Reduction in fall risk markers following CPAP treatment of obstructive sleep apnoea in people over 65 years.

OBJECTIVES: Falls in older people can lead to serious injury and significant societal health and financial burden. Obstructive sleep apnoea (OSA) is associated with impaired gait/balance and may increase fall risk, yet few studies examined whether treating OSA reduces fall risk. This study examined the effect of continuous positive airway pressure (CPAP) on fall risk markers in people over 65yrs diagnosed with OSA. DESIGN: Single arm intervention study. SETTING: University and tertiary care CPAP clinic. PARTICIPANTS: Individuals over 65 years diagnosed with OSA and recommended CPAP. INTERVENTION: 3-6 months CPAP therapy. MEASUREMENTS: 28 participants had a physiological profile assessment (PPA) at baseline and following 3-6 months of CPAP. The PPA examines visual contrast sensitivity, lower limb proprioception, knee extension strength, reaction time and postural sway to generate a fall risk score (FRS). t-tests were used to determine difference between pre- and post-treatment FRS. Regression was used to examine the associations between CPAP use and daytime sleepiness with FRS. RESULTS: CPAP significantly reduced the FRS ([Mean ± SD] 0.59 ± 1.0 vs 0.04 ± 1.1, p = 0.016), contrast sensitivity and lower limb proprioception (P < 0.05). Increased CPAP use was associated with improvement in FRS in unadjusted analysis (ß = -0.213, 95%CI -0.371 to -0.056, p = 0.01). Reduction in Epworth sleepiness score was associated with a reduction in FRS in unadjusted (p = 0.023) and adjusted analysis (adjusted for AHI p = 0.027 or O2Nadir p = 0.015). CONCLUSIONS: CPAP may reduce fall risk in people over 65yrs, possibly related to better CPAP adherence and reduced daytime sleepiness. Future controlled trials and mechanistic studies are needed to elucidate how CPAP may reduce fall risk.

Virtual consultations for patients with obstructive sleep apnoea: a systematic review and meta-analysis.

BACKGROUND: The coronavirus disease 2019 pandemic has accelerated the adoption of virtual care strategies for the management of patients with obstructive sleep apnoea/hypopnoea syndrome (OSAHS). RESEARCH QUESTION: What is the effectiveness of virtual consultations compared to in-person consultations for the management of continuous positive airway pressure (CPAP) therapy in adult patients with OSAHS? METHODS: A systematic review and meta-analysis (PROSPERO; CRD42022297532) based on six electronic databases plus manually selected journals was conducted in January 2022. Two researchers independently selected, quality appraised and extracted data. The co-primary outcomes were patient-reported sleepiness, assessed by the Epworth Sleepiness Scale (ESS), and reported cost-effectiveness. RESULTS: 12 studies (n=1823 adults) were included in the review. Seven studies (n=1089) were included in the meta-analysis which showed no difference in the magnitude of improvement in patient-reported sleepiness scores between virtual and in-person consultations (mean difference -0.39, 95% CI -1.38-0.60; p=0.4), although ESS scores improved in both groups. Virtual care strategies modestly increased CPAP therapy adherence and were found to be less costly than in-person care strategies in the three Spanish trials that reported cost-effectiveness. CONCLUSION: The findings of this review suggest that virtual care delivered by telephone or video consultations is as effective as in-person consultations for improving subjective sleepiness in patients with OSAHS treated with CPAP. This clinical management strategy may also improve CPAP adherence without increasing the costs, supporting its potential as a follow-up management strategy, where patients prefer this approach.

SARS-CoV-2 Causing Transient Central Sleep Apnea in Patients Treated for Obstructive Sleep Apnea with Continuous Positive Airway Pressure.

