Insomnia symptoms combined with nocturnal hypoxia associate with cardiovascular comorbidity in the European sleep apnea cohort (ESADA).

PURPOSE: The aim of the current study was to further investigate the concept of previously reported high occurrence of comorbidities in obstructive sleep patients (OSA) with insomnia-like symptoms. We hypothesized that this finding at least partly is mediated by nocturnal hypoxia. Moreover, we speculated that the spectrum of the clinical OSA phenotypes differs between European geographical regions. METHODS: Cohort of the European Sleep Apnea Database (n = 17,325; 29.9% females) was divided into five subcohorts according to geographical region (North, East, South, West, Central) and further into four clinical presentation phenotypes based on daytime symptoms (EDS) and characteristics suggestive of insomnia. RESULTS: The insomnia phenotype (alone or together with EDS) dominated in all European regions. Isolated insomnia, however, was less common in the West. Insomnia phenotype was associated with the highest proportion of cardiovascular comorbidity (51.7% in the insomnia vs. 43.9% in the EDS type). Measures of nocturnal hypoxemia were independently associated with cardiovascular comorbidity in phenotypes with insomnia-like symptoms. The burden of comorbidities was high across all geographical regions and clinical phenotypes. Regional differences were clinically relevant for age (48 vs. 54 years), BMI (29 vs. 34 kg/m2), and ODI (15 vs. 32/h). CONCLUSION: High prevalence of particularly cardiovascular comorbidity among patients with insomnia-like symptoms was linked to nocturnal hypoxemia. Considerable differences in clinical presentation were found among OSA patients across Europe. Our data underline that physicians should ask their patients with suspected OSA also for insomnia symptoms. It remains to be explored if a reduction of nocturnal hypoxemia predicts the improvement of insomnia symptoms.

Effects of optimized heart failure medication on central sleep apnea with Cheyne-Stokes respiration pattern in chronic heart failure with reduced left-ventricular ejection fraction.

Central Sleep Apnea with Cheyne Stokes Respiration (CSA-CSR) is often diagnosed in patients with chronic heart failure (CHF). CSA-CSR displays a periodic breathing pattern with a typical waxing and waning breathing with central sleep apnea phases in between. Optimization of heart failure medication with Angiotensin receptor neprilysin inhibition (ARNi) can effect phenotypic traits of CSA-CSR indicating improvements of both, hemodynamic parameters and central chemosensitivity.

Improved follow-up by peripheral arterial tonometry in CPAP-treated patients with obstructive sleep apnea and persistent excessive daytime sleepiness.

BACKGROUND: OSA-patients with persistent excessive daytime sleepiness (EDS) despite CPAP treatment are challenging in daily clinical life. To rule out residual sleep-disordered breathing (SDB), CPAP device-derived data are used in outpatient setting. In case of no pathological finding, a more intensive work-up with is necessary. 6-channel portable monitoring (6Ch-PM) is frequently used to exclude residual SDB. Peripheral arterial tonometry (PAT), as embodied in the WatchPAT device, represents an alternative technique for detecting SDB based on changes in autonomic tone. We wanted to investigate whether PAT might be a useful tool to improve diagnostic work-up in this specific patient group by better identifying residual SDB due to insufficient CPAP-adjustment. METHODS: Forty-nine OSA patients (39 male, 10 female) with sufficient CPAP treatment according to device-derived data were consecutively recruited. EDS was assessed by Epworth Sleepiness Scale (ESS). All patients underwent home-based CPAP therapy control by 6Ch-PM and portable monitoring using PAT technology on two consecutive nights. A sequence of both types of monitoring was randomized to prevent possible first night effect bias. RESULTS: Twelve out of 49 patients showed persistent EDS according to ESS (ESS > 10 points). 6Ch-PM showed a residually increased AHI under CPAP-treatment in 2 of those 12 subjects (positive predictive value, PPV = 16.7%). PAT-PM revealed 5 patients of those 12 with residual SDB (PPV = 41.7%). CONCLUSION: PAT could detect significantly more residual SDB under CPAP treatment than 6Ch-PM. Diagnostic work-up of CPAP-treated OSA patients with persistent EDS might be optimized, as insufficient pressure level adjustments could be recognized more precisely in time, possibly preventing more resource-consuming procedures, and potentially increased morbidity. CLINICAL TRIAL REGISTRATION: DRKS00007705.

