavorable and the worsening of polysomnographic parameters. CONCLUSIONS: In a sample of the general population, after 8 years, we did not find any relationship between upper airway and facial skeleton characteristics and the progression of OSA.

Can intraoral and facial photos predict obstructive sleep apnea in the general and clinical population?

STUDY OBJECTIVES: This study aimed to evaluate and compare measurements of standardized craniofacial and intraoral photographs between clinical and general population samples, between groups of individuals with an apnea-hypopnea index (AHI) ≥ 15 and AHI < 15, and their interaction, as well as the relationship with the presence and severity of obstructive sleep apnea (OSA). METHODS: We used data from 929 participants from Sleep Apnea Global Interdisciplinary Consortium, in which 309 patients from a clinical setting and 620 volunteers from a general population. RESULTS: AHI ≥ 15 were observed in 30.3% of the total sample and there were some interactions between facial/intraoral measures with OSA and both samples. Mandibular volume (p < 0.01) and lateral face height (p = 0.04) were higher in the AHI ≥ 15 group in the clinical sample compared to the AHI ≥ 15 group in the general population and AHI < 15 group in the clinical sample. When adjusted for sex and age, greater mandible width (p < 0.01) differed both in the clinical and in the general population samples, reflecting AHI severity and the likelihood of OSA. The measure of smaller tongue curvature (p < 0.01) reflected the severity and probability of OSA in the clinical sample and the higher posterior mandibular height (p = 0.04) showed a relationship with higher AHI and higher risk of OSA in the general population. When adjusted for sex, age, and body mass index, only smaller tongue curvature (p < 0.01) was associated with moderate/severe OSA. CONCLUSIONS: Measures of greater tongue and mandible were associated with increased OSA risk in the clinical sample and craniofacial measurement was associated in the general population sample.

Sleep parameters in patients with chronic hypersensitivity pneumonitis: a case-control study.

OBJECTIVE: To compare patients with chronic hypersensitivity pneumonitis (cHP) and controls with normal spirometry in terms of their sleep characteristics, as well as to establish the prevalence of obstructive sleep apnea (OSA) and nocturnal hypoxemia. Secondary objectives were to identify factors associated with OSA and nocturnal hypoxemia; to correlate nocturnal hypoxemia with the apnea-hypopnea index (AHI) and lung function, as well as with resting SpO2, awake SpO2, and SpO2 during exercise; and to evaluate the discriminatory power of sleep questionnaires to predict OSA. METHODS: A total of 40 patients with cHP (cases) were matched for sex, age, and BMI with 80 controls, the ratio of controls to cases therefore being = 2:1. The STOP-Bang questionnaire, the Epworth Sleepiness Scale (ESS), the Pittsburgh Sleep Quality Index, the Berlin questionnaire and the Neck circumference, obesity, Snoring, Age, and Sex (NoSAS) score were applied to all cases, and both groups underwent full-night polysomnography. RESULTS: The patients with cHP had longer sleep latency, lower sleep efficiency, a lower AHI, a lower respiratory disturbance index, fewer central apneas, fewer mixed apneas, and fewer hypopneas than did the controls. The patients with cHP had significantly lower nocturnal SpO2 values, the percentage of total sleep time spent below an SpO2 of 90% being higher than in controls (median = 4.2; IQR, 0.4-32.1 vs. median = 1.0; IQR, 0.1-5.8; p = 0.01). There were no significant differences between cases with and without OSA regarding the STOP-Bang questionnaire, NoSAS, and ESS scores. CONCLUSIONS: The prevalence of OSA in cHP patients (cases) was high, although not higher than that in controls with normal spirometry. In addition, cases had more hypoxemia during sleep than did controls. Our results suggest that sleep questionnaires do not have sufficient discriminatory power to identify OSA in cHP patients.

Beneficial Short-Term Effects of Bariatric Surgery on Nutritional Inflammatory Profile and Metabolic Biomarkers.

