Recommendations for clinical management of excessive daytime sleepiness in obstructive sleep apnoea - A Delphi consensus study.

STUDY OBJECTIVE: Excessive daytime sleepiness is common with obstructive sleep apnoea and can persist despite efforts to optimise primary airway therapy. The literature lacks recommendations regarding differential diagnosis and management of excessive daytime sleepiness in obstructive sleep apnoea. This study sought to develop expert consensus statements to bridge the gap between existing literature/guidelines and clinical practice. METHODS: A panel of 10 international experts was convened to undertake a modified Delphi process. Statements were developed based on available evidence identified through a scoping literature review, and expert opinion. Consensus was achieved through 3 rounds of iterative, blinded survey voting and revision to statements until a predetermined level of agreement was met (≥80 % voting "strongly agree" or "agree with reservation"). RESULTS: Consensus was achieved for 32 final statements. The panel agreed excessive daytime sleepiness is a patient-reported symptom. The importance of subjective/objective evaluation of excessive daytime sleepiness in the initial evaluation and serial management of obstructive sleep apnoea was recognised. The differential diagnosis of residual excessive daytime sleepiness in obstructive sleep apnoea was discussed. Optimizing airway therapy (eg, troubleshooting issues affecting effectiveness) was addressed. The panel recognised occurrence of residual excessive daytime sleepiness in obstructive sleep apnoea despite optimal airway therapy and the need to evaluate patients for underlying causes. CONCLUSIONS: Excessive daytime sleepiness in patients with obstructive sleep apnoea is a public health issue requiring increased awareness, recognition, and attention. Implementation of these statements may improve patient care, long-term management, and clinical outcomes in patients with obstructive sleep apnoea.

Compliance and side effects of tongue stabilizing device in patients with obstructive sleep apnea.

Objective: To evaluate the long-term effectiveness, compliance, and side effects of tongue stabilizing devices (TSDs).Methods: Thirty-nine patients were followed up after 12 and 30 months. The subjective effectiveness was assessed using the Epworth Sleepiness Scale (ESS), the Functional Outcomes Sleep Questionnaire (FOSQ-10), the Chalder Fatigue Scale (CFQ), and a sleep-related quality of life questionnaire (QoL). Compliance and side effects were assessed.Results: At 12-months, 35.9% of patients confirmed continuing the therapy, compared to only 15.4% of patients at 30 months. At 30 months, a significant average improvement of ESS (2.0 ± 2.8) was observed compared to baseline levels in six patients. Six patients demonstrated an average increase in blood pressure. The most frequently reported side effects were mouth dryness and excessive salivation. The 3D analysis revealed small tooth movements.Conclusion: The TSD therapy demonstrated a good long-term subjective effectiveness against OSA but had a relatively low treatment acceptance rate.

The efficacy of a titrated tongue-stabilizing device on obstructive sleep apnea: a quasi-experimental study.

STUDY OBJECTIVES: To evaluate the short-term efficacy and self-reported outcomes of tongue-stabilizing device (TSD) therapy as compared to those of mandibular advancement device (MAD) therapy in an adult population diagnosed with obstructive sleep apnea. METHODS: This study is a parallel, nonrandomized clinical trial of the TSD and MAD therapies. The efficacy of both interventions was evaluated objectively by level 3 home sleep apnea testing and by self-report using the Epworth Sleepiness Scale, the Functional Outcomes of Sleep Questionnaire, the Chalder Fatigue Scale, and the 36-Item Short-Form Health Survey. Adherence and adverse effects were self-reported. RESULTS: Of the 39 patients who received TSD therapy, 27 managed to adapt and complete the trial and were matched with 26 patients who received MAD therapy. At the 2-month follow-up, the acceptance rate of the TSD therapy was 53.8%. Both patients receiving TSD therapy and patients receiving MAD therapy showed significant improvements in their respiratory event index (P < .05), with no difference between the treatments (P > .05). In those receiving TSD therapy (n = 27), the only self-reported efficacy measure that significantly improved with TSD therapy was the Chalder Fatigue Scale (P < .05). In contrast, all 4 self-reported measures (Epworth Sleepiness Scale, Functional Outcomes of Sleep Questionnaire, 36-Item Short-Form Health Survey, and Chalder Fatigue Scale) showed a significant improvement with MAD therapy. CONCLUSIONS: This study revealed similar improvements in apneas and oxygen saturation between TSD and MAD therapies. Whereas MAD therapy was a better treatment for obstructive sleep apnea in terms of daytime sleepiness and quality-of-life improvements, TSD therapy had a low treatment acceptance rate. CLINICAL TRIAL REGISTRATION: Registry: ClinicalTrials.gov; Name: The Efficacy of Tongue Stabilizing Device in Patients with Obstructive Sleep Apnea; URL: https://clinicaltrials.gov/ct2/show/NCT02329925; Identifier: NCT02329925; and Registry: ClinicalTrials.gov; Name: Adherence and Preference of Continuous Positive Airway Pressure vs Mandibular Advancement Splints in Obstructive Sleep Apnea Patients: A Randomized Trial (CHOICE); URL: https://clinicaltrials.gov/ct2/show/NCT02242617; Identifier: NCT02242617. CITATION: Alshhrani WM, Hamoda MM, Okuno K, et al. The efficacy of a titrated tongue-stabilizing device on obstructive sleep apnea: a quasi-experimental study. J Clin Sleep Med. 2021;17(8):1607-1618.