[Lung Health Data of the Study of Health in Pomerania - a Review of Samples, Methods and First Results]. / Pneumologisch relevante Daten aus der "Study of Health in Pomerania" (SHIP) ­ eine Übersicht zu den Kohorten, Methoden und ersten Ergebnissen.

Investigating reasons for differing life expectancy and prevalence of cardiovascular risk factors between old and new states of the Federal Republic of Germany an epidemiological study in Western Pomerania - the population-based project Study of Health in Pomerania (SHIP) - was planned.Prevalence and incidence of common risk factors, subclinical disorders and clinical diseases have been assessed since 1997 in five-year intervals. The third follow up (SHIP-3) was assessed between 2014 and 2016. In addition, an independent representative population sample was investigated between 2008 - 2012 (SHIP-TREND). Recently, the first follow up of this cohort has been started (SHIP-TREND-1). This paper reports the methodological approaches for detecting pneumological relevant morbidities in this population-based study. It aims to offer insights for potential cooperation with interested research groups.

Exposure to light and darkness and its influence on physiological measures of intensive care unit patients-a systematic literature review.

Sleep-wake patterns are often significantly disturbed in critically ill patients. This disturbance is closely linked to secondary brain dysfunctions in these patients. Sedation not only impairs sleep quality in ICU patients but also has detrimental effects on short- and long-term outcome. In other contexts, light therapy has been proven to be effective in maintaining and resynchronizing circadian rhythmicity in humans. The objective of this systematic review was to analyse studies that investigated the effect of exposure to light or darkness on physiological measures and clinical outcomes of adult ICU patients. Studies were systematically identified by searching electronic bibliographic databases (The Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library, 2002) and MEDLINE via PubMed). The search algorithm identified a total of 156 articles, 10 of which were taken into final review. These 10 selected articles included 3 were monocentric RCTs, five prospective cohort studies, one retrospective cohort study, and one manuscript that included a partial systematic review of the literature. Included trials were published between 2007 and 2015. Five of these studies used multiple intervention approaches while four trials used a single intervention approach. Among all studies, 1,278 patients were analysed (489 prospectively). There was a high heterogeneity among the studies in terms of applied intervention and outcome measures. The most frequent methodological limitations were a lack of precise definitions regarding the illuminance and the light spectrum utilised. The analyses indicate that further studies including clearly defined interventions with objective outcome measures, as these are currently lacking, would add significant knowledge to this new field of research.

Feasibility of noise reduction by a modification in ICU environment.

Noise is a proven cause of wakefulness and qualitative sleep disturbance in critically ill patients. A sound pressure level reduction can improve sleep quality, but there are no studies showing the feasibility of such a noise reduction in the intensive care unit (ICU) setting. Considering all available evidence, we redesigned two ICU rooms with the aim of investigating the physiological and clinical impact of a healing environment, including a noise reduction and day-night variations of sound level. Within an experimental design, we recorded 96 h of sound-pressure levels in standard ICU rooms and the modified ICU rooms. In addition, we performed a sound source observation by human observers. Our results show that we reduced A-weighted equivalent sound pressure levels and maximum sound pressure levels with our architectural interventions. During night-time, the modification led to a significant decrease in 50 dB threshold overruns from 65.5% to 39.9% (door side) and from 50% to 10.5% (window side). Sound peaks of more than 60 decibels were significantly reduced from 62.0% to 26.7% (door side) and 59.3% to 30.3% (window side). Time-series analysis of linear trends revealed a significantly more distinct day-night pattern in the modified rooms with lower sound levels during night-times. Observed sound sources during night revealed four times as many talking events in the standard room compared to the modified room. In summary, we show that it is feasible to reduce sound pressure levels using architectural modifications.