PURPOSE: Bariatric surgery (BS) has several potential metabolic benefits. However, little is known about its impact on changes in the inflammatory potential of diet and its effect on inflammatory and metabolic markers. This study aimed to assess the short-term beneficial effects of BS on dietary inflammatory potential and inflammatory and metabolic markers. MATERIALS AND METHODS: Participants (n = 20) were evaluated 3 months before and after BS. Body mass, body mass index, anthropometric measurements, fat mass, fat-free mass, visceral fat, skeletal muscle mass, basal metabolic rate, serum lipids, HOMA-IR, QUICKI and inflammatory markers, including leptin, adiponectin, adiponectin/leptin ratio and plasminogen activator inhibitor-1 (PAI-1), were evaluated. Diet data were collected using a 3-day diet record and the dietary inflammatory index (DII®) and energy-adjusted dietary inflammatory index (E-DIITM) scores were computed. RESULTS: There was a reduction in DII® (2.56 vs 2.13) and E-DIITM (2.18 vs 0.45) indicating an improvement in inflammatory nutritional profile. Moreover, there were increases in the adiponectin/leptin ratio (0.08 vs 0.21) and QUICKI scores (0.31 vs 0.37), and reductions in leptin (36.66 vs 11.41 ng/ml) and HOMA-IR scores (3.93 vs 1.50). There were also improvements in body composition and anthropometric parameters. CONCLUSIONS: BS promotes changes in metabolic profile, inflammatory state and food intake and these modifications appeared to be associated with improvements in diet-related inflammation, an increase in the adiponectin/leptin ratio and a reduction in leptin. These results contribute to knowledge on the contribution bariatric surgery can make to the treatment of obesity and the reduction of related comorbidities.

Three-dimensional comparison between the effects of mandibular advancement device and maxillomandibular advancement surgery on upper airway.

BACKGROUND: The efficacy of mandibular advancement devices (MAD) and maxillomandibular advancement (MMA) in improving upper airway (UA) patency has been described as being comparable to continuous positive airway pressure (CPAP) outcomes. However, no previous study has compared MAD and MMA treatment outcomes for the upper airway enlargement. This study aimed to evaluate three-dimensionally the UA changes and mandibular rotation in patients after MAD compared to MMA. METHODS: The sample consisted of 17 patients with treated with MAD and 17 patients treated with MMA matched by weight, height, body mass index. Cone-beam computed tomography from before and after both treatments were used to measure total UA, superior/inferior oropharynx volume and surface area; and mandibular rotation. RESULTS: Both groups showed a significant increase in the superior oropharynx volume after the treatments (p = 0.003) and the MMA group showed greater increase (p = 0.010). No statistical difference was identified in the MAD group considering the inferior volume, while the MMA group showed a significantly gain (p = 0.010) and greater volume (p = 0.024). Both groups showed anterior mandibular displacement. However, the mandibular rotation were statistically different between the groups (p < 0.001). While the MAD group showed a clockwise rotation pattern (-3.97 ± 1.07 and - 4.08 ± 1.30), the MMA group demonstrated a counterclockwise (2.40 ± 3.43 and 3.41 ± 2.79). In the MAD group, the mandibular linear anterior displacement was correlated with superior [p = 0.002 (r=-0.697)] and inferior [p = 0.004 (r = 0.658)] oropharynx volume, suggesting that greater amounts of mandibular advancement are correlated to a decrease in the superior oropharynx and an increase in the inferior oropharynx. In the MMA group, the superior oropharynx volume was correlated to mandibular anteroposterior [p = 0.029 (r=-0.530)] and vertical displacement [p = 0.047 (r = 0.488)], indicating greater amounts of mandibular advancement may lead to a lowest gain in the superior oropharynx volume, while a great mandibular superior displacement is correlated with improvements in this region. CONCLUSIONS: The MAD therapy led to a clockwise mandibular rotation, increasing the dimensions of the superior oropharynx; while a counterclockwise rotation with greater increases in all UA regions were showed in the MMA treatment.

Immediate and Medium-Term Follow-Up of Patients with Obstructive Sleep Apnea Undergoing Pharyngeal and Nasal Surgery: A Pilot Study.

Objectives To evaluate the evolution of obstructive sleep apnea (OSA), comparing data from preoperative, immediate postoperative and late postoperative, in patients undergoing pharyngeal surgery associated with nasal surgery, and to compare the findings of arterial tonometry and type 1 polysomnography in the late postoperative period. Methods Seventeen adults with moderate or severe OSA were included in the study. They underwent clinical evaluation, surgical intervention, and sleep study preoperatively, on the 1 st night after surgery, and after a minimum period of 3 months. The data for the three moments were compared. Results The mean age was 38.1 ± 12.5 years old (22 to 59 years old), and 82.3% were male. Body mass index (BMI) ranged from 25.6 to 45.1 kg/m2 (mean = 33.1 ± 5.8 kg/m 2 ). Fifteen patients (88.2%) were diagnosed with severe OSA. There was a progressive improvement, with a decrease in the indexes (AHI and RDI) and in the percentage of time with peripheral oxyhemoglobin saturation below 90% (tSpO < 90%), and an increase in nadir of SpO2. In the comparison between the 2 methods used in the late postoperative period - arterial tonometry and polysomnography - there was no difference in the indexes and in the tSpO < 90%. Discussion There was a progressive and favorable impact of pharyngeal surgery on the improvement of polysomnographic and clinical respiratory parameters; however, many patients maintained residual OSA, suggesting the need for a new sleep study in the postoperative period. The arterial tonometry showed similar findings to polysomnography, which can be considered as an option in postoperative follow-up of patients.