Tongue Stabilizing Device-Emergent Central Sleep Apnea: A Case Report.

ABSTRACT: Treatment-emergent central sleep apnea is a phenomenon that has been reported after many obstructive sleep apnea treatment modalities. We present a case of demonstrating treatment-emergent central sleep apnea while using the tongue stabilizing device therapy. This case adds to the evidence that showed the effect of the supine position on the severity of central sleep apnea and shows the advantage of polysomnography follow-up after oral appliance therapy for central apnea assessment.

Pediatric sleep disorder medicine training in Canada: past, present and future.

Pediatric sleep medicine is rapidly evolving in Canada. As pediatric sleep disorders are increasingly recognized, there is a growing need for clinicians educated in the evaluation and treatment of pediatric sleep disorders. Current pediatric sleep resources in Canada are inadequate to meet the needs of the population. Until this year, there was no formal pathway or specific requirements for pediatric sleep disorder medicine training in Canada and exposure to this field of medicine in post-graduate training was limited. In 2018, the Royal College of Physicians of Canada approved an Area of Focused Competence program for certification and maintenance of competence in Sleep Disordered Medicine. It was designed to ensure adequate breadth and depth of training experiences in this diverse field. The goals of the program are to ensure competence in the assessment and management of adults and children with a range of sleep-wake disorders and sleep-disordered breathing, to interpret sleep investigations, to administratively manage a sleep laboratory and to advance the discipline of Sleep Disorder Medicine through research. The program follows a competency-based model in which, within the year of training, trainees accumulate a dossier of experiences which are evaluated by a Royal College of Physicians and Surgeons committee. This new program will ensure that a critical mass of trained sleep medicine physicians is developed to meet the needs of the Canadian pediatric population and to contribute to advancement of the field of pediatric sleep medicine.

Sleep Stage Coordination of Respiration and Swallowing: A Preliminary Study.

Swallowing is an important physiological response that protects the airway. Although aspiration during sleep may cause aspiration pneumonia, the mechanisms responsible have not yet been elucidated. We evaluated the coordination between respiration and swallowing by infusing water into the pharynx of healthy young adults during each sleep stage. Seven normal subjects participated in the study. During polysomnography recordings, to elicit a swallow we injected distilled water into the pharynx during the awake state and each sleep stage through a nasal catheter. We assessed swallow latency, swallow apnea time, the respiratory phase during a swallow, the number of swallows, and coughing. A total number of 79 swallows were recorded. The median swallow latency was significantly higher in stage 2 (10.05 s) and stage 3 (44.17 s) when compared to awake state (4.99 s). The swallow latency in stage 3 showed a very wide interquartile range. In two subjects, the result was predominantly prolonged compared to the other subjects. There was no significant difference in the swallow apnea time between sleep stages. The presence of inspiration after swallowing, repetitive swallowing, and coughing after swallowing was more frequent during sleep than when awake. This study suggests that the coordination between respiration and swallowing as a defense mechanism against aspiration was impaired during sleep. Our results supported physiologically the fact that healthy adult individuals aspirate pharyngeal secretions during sleep.

Swallowing and breathing patterns during sleep in patients with obstructive sleep apnea.

PURPOSE: The aims of this study were to determine the frequencies of swallowing and swallowing associated with arousals during sleep in patients with obstructive sleep apnea (OSA) and to determine whether these were associated with the severity of OSA and differed according to the preceding breathing route. METHODS: Standard audio-video polysomnography including an evaluation of swallowing-related elevation of the thyroid cartilage and breathing route (i.e., nasal or oronasal) was undertaken in an academic sleep laboratory. Fifty-six patients were analyzed (13 non-OSA patients, 17 mild, 10 moderate, and 16 severe OSA). RESULTS: The frequency of swallowing per hour of sleep was significantly higher in the severe OSA patients when compared to mild OSA patients (mild OSA, 3.1/h and severe OSA, 8.4/h). This was mainly due to the significantly higher frequency of swallowing associated with a respiratory event-related arousal in the severe OSA patients when compared to non- and mild OSA patients (non-OSA, 0.6/h; mild OSA, 1.0/h; severe OSA, 6.0/h), especially when swallowing was preceded by oronasal breathing (non-OSA, 0.2/h; mild OSA, 0.4/h; severe OSA, 4.2/h). CONCLUSIONS: Swallowing frequency during sleep can increase with increasing OSA severity in most OSA patients. These events are predominately associated with respiratory event-related arousals and are more frequent when preceded by oronasal breathing. The observed swallowing under high ventilatory needs may compromise the maintenance of the pharynx as a conduit for airflow in OSA patients.