[Diagnosis of sleep disordered breathing using portable methods]. / Diagnostik schlafbezogener Atmungsstörungen mittels portabler Verfahren.

Portable monitoring of sleep disordered breathing is the first diagnostic method not only in Germany but today in other countries as well. The conditions under which portable monitoring can be done with reliable results are now well defined. The limitations for the use of portable monitoring are specified as well. The devices used for portable monitoring are classified in four categories according to the number and the kind of signals recorded. New technical developments in the field of portable monitoring (polygraphy) use an indirect assessment of sleep disordered breathing based on signals not directly recording respiration. The recording of ECG and deriving respiration, the analysis of the plethysmographically recorded pulse wave, the recording of jaw movements using magnets, and advanced analysis of respiratory sounds are recent approaches. These new methods are presented with few studies until now. More and larger clinical studies are needed in order to show which of these systems is useful in the diagnosis of sleep disordered breathing and which are the specific strengths and weaknesses.

[Portable sleep monitoring in patients with disorders in falling asleep or maintaining sleep]. / Erweiterte ambulante Polygraphie bei Patienten mit Ein- und/oder Durchschlafstörungen.

BACKGROUND: The most common diagnoses in sleep medicine are insomnia, sleep disordered breathing (SDB) and periodic leg movements (PLM). These disorders may coincide. This study examined the role of portable sleep monitoring in the diagnostic process and which sleep medicine diagnoses are additionally found in patients with disorders of initiating and maintaining sleep. METHODS: A total of 217 patients, including 103 men (47.5%) and 114 (52.5%) women aged 52.2 ± 13.6 years with disorders of initiating or maintaining sleep were included in the study. Patients with known SDB were excluded. Patients were investigated using a stepwise diagnostic procedure with clinical interviews, questionnaires, clinical examination and portable sleep recording with electromyography (EMG) of the tibialis anterior muscle to diagnose SDB and PLM. RESULTS: Of the patients 125 (57.6%) were diagnosed with insomnia according to the International Classification of Sleep Disorders (ICSD) and 70 (56%) had no other sleep disorder. Out of the 217 patients SDB was found in 107 (49.3%) patients, PLM in 90 patients (41.5%) and in 78 patients (35.9%) restless legs syndrome (RLS) was diagnosed. Among the 125 patients with insomnia 44 patients had RLS/PLMD and 35 had SDB in addition whereas SDB and RLS/PLMD were found in 33 subjects. All 3 disorders insomnia, RLS/PLMD and SDB were found in 24 subjects. CONCLUSIONS: Out of 217 patients with a complaint of non-restorative sleep only 125 were finally diagnosed with insomnia. As 25.3% of patients showed combinations of sleep disorders, 49.3% with SDB and 41.5% with RLS/PLMD portable monitoring with electromyography of the legs is recommended. The investigation with a portable sleep monitoring system including an EMG of the tibialis muscle is very useful in patients with insomnia in addition to a clinical interview and questionnaires.

[Sleep-disordered breathing and atrial fibrillation]. / Schlafbezogene Atmungsstörungen und Vorhofflimmern.

Sleep-disordered breathing is one of the most common sleep disorders. Especially obstructive sleep apnea (OSA) is an independent cardiovascular risk factor. Clinical studies have proven a significant association between OSA and atrial fibrillation, the most common cardiac arrhythmia. Currently, there is no proven evidence for causality. Untreated OSA seems to be a risk factor for failure of rhythm control strategy in atrial fibrillation. The recurrence rate after cardioversion is higher in case of additional untreated OSA. Continuous positive airway pressure (CPAP) therapy in OSA patients could reduce relapse rate. However, there is a lack of randomized controlled clinical trials with defined end points on this topic. A specific sleep medicine interview as well as sleep studies with portable monitoring and cardiorespiratory polysomnography are recommended when sleep-disordered breathing is suspected. Procedures for the management of patients with atrial fibrillation are given.

Effect of CPAP therapy on daytime cardiovascular regulations in patients with obstructive sleep apnea.