Facial and Intraoral Photographic Traits Related to Sleep Apnea in a Clinical Sample with Genetic Ancestry Analysis.

Rationale: Craniofacial and pharyngeal morphology influences risk for obstructive sleep apnea (OSA). Quantitative photography provides phenotypic information about these anatomical factors and is feasible in large samples. However, whether associations between morphology and OSA severity differ among populations is unknown. Objectives: The aim of this study was to examine this question in a large sample encompassing people from different ancestral backgrounds. Methods: Participants in SAGIC (Sleep Apnea Global Interdisciplinary Consortium) with genotyping data were included (N = 2,393). Associations between photography-based measures and OSA severity were assessed using linear regression, controlling for age, sex, body mass index, and genetic ancestry. Subgroups (on the basis of 1000 Genomes reference populations) were identified: European (EUR), East Asian, American, South Asian, and African (AFR). Interaction tests were used to assess if genetically determined ancestry group modified these relationships. Results: Cluster analysis of genetic ancestry proportions identified four ancestrally defined groups: East Asia (48.3%), EUR (33.6%), admixed (11.7%; 46% EUR, 27% Americas, and 22% AFR), and AFR (6.4%). Multiple anatomical traits were associated with more severe OSA independent of ancestry, including larger cervicomental angle (standardized ß [95% confidence interval (CI)] = 0.11 [0.06-0.16]; P < 0.001), mandibular width (standardized ß [95% CI] = 0.15 [0.10-0.20]; P < 0.001), and tongue thickness (standardized ß [95% CI] = 0.06 [0.02-0.10]; P = 0.001) and smaller airway width (standardized ß [95% CI] = -0.08 [-0.15 to -0.002]; P = 0.043). Other traits, including maxillary and mandibular depth angles and lower face height, demonstrated different associations with OSA severity on the basis of ancestrally defined subgroups. Conclusions: We confirm that multiple facial and intraoral photographic measurements are associated with OSA severity independent of ancestral background, whereas others differ in their associations among the ancestrally defined subgroups.

Influence of social jetlag on daytime sleepiness in obstructive sleep apnea.

Social jetlag is the discrepancy between socially determined sleep timing on workdays and biologically determined sleep timing on days free of social obligation. Poor circadian timing of sleep may worsen sleep quality and increase daytime sleepiness in obstructive sleep apnea (OSA). We analysed de-identified data from 2,061 participants (75.2% male, mean [SD] age 48.6 [13.4] years) who completed Sleep Apnea Global Interdisciplinary Consortium (SAGIC) research questionnaires and underwent polysomnography at 11 international sleep clinic sites. Social jetlag was calculated as the absolute difference in the midpoints of sleep between weekdays and weekends. Daytime sleepiness was assessed using the Epworth Sleepiness Scale (ESS). Linear regression analyses were performed to estimate the association between social jetlag and daytime sleepiness, with consideration of age, sex, body mass index, ethnicity, insomnia, alcohol consumption, and habitual sleep duration as confounders. Of the participants, 61.5% had <1 h of social jetlag, 27.5% had 1 to <2 h, and 11.1% had ≥2 h. Compared to those with <1 h of social jetlag, those with ≥2 h of social jetlag had 2.07 points higher ESS (95% confidence interval [CI] 0.77-3.38, p = 0.002), and those with 1 to <2 h of social jetlag had 0.80 points higher ESS (95% CI 0.04-1.55, p = 0.04) after adjustment for potential confounding. Interaction with OSA severity was observed; social jetlag appeared to have the greatest effect on daytime sleepiness in mild OSA. As social jetlag exacerbates daytime sleepiness in OSA, improving sleep timing may be a simple but novel therapeutic target for reducing the impact of OSA.

How much does sleep deprivation impair endurance performance? A systematic review and meta-analysis.