BACKGROUND SARS-CoV-2 has globally affected humanity and devastated many families. Here, we attempt to identify which diseases are independent risk factors for severe SARS-CoV-2. There have been multiple studies that have evaluated the impact of obstructive sleep apnea (OSA) on SARS-CoV-2 outcomes, suggesting that OSA is an independent risk factor. SARS-CoV-2 has also been suggested to invade the central nervous system and be responsible for neurological signs and decreasing central respiratory drive. Central sleep apnea (CSA) is defined when apneas and hypopneas are associated with absent or reduced ventilatory effort, respectively, due to diminished central respiratory drive. CASE REPORT Here, we describe 2 cases involving patients with OSA that developed transient central sleep apnea after being diagnosed with SARS-CoV-2 by polymerase chain reaction. They had similar past medical histories and presentation of illness. The differences included compliance of continuous positive airway pressure (CPAP), recovery, and severity of central sleep index. We review and address alternate causes for the development of CSA. We hypothesize that continuous and compliant use of CPAP machines may be beneficial in reducing recovery and severity of SARS-CoV-2. CONCLUSIONS Our case report calls attention to the acquired central respiratory drive neurological complication associated with SARS-CoV-2. Our case report highlights the plausible existence of a relationship between development of central respiratory drive leading to CSA and SARS-CoV-2 infection. Further studies are needed to explore this relationship, including evaluating whether CSA occurs in SARS-CoV-2 patients with no history of OSA.

The impact of different CPAP delivery approaches on nightly adherence and discontinuation rate in patients with obstructive sleep apnea.

STUDY OBJECTIVES: The impact of direct mail order sales of positive airway pressure (PAP) devices, accentuated by the coronavirus disease 2019 (COVID-19) pandemic, on PAP adherence in patients with obstructive sleep apnea remains unclear. In this study we compared the impact of different modes of continuous positive airway pressure delivery on adherence and daytime symptoms. We hypothesized that adherence would not be affected by remote PAP setup, aided by telehealth technology. METHODS: Three groups were studied: 1) standard group PAP setup (3-4 people); 2) direct home shipment of PAP, followed by telehealth interactions; 3) direct home shipment of PAP, during the COVID-19 pandemic where delivery choice was removed. Demographics, sleepiness, PAP data, and insurance information were also compared. RESULTS: A total of 666 patients were studied in 3 groups. 1) Standard group PAP setup had 225 patients and adherence with PAP (% of nights used more than 4 hours) was 65.3 ± 2.1%. 2) Direct home shipment of PAP group had 231 patients, and adherence was 54.2 ± 2.4%. 3) Direct mailed PAP units during the COVID-19 pandemic group had 210 patients, and adherence was 55.9 ± 2.5%. Adherence was lower in both groups receiving home shipments compared to those in groups in-center (analysis of variance, Tukey, P = .002). Discontinuation of PAP was less in the in-center group setup patients (χ2 = 10.938 P ≤ .001). CONCLUSIONS: Patients receiving direct home PAP shipments had lower adherence and were more likely to discontinue PAP compared to standard in-person setup. CITATION: Stanchina M, Lincoln J, Prenda S, et al. The impact of different CPAP delivery approaches on nightly adherence and discontinuation rate in patients with obstructive sleep apnea. J Clin Sleep Med. 2022;18(8):2023-2027.

Top 10 research priorities for people with obstructive sleep apnoea, families and clinicians: James Lind Alliance Priority Setting Partnership.

Obstructive sleep apnoea (OSA) is associated with significant comorbidity, preventable accidents and reduced quality of life. Little is known about the research priorities of patients with OSA, family members and clinicians. A James Lind Alliance research priority setting partnership was conducted. An initial survey (690 respondents who generated 1110 questions), a prioritisation survey (250 respondents), and a final workshop were used to identify the top 10 research priorities. Consensus was achieved on the top-ranked research priorities. Our results will inform the efforts of funders, researchers and policy-makers to align directly with stakeholder priorities related to OSA.

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

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

Telemonitoring for the Follow-Up of Obstructive Sleep Apnea Patients Treated with CPAP: Accuracy and Impact on Therapy.

Continuous positive airway pressure (CPAP) telemonitoring (TMg) has become widely implemented in routine clinical care. Objective measures of CPAP compliance, residual respiratory events, and leaks can be easily monitored, but limitations exist. This review aims to assess the role of TMg in CPAP-treated obstructive sleep apnea (OSA) patients. We report recent data related to the accuracy of parameters measured by CPAP and try to determine the role of TMg in CPAP treatment follow-up, from the perspective of both healthcare professionals and patients. Measurement and accuracy of CPAP-recorded data, clinical management of these data, and impacts of TMg on therapy are reviewed in light of the current literature. Moreover, the crucial questions of who and how to monitor are discussed. TMg is a useful tool to support, fine-tune, adapt, and control both CPAP efficacy and compliance in newly-diagnosed OSA patients. However, clinicians should be aware of the limits of the accuracy of CPAP devices to measure residual respiratory events and leaks and issues such as privacy and cost-effectiveness are still a matter of concern. The best methods to focus our efforts on the patients who need TMg support should be properly defined in future long-term studies.