Obstructive sleep apnea (OSA) is a sleep disorder with a high prevalence that causes pathological changes in cardiovascular regulation during the night and also during daytime. We investigated whether the treatment of OSA at night by means of continuous positive airway pressure (CPAP) improves the daytime consequences. Twenty-eight patients with OSA, 18 with arterial hypertension, 10 with normal blood pressure, were investigated at baseline and with three months of CPAP treatment. Ten age and sex matched healthy control subjects were investigated for comparisons. We recorded a resting period with 20min quiet breathing and an exercise stress test during daytime with ECG and blood pressure (Portapres). The bicycle ergometry showed a significant reduction of the diastolic blood pressure at a work load of 50W and 100W (p<0.05 and p<0.01, respectively) and a decrease of the heart rate recovery time after the stress test (p<0.05). These results indicate a reduction of vascular resistance and sympathetic activity during daytime. The coupling analysis of the resting periods by means of symbolic coupling traces approach indicated an effect of the CPAP therapy on the baroreflex reaction in hypertensive patients where influences of the systolic blood pressure on the heart rate changed from pathological patterns to adaptive mechanisms of the normotensive patients (p<0.05).

[Sleep apnoea syndrome in the rehabilitation setting]. / Das Schlafapnoe-Syndrom in der Rehabilitation.

Sleep-related breathing disorders are a common finding in patients undergoing cardiological rehabilitation. Sleep apnoea is recognized as a major risk factor for cardiovascular disorders. The diagnosis of sleep-related breathing disorders begins with taking a thorough sleep medicine-related patient history and answering dedicated questionnaires. The second step involves portable monitoring to assess oxygen saturation, heart rate, respiratory flow and effort. Portable monitoring is able to detect the severity of the breathing disorder and forms the basis on which to refer the patient for further sleep laboratory diagnosis or, in the case of positive results, to initiate appropriate treatment. In order to exclude a sleep-related breathing disorder, to distinguish between obstructive and central sleep apnoea, or to diagnose other sleep disorders a cardiorespiratory polysomnography in a sleep laboratory is required. Polysomnography is also needed if comorbidities are present. Appropriate and prompt treatment of sleep-related breathing disorders can shorten cardiological rehabilitation and improve outcomes in this patient group.

[Sleep medicine services in Germany]. / Schlafmedizinische Versorgung in Deutschland.

The increase in sleep medicine services has paralleled the increased in nocturnal ventilation therapy in patients with sleep apnea. Even if the sleep medicine expertise did increase in the past, this is not sufficient to cover the increasing demand for sleep medicine services. To serve patients with nonrestorative sleep, a clinical algorithm showing the pathway from the clinical interview to sleep laboratory investigations is available. However, there is a gap in the services offered by family physicians, other medical specialists, and sleep medicine practitioners. For sleep apnea, the diagnostic process and therapy are established; however, for other sleep disorders such as insomnia, parasomnia, movement disorders, hypersomnia, and circadian rhythm disorders, this is not the case. A basic investigation for sleep disorders is attended cardiorespiratory polysomnography, which is not always essential. There is a network of qualified sleep centers for stationary and ambulatory care, but their work is becoming more difficult under increasing health care economic pressure. Sleep medicine needs a solid structural and financial basis to provide good coverage of high quality health care service. New sleep medicine service centers for ambulatory care with a better network structure linked with other medical specialties and with offers for preventive medicine can serve all patients with sleep disorders over long periods of time.

The European Sleep Apnoea Database (ESADA): report from 22 European sleep laboratories.