We conducted a systematic review and meta-analysis to investigate the effect of sleep deprivation on endurance performance, as well as possible effect-modifying factors. Searches were done in Pubmed, Web of Science, Embase, and Scopus on 12 July 2022. We additionally searched the bibliographic references and citations on Google Scholar of the papers whose full text was analyzed. Eligible studies were randomized and non-randomized controlled trials that compared sleep deprivation and habitual-sleep night effects on endurance performance in healthy humans. The studies' quality was examined by the Cochrane Collaboration's risk of bias tool. We calculated the pooled standardized mean differences (pooled SMD) and 95% confidence interval (95%CI) by a random-effects model. A mixed-effects model analyzed subgroups. Thirty-one studies were analyzed (n = 478), generating 38 effect sizes in full. The overall risk of bias was low in 8% of the studies, unclear in 74%, and high in 18%. Sleep deprivation in general had a moderate negative effect on endurance performance (polled SMD [95%CI] = -0.52 [-0.67; -0.38]). Training status, sleep deprivation magnitude, assessment time, exercise mode, and endpoint type did not influence the sleep deprivation effect, whereas longer exercises (>30 min) were more affected by sleep deprivation than shorter ones (P = 0.035). Therefore, the available evidence supports that sleep deprivation's deleterious effect on endurance performance is of moderate size and depends on exercise duration. This information can be useful to estimate the performance decrement of endurance exercise practitioners under sleep deprivation in training routines and competitions.PROSPERO registration number CRD42021229717.

Sleep deprivation causes a moderate deleterious effect on endurance performance.Sleep deprivation similarly impairs endurance performance in untrained, recreationally-trained, and trained people, but its effect on well-trained and professional endurance athletes is unknown.One or more nights of partial sleep deprivation or one night of total sleep deprivation similarly compromise endurance performance. Uncertainties about the effect of more than one night of total sleep deprivation warrant more studies.Sleep deprivation impairs walking, running, and cycling endurance performance regardless of the exercise endpoint being unknown (i.e. incremental or constant load tests) or known (i.e. time trial tests) and assessment time. However, sleep deprivation causes a more deleterious effect on endurance performance in exercises lasting more than 30 min.

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.

The effects of sleep deprivation and obstructive sleep apnea syndrome on male reproductive function: a multi-arm randomised trial.

Sleep is essential for the maintenance of health and systemic homeostasis. Decreased sleep time and sleep quality have been associated with a wide range of diseases. To evaluate the effects of obstructive sleep apnea (OSA) and total or selective rapid eye movement (REM) sleep deprivation on male reproductive function, we performed a three-arm parallel study with one pre-defined OSA group and a group of healthy volunteers who were then randomised into total or REM sleep deprivation groups. Questionnaires were completed and overnight polysomnography was undertaken, and blood and sperm samples were collected at the Sleep Institute, São Paulo, Brazil. OSA was diagnosed using questionnaires and polysomnography. Male sexual function was assessed through the questionnaires, blood tests, and semen samples. Data showed an association between OSA and lower circulating levels of total and free testosterone and high-density lipoproteins, as well as a lower proportion of healthy sperm cells and decreased sperm concentration, in comparison to volunteers. Volunteers subjected to either total or REM sleep deprivation had increased circulating levels of thyroid-stimulating hormone, insulin, and higher homeostatic model assessment of insulin resistance (HOMA-IR) values. Both sleep-deprived groups also shown decreased cholesterol, and low-density lipoproteins when compared to their baseline levels, but had no alterations in their spermograms. We observed a reduction in total testosterone following total sleep deprivation, but no effect after REM sleep deprivation. OSA was associated with a hormonal imbalance, which is probably linked with impaired reproductive function and associated comorbidities, such as sleep fragmentation/loss and obesity.

Sleep parameters in patients with chronic hypersensitivity pneumonitis: a case-control study / Parâmetros do sono em pacientes com pneumonite de hipersensibilidade crônica: estudo de caso-controle