Short-Term Continuous Positive Air Pressure Treatment: Effects on Quality of Life and Sleep in Patients with Obstructive Sleep Apnea.

Background and Objectives: The aim of this study was to evaluate short-term continuous positive air pressure (CPAP) treatment for health-related quality of life (HRQL) in patients with obstructive sleep apnea. Materials and Methods: Our subjects were 18-65 years old, diagnosed with moderate-to-severe obstructive sleep apnea and treated with CPAP between January 2020 and June 2021 in Hospital of Lithuanian University of Health Sciences Kaunas clinics. All the patients completed the Epworth Sleepiness Scale (ESS), the 36-Item Short Form Health Survey (SF-36), the and Pittsburgh Sleep Quality Index (PSQI) before and after 3 months of treatment. Polysomnography was also repeated. Statistical analyses were performed using SPSS 27.0 software. The value of p < 0.05 was considered as statistically significant. Results: The active-treatment group comprised 17 subjects with a mean age of 51.9 ± 8.9 years. The total SF-36 questionnaire score improved from 499.8 ± 122.3 to 589.6 ± 124.7 (p = 0.012). The SF-36 role limitations due to emotional problems (p = 0.021), energy (fatigue) (p = 0.035), and general health (p = 0.042) domains score significantly improved after CPAP treatment for 3 months. The PSQI mean score at baseline was 12.6 ± 2.9 and in the post-treatment group, it was -5.5 ± 2.3 (p = 0.001). The ESS also changed significantly from a pretreatment mean score of 10.9 ± 5.7 to -5.3 ± 3.2 (p = 0.002) after 3 months. Conclusions: Improvement in HRQL is seen even after a short treatment period with CPAP. Questionnaires are a good tool to evaluate CPAP treatment efficacy.

Running a paediatric ambulatory sleep service in a pandemic and beyond.

OBJECTIVES: In response COVID-19, re-establishing safe elective services was prioritised in the UK. We assess the impact on face-to-face hospital attendance, cost and efficiency of implementing a virtual sleep clinic (intervention 1) to screen for children requiring level 3 ambulatory sleep studies using newly implemented ENT-UK guidelines for obstructive sleep apnoea (OSA) investigation (intervention 2). OBJECTIVES: (1) compare the proportion of children attending sleep clinic undertaking a sleep study before and after implementation of these interventions; (2) compare clinic cancellations and first-time success rates of sleep studies before and after intervention. DESIGN: Retrospective analysis. SETTING: District general hospital paediatric sleep clinic. PARTICIPANTS: Children aged 3 months to 16 years referred to sleep clinic by ENT for investigation of OSA over 3 months immediately following interventions (1 June 2020 - 1 September 2020) to the same period in the previous year (1 June 2019 - 1 September 2019). MAIN OUTCOME MEASURES: Number of children attending sleep clinic, date of birth/age of children attending sleep clinic, number of children undergoing sleep study, diagnostic outcomes, number of appointment cancellations, number of first-time sleep study failures. RESULTS: Post intervention, there was a significant reduction in the proportion of children undertaking ambulatory sleep studies, and nonsignificant reductions in appointment cancellations and in first-time sleep study failures. CONCLUSIONS: The introduction of the virtual sleep clinic meant that only those children requiring a sleep study attended a face-to-face appointment, which led to reduced face-to-face attendance. There were also unintended cost-effectiveness and efficiency benefits, with potential longer-term learning implications for the wider sleep community and other diagnostic services.

Feasibility of remote neurocognitive assessment: pandemic adaptations for a clinical trial, the Cognition and Obstructive Sleep Apnea in Parkinson's Disease, Effect of Positive Airway Pressure Therapy (COPE-PAP) study.