The European Sleep Apnoea Database (ESADA) reflects a network of 22 sleep disorder centres in Europe enabled by a COST action B26 programme. This ongoing project aims to describe differences in standard clinical care of patients with obstructive sleep apnoea (OSA) and to establish a resource for genetic research in this disorder. Patients with suspected OSA are consecutively included and followed up according to local clinical standards. Anthropometrics, medical history, medication, daytime symptoms and sleep data (polysomnography or cardiorespiratory polygraphy) are recorded in a structured web-based report form. 5,103 patients (1,426 females, mean±sd age 51.8±12.6 yrs, 79.4% with apnoea/hypopnoea index (AHI) ≥5 events·h(-1)) were included from March 15, 2007 to August 1, 2009. Morbid obesity (body mass index ≥35 kg·m(-2)) was present in 21.1% of males and 28.6% of females. Cardiovascular, metabolic and pulmonary comorbidities were frequent (49.1%, 32.9% and 14.2%, respectively). Patients investigated with a polygraphic method had a lower AHI than those undergoing polysomnography (23.2±23.5 versus 29.1±26.3 events·h(-1), p<0.0001). The ESADA is a rapidly growing multicentre patient cohort that enables unique outcome research opportunities and genotyping. The first cross-sectional analysis reveals a high prevalence of cardiovascular and metabolic morbidity in patients investigated for OSA.

Non-CPAP therapies in obstructive sleep apnoea.

In view of the high prevalence and the relevant impairment of patients with obstructive sleep apnoea syndrome (OSAS) lots of methods are offered which promise definitive cures for or relevant improvement of OSAS. This report summarises the efficacy of alternative treatment options in OSAS. An interdisciplinary European Respiratory Society task force evaluated the scientific literature according to the standards of evidence-based medicine. Evidence supports the use of mandibular advancement devices in mild to moderate OSAS. Maxillomandibular osteotomy seems to be as efficient as continuous positive airway pressure (CPAP) in patients who refuse conservative treatment. Distraction osteogenesis is usefully applied in congenital micrognathia or midface hypoplasia. There is a trend towards improvment after weight reduction. Positional therapy is clearly inferior to CPAP and long-term compliance is poor. Drugs, nasal dilators and apnoea triggered muscle stimulation cannot be recommended as effective treatments of OSAS at the moment. Nasal surgery, radiofrequency tonsil reduction, tongue base surgery, uvulopalatal flap, laser midline glossectomy, tongue suspension and genioglossus advancement cannot be recommended as single interventions. Uvulopalatopharyngoplasty, pillar implants and hyoid suspension should only be considered in selected patients and potential benefits should be weighed against the risk of long-term side-effects. Multilevel surgery is only a salvage procedure for OSA patients.

Management of obstructive sleep apnea in Europe.

OBJECTIVES: In Europe, the services provided for the investigation and management of obstructive sleep apnoea (OSA) varies from country to country. The aim of this questionnaire-based study was to investigate the current status of diagnostic pathways and therapeutic approaches applied in the treatment of OSA in Europe, qualification requirements of physicians involved in diagnosis and treatment of OSA, and reimbursement of these services. METHODS: Two questionnaires were sent to 39 physicians in 22 countries in Europe. In order to standardize the responses, the questionnaire was accompanied by an example. RESULTS: Sleep centers from 21 countries (38 physicians) participated. A broad consistency among countries with respect to the following was found: pathways included referral to sleep physicians/sleep laboratories, necessity for objective diagnosis (primarily by polysomnography), use of polygraphic methods, analysis of polysomnography (PSG), indications for positive airway pressure (PAP) therapy, application of standard continuous PAP (CPAP) therapy (100% with an CPAP/APAP ratio of 2.24:1), and the need (90.5%) and management of follow-up. Differences were apparent in reimbursement of the diagnostic procedures and follow-up, in the procedures for PAP titration from home APAP titration with portable sleep apnea monitoring (38.1%) up to hospital monitoring with PSG and APAP (85.7%), and in the qualification requirements of sleep physicians. CONCLUSIONS: Management of OSA in different European countries is similar except for reimbursement rules, qualification of sleep specialists and procedures for titration of the CPAP treatment. A European network (such as the one accomplished by the European Cooperation in Science and Technology [COST] B26 Action) could be helpful for implementing these findings into health-service research in order to standardize management in a cost effective perspective.