ABSTRACT Objective: To compare patients with chronic hypersensitivity pneumonitis (cHP) and controls with normal spirometry in terms of their sleep characteristics, as well as to establish the prevalence of obstructive sleep apnea (OSA) and nocturnal hypoxemia. Secondary objectives were to identify factors associated with OSA and nocturnal hypoxemia; to correlate nocturnal hypoxemia with the apnea-hypopnea index (AHI) and lung function, as well as with resting SpO2, awake SpO2, and SpO2 during exercise; and to evaluate the discriminatory power of sleep questionnaires to predict OSA. Methods: A total of 40 patients with cHP (cases) were matched for sex, age, and BMI with 80 controls, the ratio of controls to cases therefore being = 2:1. The STOP-Bang questionnaire, the Epworth Sleepiness Scale (ESS), the Pittsburgh Sleep Quality Index, the Berlin questionnaire and the Neck circumference, obesity, Snoring, Age, and Sex (NoSAS) score were applied to all cases, and both groups underwent full-night polysomnography. Results: The patients with cHP had longer sleep latency, lower sleep efficiency, a lower AHI, a lower respiratory disturbance index, fewer central apneas, fewer mixed apneas, and fewer hypopneas than did the controls. The patients with cHP had significantly lower nocturnal SpO2 values, the percentage of total sleep time spent below an SpO2 of 90% being higher than in controls (median = 4.2; IQR, 0.4-32.1 vs. median = 1.0; IQR, 0.1-5.8; p = 0.01). There were no significant differences between cases with and without OSA regarding the STOP-Bang questionnaire, NoSAS, and ESS scores. Conclusions: The prevalence of OSA in cHP patients (cases) was high, although not higher than that in controls with normal spirometry. In addition, cases had more hypoxemia during sleep than did controls. Our results suggest that sleep questionnaires do not have sufficient discriminatory power to identify OSA in cHP patients.

RESUMO Objetivo: Comparar pacientes com pneumonite de hipersensibilidade crônica (PHc) e controles com espirometria normal quanto às características do sono, bem como estabelecer a prevalência de apneia obstrutiva do sono (AOS) e hipoxemia noturna. Os objetivos secundários foram identificar fatores associados à AOS e hipoxemia noturna; correlacionar a hipoxemia noturna com o índice de apneias e hipopneias (IAH), função pulmonar, SpO2 em repouso, SpO2 em vigília e SpO2 durante o exercício; e avaliar o poder discriminatório de questionários do sono para predizer AOS. Métodos: Um total de 40 pacientes com PHc (casos) foram emparelhados por sexo, idade e IMC com 80 controles (2:1). O questionário STOP-Bang, a Escala de Sonolência de Epworth (ESE), o Índice de Qualidade do Sono de Pittsburgh, o questionário de Berlim e o escore Neck circumference, obesity, Snoring, Age, and Sex (NoSAS, circunferência do pescoço, obesidade, ronco, idade e sexo) foram aplicados a todos os casos, e ambos os grupos foram submetidos a polissonografia de noite inteira. Resultados: Os pacientes com PHc apresentaram maior latência do sono, menor eficiência do sono, menor IAH, menor índice de distúrbio respiratório, menos apneias centrais, menos apneias mistas e menos hipopneias do que os controles. Os pacientes com PHc apresentaram SpO2 noturna significativamente menor; a porcentagem do tempo total de sono com SpO2 < 90% foi maior que nos controles (mediana = 4,2; IIQ: 0,4-32,1 vs. mediana = 1,0; IIQ: 0,1-5,8; p = 0,01). Não houve diferenças significativas entre os casos com e sem AOS quanto à pontuação no questionário STOP-Bang, no NoSAS e na ESE. Conclusões: A prevalência de AOS em pacientes com PHc (casos) foi alta, embora não tenha sido maior que a observada em controles com espirometria normal. Além disso, os casos apresentaram mais hipoxemia durante o sono do que os controles. Nossos resultados sugerem que os questionários do sono não têm poder discriminatório suficiente para identificar AOS em pacientes com PHc.

Risk prediction for Obstructive Sleep Apnea prognostic in Obese patients referred for bariatric surgery.

OBJECTIVES: (i) To assess the anthropometric measurements, along with the clinical characteristics and quality of life profiles of the studied patients; (ii) To determine the occurrence and severity of Obstructive Sleep Apnea (OSA), using polysomnography; and (iii) To identify the best anthropometric and clinical indicators to predict OSA in obese patients who are candidates for bariatric surgery. METHODS: a prospective observational study conducted in a private clinic, using consecutive sampling of patients eligible for bariatric surgery with a BMI ≥ 40, or with a BMI of ≥ 35 kg/m² accompanied by comorbidities associated with obesity. RESULTS: Sixty patients were initially selected, of whom 46 agreed to take part in the preoperative evaluation. OSA was observed in 76% of patients, 59% of whom had moderate-to-severe OSA, with a predominance of men in these groups. Among the variables suggesting statistical difference between groups, waist-to-hip ratio (WHR) was the only clinical factor associated with scores the apnea hypopnea index (AHI) ≥ 15, with a cut-off value of 0.95. The results showed that patients scoring above 0.95 are three times more likely to have moderate-to-severe apnea. CONCLUSION: The best risk factor for the prognostic of moderate-to-severe OSA was presenting a WHR score with a cut-off value of 0.95 or above.