BACKGROUND: The COVID-19 pandemic poses challenges for timely outcome assessment in randomized clinical trials (RCT). Our aim was to describe our remote neurocognitive testing (NCT) protocol administered by telephone in patients with Parkinson's disease (PD) and obstructive sleep apnea (OSA). METHODS: We studied PD patients with OSA and Montreal Cognitive Assessment (MoCA) score ≤ 27 participating in a RCT assessing OSA treatment impact on cognition. Trial outcomes included change in MoCA and specific cognitive domains from baseline to 3 and 6 months. With COVID19 pandemic-related restrictions, 3-month visits were converted from in-person to telephone administration with materials mailed to participants for compatible tests and retrieved by courier the same day. In exploratory analyses, we compared baseline vs. 3-month results in the control arm, which were not expected to change significantly (test-re-test), using a paired t-test and assessed agreement with the intraclass correlation coefficient (ICC). RESULTS: Seven participants were approached and agreed to remote NCT at 3-month follow-up. Compared to the in-person NCT control arm group, they were younger (60.6 versus 70.6 years) and had a shorter disease course (3.9 versus 9.2 years). Remote NCT data were complete. The mean test-retest difference in MoCA was similar for in-person and remote NCT control-arm groups (between group difference - 0.69; 95%CI - 3.67, 2.29). Agreement was good for MOCA and varied for specific neurocognitive tests. CONCLUSION: Telephone administration of the MoCA and a modified neurocognitive battery is feasible in patients with PD and OSA. Further validation will require a larger sample size.

Current and future strategies for diagnostic and management of obstructive sleep apnea.

INTRODUCTION: Obstructive sleep apnea (OSA) is a common sleep disorder with multiple comorbidities including hypertension, diabetes, and cardiovascular disorders. Detected based on an overnight sleep study is called polysomnography (PSG); OSA still remains undiagnosed in majority of the population mainly attributed to lack of awareness. To overcome the limitations posed by PSG such as patient discomfort and overnight hospitalization, newer technologies are being explored. In addition, challenges associated with current management of OSA using continuous positive airway pressure (CPAP), etc. presents several pitfalls. AREAS COVERED: Conventional and modern detection/management techniques including PSG, CPAP, smart wearable/pillows, bio-motion sensors, etc., have both pros and cons. To fulfill the limitations in OSA diagnostics, there is an imperative need for new technology for screening of symptomatic and more importantly asymptomatic OSA patients to reduce the risk of several associated life-threatening comorbidities. In this line, molecular marker-based diagnostics have shown great promises. EXPERT OPINION: A detailed overview is presented on the OSA management and diagnostic approaches and recent advances in the molecular screening methods. The potentials of biomarker-based detection and its limitations are also portrayed and a comparison between the standard, current modern approaches, and promising futuristic technologies for OSA diagnostics and management is set forth.ABBREVIATIONS AHI: Apnea hypopnea index; AI: artificial intelligence; CAM: Cell adhesion molecules; CPAP: Continuous Positive Airway Pressure; COVID-19: Coronavirus Disease 2019; CVD: Cardiovascular disease; ELISA: Enzyme linked immunosorbent assay; HSAT: Home sleep apnea testing; IR-UWB: Impulse radio-ultra wideband; MMA: maxillomandibular advancement; PSG: Polysomnography; OSA: Obstructive sleep apnea; SOD: Superoxide dismutase; QD: Quantum dot.

The effect of continuous positive airway pressure on blood pressure in patients with obstructive sleep apnea and uncontrolled hypertension - Study design and challenges during the COVID-19 pandemic.

OBJECTIVES: To describe the MORPHEOS (Morbidity in patients with uncontrolled HTN and OSA) trial, and describe the challenges imposed by the COVID-19 pandemic. METHODS: MORPHEOS is a multicenter (n=6) randomized controlled trial designed to evaluate the blood pressure (BP) lowering effects of treatment with continuous positive airway pressure (CPAP) or placebo (nasal strips) for 6 months in adult patients with uncontrolled hypertension (HTN) and moderate-to-severe obstructive sleep apnea (OSA). Patients using at least one antihypertensive medication were included. Uncontrolled HTN was confirmed by at least one abnormal parameter in the 24-hour ABPM and ≥80% medication adherence evaluated by pill counting after the run-in period. OSA was defined by an apnea-hypopnea index ≥15 events/hours. The co-primary endpoints are brachial BP (office and ambulatory BP monitoring, ABPM) and central BP. Secondary outcomes include hypertension-mediated organ damage (HMOD) to heart, aorta, eye, and kidney. We pre-specified several sub-studies from this investigation. Visits occur once a week in the first month and once a month thereafter. The programmed sample size was 176 patients but the pandemic prevented this final target. A post-hoc power analysis will be calculated from the final sample. ClinicalTrials.gov: NCT02270658. RESULTS: The first 100 patients are predominantly males (n=69), age: 52±10 years, body mass index: 32.7±3.9 kg/m2 with frequent co-morbidities. CONCLUSIONS: The MORPHEOS trial has a unique study design including a run-in period; pill counting, and detailed analysis of hypertension-mediated organ damage in patients with uncontrolled HTN that will allow clarification of the impact of OSA treatment with CPAP.