AASM standards of practice compliant validation of actigraphic sleep analysis from SOMNOwatch™ versus polysomnographic sleep diagnostics shows high conformity also among subjects with sleep disordered breathing.

In recent AASM practice, parameter actimetry is cited to measure total sleep time in obstructive sleep apnoea patients, when polysomnography is not available. An actigraph was therefore compared to polysomnographic data in 28 subjects with known sleep disordered breathing. Total sleep time (TST), sleep period time (SPT), sleep efficiency (SE), sustained sleep efficiency (SSE), sleep onset latency (SL) and sleep/wake pattern were compared to gold standard polysomnography. The results of an epoch-by-epoch comparison of sleep/wake from actigraphy to sleep stages from polysomnography gave a sensitivity of 90.2%, a specificity of 95.2% and an overall accuracy of 85.9%. Correlations were moderately strong for SE (0.71, p < 0.001) and SSE (0.65, p < 0.001) and high for TST (0.89, p < 0.001), SPT (0.91, p < 0.001) and SL (0.89, p < 0.001). It was concluded that actigraphy is not identical with PSG recording but gives good results in sleep/wake patterns and predicting TST, SPT, SSE, SE and SL also in sleep apnoea patients not suffering from other sleep disorders. The difficult detection of correct sleep onset causes SSE and SL to be less predictable. Therefore a 15-epoch criterion was introduced and resulted in high correlation of 0.89 for sleep latency, but has to be tested on a bigger population.

[Management of sleep-related abnormal breathing by cardiologists and hospital departments of cardiology]. / Versorgung von Patienten mit obstruktiver Schlafapnoe in kardiologischen Praxen und Kliniken.

BACKGROUND AND OBJECTIVES: In the general population there is a high prevalence of sleep-related disorders of breathing (sleep apnea). In addition to being leading symptom of excessive day-time sleepiness they are also important predictors are cardiovascular disease such as arterial hypertension, heart failure, cardiac arrhythmias and stroke. Are the cardiologists the specialists who recognize such patients and refer them to diagnostic procedures and treatment? METHODS: We sent out a questionnaires to cardiologists in private practice, to hospitals with cardiology departments and to cardiology rehabilitation units in Germany in order to assess the knowledge about sleep apnea and of the current diagnostic and therapeutic procedures in patients with suspected sleep apnea. All cardiology rehabilitation units and every other practice and cardiology department listed in the reference book 'Medführer' were approached. RESULTS: 98% of 388 cardiologists with private practice were found to know about the disorder sleep apnea. 94.3% routinely asked their patients about any sleep disorder and specifically about excessive day-time sleepiness. More than half of the cardiologists (59.3%) questioned patients about possible sleep apnea as part of their interview, but only 32.7% carried out tests with a portable sleep apnea monitor. Most patients were referred to a sleep center. In 60% of the cardiology departments a portable sleep apnea monitor was used. Further diagnostic investigation followed in collaborating sleep centers (66.4%), because only 22.4% of the departments had a sleep laboratories. The main focus was on the diagnosis of abnormal sleep due to central or obstructive disorders of breathing. More than two thirds of the cardiology departments initiate nocturnal ventilation treatment. CONCLUSION: Cardiologists in private practice and cardiologists in hospital departments know about sleep-related abnormal breathing. The use of portable sleep apnea monitors and of polysomnography in special as parts of sleep centers within cardiology departments should be improved.

Medico-legal implications of sleep apnoea syndrome: driving license regulations in Europe.