Comparing CPAP masks during initial titration for Obstructive Sleep Apnea Syndrome: one-year experience

Abstract Objective: Continuous Positive Airway Pressure (CPAP) is the gold standard treatment for OSA. A wide variety of masks are used during CPAP therapy. The aim of the study is to compare polysomnography outcomes during titration for different types of masks (oronasal, nasal and pillow) and assess the impact on PAP titration. Methods: We retrospectively analyzed all CPAP titration polysomnography for one year. Anthropometric data and baseline apnea severity were documented. Results: A total of 497 patients were evaluated. Nasal masks were used in 82.3% (n = 409), pillow in 14.1% (n = 70) and oronasal in 3.6% (n = 18). There was no difference according to body mass index and baseline apnea-hypopnea index among the groups. The oronasal group was older and had higher titrated CPAP pressure, higher residual apnea-hypopnea index, lower sleep efficiency, more superficial N1 sleep and longer wake time after sleep onset. All other polysomnography outcomes were similar among the groups. The mean CPAP level was 11.6 ± 2.1 cm H2O for the oronasal mask, 10.1 ± 2.1 cm H2O for the nasal mask and 9.8 ± 2.2 cm H2O for the pillow. The residual apnea-hypopnea index was 10.4 ± 7.9 for the oronasal mask, 5.49 ± 5.34 events/h for the nasal mask and 4.98 ± 5.48 events/h for the pillow. The baseline apnea-hypopnea index was correlated with of a higher CPAP pressure for all the groups (p< 0.001 for the nasal group, p = 0.001 for the pillow group and p = 0.049 for the oronasal group). Body mass index and residual AHI were correlated with of a higher CPAP pressure for the nasal and pillow groups only (p < 0.001). Conclusion: The interface can have a significant impact on the effectiveness of PAP titration. Patients with oronasal masks have higher CPAP pressure, higher residual apnea-hypopnea index, lower sleep efficiency and higher wake time after sleep onset. Oronasal masks should not be recommended as the first choice for apnea patients. Level of evidence: Level 3.

The reproducibility of clinical OSA subtypes: a population-based longitudinal study.

PURPOSE: The identification of subgroups of obstructive sleep apnea (OSA) is critical to understand disease outcome and treatment response and ultimately develop optimal care strategies customized for each subgroup. In this sense, we aimed to perform a cluster analysis to identify subgroups of individuals with OSA based on clinical parameters in the Epidemiological Sleep Study of São Paulo city (EPISONO). We aimed to analyze whether or not subgroups remain after 8 years, since there is not any evidence showing if these subtypes of clinical presentation of OSA in the same population can change overtime. METHODS: We used data derived from EPISONO cohort, which was followed over 8 years after baseline evaluation. All individuals underwent polysomnography, answered questionnaires, and had their blood collected for biochemical examinations. OSA was defined according to AHI ≥ 15 events/h. Cluster analysis was performed using latent class analysis (LCA). RESULTS: Of the 1042 individuals in the EPISONO cohort, 68% agreed to participate in the follow-up study (n = 712), and 704 were included in the analysis. We were able to replicate the OSA 3-cluster solution observed in previous studies: disturbed sleep, minimally symptomatic and excessively sleepy in both baseline (36%, 45% and 19%, respectively) and follow-up studies (42%, 43%, and 15%, respectively). The optimal cluster solution for our sample based on Bayesian information criterion (BIC) was 2 cluster for baseline (disturbed sleep and excessively sleepy) and 3 clusters for follow-up (disturbed sleep, minimally symptomatic, and excessively sleepy). A total of 45% of the participants migrated clusters between the two evaluations (and the factor associated with this was a greater delta-AHI (B = - 0.033, df = 1, p = 0.003). CONCLUSIONS: The results replicate and confirm previously identified clinical clusters in OSA which remain in the longitudinal analysis, with some percentage of migration between clusters.

Depression and obesity, but not mild obstructive sleep apnea, are associated factors for female sexual dysfunction.