Effect of High-Risk Obstructive Sleep Apnea on Clinical Outcomes in Adults with Coronavirus Disease 2019: A Multicenter, Prospective, Observational Clinical Trial.

Rationale: Coronavirus disease (COVID-19) is an ongoing pandemic, in which obesity, hypertension, and diabetes have been linked to poor outcomes. Obstructive sleep apnea (OSA) is associated with these conditions and may influence the prognosis of adults with COVID-19. Objectives: To determine the effect of OSA on clinical outcomes in patients with COVID-19. Methods: The current prospective observational study was conducted in three hospitals in Istanbul, Turkey from March 10 to June 22, 2020. The participants were categorized as high-risk or low-risk OSA according to the Berlin questionnaire that was administered in the out-patient clinic, in hospital, or shortly after discharge from hospital blinded to the clinical outcomes. A modified high-risk (mHR)-OSA score based on the snoring patterns (intensity and/or frequency), breathing pauses, and morning/daytime sleepiness, without taking obesity and hypertension into account, were used in the regression models. Results: The primary outcome was the clinical improvement defined as a decline of two categories from admission on a 7-category ordinal scale that ranges from 1 (discharged with normal activity) to 7 (death) on Days 7, 14, 21, and 28, respectively. Secondary outcomes included clinical worsening (an increase of 1 category), need for hospitalization, supplemental oxygen, and intensive care. In total, 320 eligible patients (median [interquartile range] age, 53.2 [41.3-63.0] yr; 45.9% female) were enrolled. In all, 121 (37.8%) were categorized as known (n = 3) or high-risk OSA (n = 118). According to the modified scoring, 70 (21.9%) had mHR-OSA. Among 242 patients requiring hospitalization, clinical improvement within 2 weeks occurred in 75.4% of the mHR-OSA group compared with 88.4% of the modified low-risk-OSA group (P = 0.014). In multivariate regression analyses, mHR-OSA (adjusted odds ratio [OR], 0.42; 95% confidence interval [CI], 0.19-0.92) and male sex (OR, 0.39; 95% CI, 0.17-0.86) predicted the delayed clinical improvement. In the entire study population (n = 320), including the nonhospitalized patients, mHR-OSA was associated with clinical worsening (adjusted hazard ratio, 1.55; 95% CI, 1.00-2.39) and with the need for supplemental oxygen (OR, 1.95; 95% CI, 1.06-3.59). Snoring patterns, especially louder snoring, significantly predicted delayed clinical improvement, worsening, need for hospitalization, supplemental oxygen, and intensive care. Conclusions: Adults with mHR-OSA in our COVID-19 cohort had poorer clinical outcomes than those with modified low-risk OSA independent of age, sex, and comorbidities. Clinical trial registered with www.clinicaltrials.gov (NCT04363333).

Sleep medicine and coronavirus disease 2019.

PURPOSE OF REVIEW: To evaluate the impact of the COVID-19 pandemic on the care of people with sleep disorders, to explore relationships between OSA and COVID-19, and to describe current knowledge of the effect of the pandemic on sleep globally. RECENT FINDINGS: COVID-19 has led to significant changes in the practice of sleep medicine, including the care of patients with OSA. An OSA diagnosis may portend a worse prognosis with COVID-19, whilst prior COVID-19 may have an impact on sleep breathing. SUMMARY: The pandemic has caused marked difficulties with access to diagnostic sleep studies and reduced capacity for CPAP initiation. Conversely, adherence to CPAP therapy may have improved, and use of remote consultations and telemonitoring has increased. An OSA diagnosis may be associated with increased risk of severe COVID-19, although any apparent relationship may be attributable to confounding factors, such as obesity and metabolic disease. Small studies have reported some increase in CPAP requirements in OSA patients following COVID-19 infection. More generally, the pandemic has been associated with a deterioration in subjective sleep quality across the population; much of this appears because of increased anxiety and stress. Finally, studies assessing putative links between COVID-19 and REM sleep issues are ongoing.