BACKGROUND: Sleep apnoea syndrome (SAS), one of the main medical causes of excessive daytime sleepiness, has been shown to be a risk factor for traffic accidents. Treating SAS results in a normalized rate of traffic accidents. As part of the COST Action B-26, we looked at driving license regulations, and especially at its medical aspects in the European region. METHODS: We obtained data from Transport Authorities in 25 countries (Austria, AT; Belgium, BE; Czech Republic, CZ; Denmark, DK; Estonia, EE; Finland, FI; France, FR; Germany, DE; Greece, GR; Hungary, HU; Ireland, IE; Italy, IT; Lithuania, LT; Luxembourg, LU; Malta, MT; Netherlands, NL; Norway, EC; Poland, PL; Portugal, PT; Slovakia, SK; Slovenia, SI; Spain, ES; Sweden, SE; Switzerland, CH; United Kingdom, UK). RESULTS: Driving license regulations date from 1997 onwards. Excessive daytime sleepiness is mentioned in nine, whereas sleep apnoea syndrome is mentioned in 10 countries. A patient with untreated sleep apnoea is always considered unfit to drive. To recover the driving capacity, seven countries rely on a physician's medical certificate based on symptom control and compliance with therapy, whereas in two countries it is up to the patient to decide (on his doctor's advice) to drive again. Only FR requires a normalized electroencephalography (EEG)-based Maintenance of Wakefulness Test for professional drivers. Rare conditions (e.g., narcolepsy) are considered a driving safety risk more frequently than sleep apnoea syndrome. CONCLUSION: Despite the available scientific evidence, most countries in Europe do not include sleep apnoea syndrome or excessive daytime sleepiness among the specific medical conditions to be considered when judging whether or not a person is fit to drive. A unified European Directive seems desirable.

[Are there alternative therapeutical options other than CPAP in the treatment of the obstructive sleep apnea syndrome]. / Gibt es Alternativen zum nCPAP-Verfahren in der Behandlung des obstruktiven Schlafapnoesyndroms?

Many patients with the obstructive sleep apnea syndrome (OSAS) look for alternative conservative or surgical therapies to avoid to be treated with continuous positive airway pressure. In view of the high prevalence and the relevant impairment of the patients lots of methods are offered which promise definitive cure or relevant improvement of OSAS. The working group "Apnea" in the German Society of Sleep Medicine and Research established a task force to evaluate the scientific literature on non-CPAP therapies in the treatment of OSAS according to the standards of evidence-based medicine. This paper summarizes the results of the task force. The data were unsatisfactorily for most of the methods. Sufficient data were available for intraoral appliances (IOA) and the maxillomandibular osteotomy (MMO). IOA's can reduce mild to moderate respiratory disturbances, MMO are efficient in the short and long term but are performed only in special situations such as craniofacial dysmorphias. Weight reduction and body positioning cannot be recommended as a single treatment of OSAS. Most surgical procedures still lack sufficient data according to the criteria of evidence based medicine. Resections of muscular tissue within the soft palate have to be strictly avoided. But even success following gentle soft palate procedures is difficult to predict and often decreases after years. Results in other anatomical regions seem to be more stable over time. Today combined surgeries in the sense of multi-level surgery concepts are of increasing interest in the secondary treatment after failure of nasal ventilation therapy although more data from prospective controlled studies are needed. There is no evidence for any other treatment options.

Sleep apnoea in heart failure.

Studies from the USA have reported that sleep apnoea is common in congestive heart failure (CHF), with Cheyne-Stokes respiration (CSR) being the most frequent type of sleep-disordered breathing (SDB) in these patients. Within the present study, the authors sought to assess the prevalence and type of SDB among CHF patients in Germany. A total of 203 CHF patients participated in this prospective multicentre study. All patients were stable in New York Heart Association classes II and III and had a left ventricular ejection fraction (LVEF)<40%. The patients were investigated by polygraphy and all data were centrally analysed. Patient enrolment was irrespective of sleep-related symptoms. The majority of patients were male with a mean age of 65 yrs and hospitalised. Of the 203 patients, 145 (71%) had an apnoea/hypopnoea index>10.h(-1), obstructive sleep apnoea (OSA) occurred in 43% (n=88) and CSR in 28% (n=57) of patients. The prevalence of sleep-disordered breathing is high in patients with stable severe congestive heart failure from a European population. As sleep-disordered breathing may have a negative impact on the prognosis of congestive heart failure, a sleep study should be performed in every patient with congestive heart failure and a left ventricular ejection fraction of <40%. This diagnostic approach should probably be adopted for all of these patients irrespective of the presence of sleep-related symptoms.