PURPOSE: Mild obstructive sleep apnea (OSA) is more prevalent than moderate and severe OSA and is more frequent in men than women. The association between OSA and female sexual dysfunction (FSD) is still poorly explored in published studies. Our aim was to investigate the prevalence of FSD in women with mild OSA and assess the impact of OSA on FSD, as well as to determine the predictors for FSD risk. METHODS: The sample comprised 70 women aged 26-65 years: a control group (N = 28) with no sleep complaints, and a group with mild OSA (an apnea-hypopnea index of 5 or more and less than 15 events/hour, N = 42), who had been diagnosed using polysomnography performed in the sleep laboratory of a sleep research institute. All participants volunteered to take part in the study and completed the female sexual function index (FSFI), the Beck depression index (BDI), the Kupperman menopausal index (KMI), and the Epworth sleepiness scale (ESS). Their socioeconomic group was assessed using the Brazilian Economic Classification Criterion. Polysomnography and serum levels of free testosterone and total testosterone were analyzed. RESULTS: We found low FSFI scores (< 26.55) in the mild OSA (18.1) and control (21.7) groups (p = 0.97). There was no statistically significant difference between the mild OSA group and the control group. However, a higher BMI (p = 0.04), a higher BDI (p = 0.02), and being sexuality inactive (p = 0.001) were risk factors for FSD. CONCLUSION: There was a high prevalence of FSD in the entire sample. The presence of mild OSA did not affect sexual function in this sample. Depressive symptoms and a high BMI were associated risk factors for FSD. Being sexually active may protect female sexual function.

Three-dimensional craniofacial characteristics associated with obstructive sleep apnea severity and treatment outcomes.

OBJECTIVES: This study aims to assess craniofacial dimensions in obstructive sleep apnea (OSA) patients treated with a mandibular advancement device (MAD) and to identify anatomic influences on OSA severity and MAD therapy outcomes. MATERIALS AND METHODS: Twenty patients with OSA were prospectively treated with MAD. Clinical, cone-beam computed tomography, and polysomnography exams were performed before treatment and 4-6 months after achieving the MAD therapeutic position. Polysomnographic exams and three-dimensional maxillary, mandibular, and upper airway (UA) measurements were evaluated. Pearson's correlation and t-tests were applied. RESULTS: Before MAD treatment, the transverse width measured at the frontomaxillary suture and the angle between the mandibular ramus and Frankfurt horizontal were statistically correlated with apnea and the hypopnea index (AHI), while the gonial angle was correlated with therapeutic protrusion. After MAD treatment, all patients showed a significant AHI reduction and an improvement in minimum oxyhemoglobin saturation. The UA total volume, superior and inferior oropharynx volume, and area were statistically correlated with MAD therapeutic protrusion. The UA total area showed a statistical correlation with the improvement in AHI, and the superior oropharynx volume and area increased significantly. CONCLUSIONS: The transversal frontomaxillary suture width and the mandibular ramus facial angle may influence OSA severity. The gonial angle, volume, and area of all UA regions may indicate the amount of protrusion needed for successful MAD treatment. CLINICAL RELEVANCE: The craniofacial characteristics reported as important factors for OSA severity and MAD treatment outcomes impact therapy planning for OSA patients, considering individual anatomic characteristics, prognosis, and cost benefits.

Comparing CPAP masks during initial titration for Obstructive Sleep Apnea Syndrome: one-year experience.

OBJECTIVE: Continuous Positive Airway Pressure (CPAP) is the gold standard treatment for OSA. A wide variety of masks are used during CPAP therapy. The aim of the study is to compare polysomnography outcomes during titration for different types of masks (oronasal, nasal and pillow) and assess the impact on PAP titration. METHODS: We retrospectively analyzed all CPAP titration polysomnography for one year. Anthropometric data and baseline apnea severity were documented. RESULTS: A total of 497 patients were evaluated. Nasal masks were used in 82.3% (n = 409), pillow in 14.1% (n = 70) and oronasal in 3.6% (n = 18). There was no difference according to body mass index and baseline apnea-hypopnea index among the groups. The oronasal group was older and had higher titrated CPAP pressure, higher residual apnea-hypopnea index, lower sleep efficiency, more superficial N1 sleep and longer wake time after sleep onset. All other polysomnography outcomes were similar among the groups. The mean CPAP level was 11.6 ±â€¯2.1 cm H2O for the oronasal mask, 10.1 ±â€¯2.1 cm H2O for the nasal mask and 9.8 ±â€¯2.2 cm H2O for the pillow. The residual apnea-hypopnea index was 10.4 ±â€¯7.9 for the oronasal mask, 5.49 ±â€¯5.34 events/h for the nasal mask and 4.98 ±â€¯5.48 events/h for the pillow. The baseline apnea-hypopnea index was correlated with of a higher CPAP pressure for all the groups (p < 0.001 for the nasal group, p = 0.001 for the pillow group and p = 0.049 for the oronasal group). Body mass index and residual AHI were correlated with of a higher CPAP pressure for the nasal and pillow groups only (p < 0.001). CONCLUSION: The interface can have a significant impact on the effectiveness of PAP titration. Patients with oronasal masks have higher CPAP pressure, higher residual apnea-hypopnea index, lower sleep efficiency and higher wake time after sleep onset. Oronasal masks should not be recommended as the first choice for apnea patients. LEVEL OF EVIDENCE: Level 3.