Prolonged Effects of the COVID-19 Pandemic on Sleep Medicine Services-Longitudinal Data from the Swedish Sleep Apnea Registry.

The worldwide COVID-19 pandemic has affected the operation of health care systems. The direct impact of obstructive sleep apnea (OSA) on COVID-19 infection outcome remains to be elucidated. However, the coincidence of common risk factors for OSA and severe COVID-19 suggests that patients with OSA receiving positive airway pressure therapy may have an advantage relative to those untreated when confronted with a COVID-19 infection. The ongoing COVID-19 pandemic has led to a substantial reduction of sleep medicine services, and the long-term consequences may be considerable. New strategies for the management of sleep disorders are needed to overcome the current underdiagnosis and delay of treatment.

Daytime polysomnography to perform titration for upper airway stimulation in patients with obstructive sleep apnea.

PURPOSE: Upper airway stimulation (UAS) is an innovative treatment for patients with obstructive sleep apnea (OSA). UAS titrations are performed 3 months after activation of the device to optimize its effectiveness. In general, these titrations are performed during an in-laboratory overnight polysomnography (PSG). However, overnight titrations are expensive and can be logistically challenging because they are labor-intensive which causes shortage of sleep technicians available for night shifts. In addition, recently, overnight PSGs were postponed and canceled due to the COVID-19 pandemic. We aimed to assess the feasibility of a daytime PSG to perform titration of UAS therapy as an alternative for a conventional overnight PSG. METHODS: We performed a prospective single-center observational cohort study. Patients were included when planned for UAS titration; this was approximately 6 months after UAS activation. Data on sleep architecture, patient experience, and respiratory outcomes were collected to evaluate the feasibility. An overnight follow-up PSG 12 months after implantation was used to compare sleep architecture and therapy response. RESULTS: Of 23 patients, four were excluded from analysis because of technical issues during PSG. Even though patients slept significantly shorter during the daytime PSG, this was enough time to complete the titration successfully with 30-min sleep in final therapeutic settings in 84% of the patients. Patients (94%) had a positive experience with the daytime titration. Respiratory outcomes were significantly reduced during titration and were maintained at the 12-month follow-up. CONCLUSION: Daytime titrations are a valuable alternative for conventional overnight titrations. Our findings suggest the implementation of daytime titrations as standard of care. This will contribute to easier logistics and better work circumstances for sleep technicians without jeopardizing titration quality.

Sleep disorders and COVID-19.

This chapter summarizes the known associations between COVID-19 and sleep dysfunction, including insomnia, excessive daytime sleepiness, restless legs syndrome and nightmares, and touches upon pandemic-related considerations for obstructive sleep apnea and continuous positive airway pressure treatment. Treatment strategies and management approaches are also briefly discussed.

Identifying Signs and Symptoms of Obstructive Sleep Apnea in a Men's Health Clinic: The Utility of Home Sleep Apnea Testing During COVID-19.

The objective of the study was to identify symptoms of men presenting for an outpatient urology visit that prompted referral for a Home Sleep Apnea Test (HSAT) to assess for obstructive sleep apnea (OSA) by a single provider. To assess the proportion of patients referred for the HSAT who underwent the test and, out of these patients, the proportion of men diagnosed with sleep apnea, we performed a retrospective chart review of men 18-99 years old seen by a single provider in the Department of Urology referred for an HSAT to evaluate for presenting symptoms. Patients with a prior diagnosis of OSA were excluded. Eighteen patients were identified (mean age at time of referral 51 + SD 13 years). Half of patients reported erectile dysfunction/concerns, 56% reported nocturia, 44% had been diagnosed with testosterone deficiency, and 39% reported low libido. Nearly all (89%) of patients snored, all reported fatigue, 56% were over the age of 50, 44% had a BMI >35, and 78% had hypertension. Twelve patients completed the HSAT, all of whom were diagnosed with OSA for which continuous positive airway pressure (CPAP) therapy was initiated. Men presenting with genitourinary concerns to an outpatient urology clinic may also have OSA. About half of included patients reported genitourinary concerns. Hundred percent of patients who completed their sleep study were diagnosed with OSA. Genitourinary concerns, in addition to signs and symptoms commonly associated with OSA, should prompt consideration of sleep apnea evaluation.