Risk prediction for Obstructive Sleep Apnea prognostic in Obese patients referred for bariatric surgery / Predição de risco para o prognóstico de Apneia Obstrutiva do Sono em pacientes encaminhados para cirurgia bariátrica

ABSTRACT Objectives (i) To assess the anthropometric measurements, along with the clinical characteristics and quality of life profiles of the studied patients; (ii) To determine the occurrence and severity of Obstructive Sleep Apnea (OSA), using polysomnography; and (iii) To identify the best anthropometric and clinical indicators to predict OSA in obese patients who are candidates for bariatric surgery. Methods a prospective observational study conducted in a private clinic, using consecutive sampling of patients eligible for bariatric surgery with a BMI ≥ 40, or with a BMI of ≥ 35 kg/m² accompanied by comorbidities associated with obesity. Results Sixty patients were initially selected, of whom 46 agreed to take part in the preoperative evaluation. OSA was observed in 76% of patients, 59% of whom had moderate-to-severe OSA, with a predominance of men in these groups. Among the variables suggesting statistical difference between groups, waist-to-hip ratio (WHR) was the only clinical factor associated with scores the apnea hypopnea index (AHI) ≥ 15, with a cut-off value of 0.95. The results showed that patients scoring above 0.95 are three times more likely to have moderate-to-severe apnea. Conclusion The best risk factor for the prognostic of moderate-to-severe OSA was presenting a WHR score with a cut-off value of 0.95 or above.

RESUMO Objetivos (i) Avaliar as medições antropométricas e as características clínicas e perfis de qualidade de vida dos pacientes estudados, (ii) determinar a ocorrência e severidade da Apneia Obstrutiva do Sono (AOS) por meio de polissonografia e (iii) identificar os melhores indicadores antropométricos e clínicos para prever a AOS em pacientes obesos que são candidatos à cirurgia bariátrica. Métodos Estudo prospectivo de observação conduzido em uma clínica particular, por meio de amostragem consecutiva de pacientes qualificados para cirurgia bariátrica com IMC ≥ 40 ou IMC de ≥ 35 kg/m² e comorbidades associadas à obesidade. Resultados Inicialmente, 60 pacientes foram selecionados, dos quais 46 concordaram em participar de avaliação pré-operatória. A AOS foi observada em 76% dos pacientes, sendo que 59% deles apresentavam AOS de moderada a grave, com uma predominância de homens nesses grupos. Entre as variáveis que sugerem diferença estatística entre os grupos, a relação cintura/quadril (RCQ) foi o único fator clínico associado à pontuação no índice de apneia-hipopneia (IAH) ≥ 15, com um valor de corte de 0.95. Os resultados mostram que pacientes com uma pontuação acima de 0,95 têm três vezes mais probabilidade de apresentarem apneia de moderada a grave. Conclusão O melhor fator de risco para o prognóstico de AOS de moderada a grave foi apresentado na pontuação de RCQ, com um valor de corte de 0,95 ou acima.

Obstructive sleep apnea and the retina: a review.

CITATION: This review's objective was to synthesize the literature on the repercussions of obstructive sleep apnea (OSA) in the retinal vascular system. Two independent investigators conducted a search using the MEDLINE/PubMed database using the following terms: sleep apnea syndrome, obstructive sleep apnea, retina, vascular tortuosity, central serous chorioretinopathy, diabetes mellitus, and subfoveal choroidal thickness. Patients with OSA present increased vascular tortuosity compared with patients without OSA, decreased parafoveal and peripapillary vessel density, and increased retinal vein occlusion incidence. In central serous chorioretinopathy patients and patients who are poor responders to intravitreal anti-VEGF (-vascular endothelial growth factor) treatment for macular edema, OSA is more frequent. Macular choroidal thickness alterations are controversial, and OSA may worsen diabetic maculopathy, thus being a risk factor for diabetic retinopathy, proliferative diabetic retinopathy, and macular edema. OSA is a prevalent syndrome with many systemic vascular changes. The retina and choroid are the most affected ocular structures, with primarily vascular changes. New noninvasive technologies such as optical coherence tomography and optical coherence tomography angiography could help to better understand retinal structures and help clarify the ophthalmological repercussions of OSA. CITATION: Nakayama LF, Tempaku PF, Bergamo VC, et al. Obstructive sleep apnea and the retina: a review. J Clin Sleep Med. 2021;17(9):1947-1952.