Mandibular advancement splint as short-term alternative treatment in patients with obstructive sleep apnea already effectively treated with continuous positive airway pressure.

STUDY OBJECTIVES: CPAP is used as the first-line treatment for patients with severe OSA, but this machine is not always feasible to use on the long term. We performed a clinical trial to determine whether patients with OSA could use a mandibular advancement splint (MAS) as a short-term treatment alternative to CPAP. METHODS: Twenty-two patients adherent with CPAP therapy were recruited to the study. Each patient used the MAS for approximately 4 months. The transition between CPAP to MAS was gradual, and patients were asked to start using MAS together with CPAP during the MAS titration until subjective improvement or maximum mandibular advancement was achieved. Sleepiness (ESS), quality of life (SAQLI), and polysomnography were recorded prior to and after MAS titration. Patients recorded CPAP or MAS usage for the following 3 months. RESULTS: Seven women and 12 men with a mean age of 53.8 (± 12.1) years and mean body mass index of 28.1 (± 4.8) kg/m² completed the clinical trial. Prior to MAS, CPAP adherence was 5.8 h/night. AHI decreased significantly with MAS use compared to baseline (30.7 ± 23.1 vs 13.2 ± 11; p < 0.01). Fourteen patients (74%) had > 50% decrease in their AHI, while 2 patients had an increase in their AHI. There were no significant differences in SAQLI between MAS and CPAP treatment, while ESS decreased significantly on MAS. MAS self-reported usage was correlated with treatment efficacy (r = 0.52; p < 0.05). Seventy-five percent of the patients reported being sufficiently satisfied with MAS to continue to use it as an alternative short-term therapy. CONCLUSIONS: MAS partially or completely reduced sleep disordered breathing in the majority of selected, successfully CPAP-treated severe OSA patients. Many patients can probably effectively use MAS as a short-term treatment alternative to CPAP.

Patient preferences and experiences of CPAP and oral appliances for the treatment of obstructive sleep apnea: a qualitative analysis.

OBJECTIVES: The aim of this study is to better understand patients' perspectives and preferences about treatment with continuous positive airway pressure (CPAP) and oral appliance (OA) devices for obstructive sleep apnea. METHODS: The current study used qualitative analysis of four focus group sessions with current CPAP and OA users. Twenty-two participants with OSA who currently use either CPAP or OA participated in the sessions at the University of British Columbia. RESULTS: Five topics from the focus group sessions were descriptively analyzed using NVivo software: goals and expectations of treatment, benefits of treatment for bed partners, side effects and inconveniences of CPAP, side effects and inconveniences of OA, and factors impacting treatment choice. In order of most to least frequently mentioned, patients expressed six expectations of treatment: improved health, apnea elimination, improved sleep, reduced fatigue, reduced snoring, and bed-partner benefits. The most to least mentioned factors impacting treatment choice were device effectiveness, transportability, embarrassment, and cost. CONCLUSIONS: This qualitative study showed that many factors impact patients' experience with their treatment device and that their treatment needs are not only physical but also relate to their lifestyle. This preliminary study provides treatment characteristics and attributes necessary to develop a quantitative questionnaire study, to assist in the selection of therapy, weighing the relative importance of patient and OSA treatment characteristics on treatment preference and adherence. Matching therapy to patient preferences may help identify the most appropriate treatment, and this may achieve greater likelihood of adherence.

Coinfection with Cryptococcus gattii and Mycobacterium tuberculosis in an otherwise healthy 18-year-old woman.

A case of Cryptococcus gattii (pulmonary and central nervous system) and Mycobacterium tuberculosis (pulmonary) coinfection in an otherwise healthy young woman is reported. The patient presented with a two-month history of dry cough. She had an unremarkable medical history. Both tuberculosis and cryptococcosis were diagnosed following bronchoscopy, and a subsequent lumbar puncture revealed C gattii in the cerebrospinal fluid. There is evidence that both M tuberculosis and C gattii may have suppressive effects on the host immune system. This suggests a mechanism by which an otherwise healthy individual developed these two infections.

The relationship between mouth opening and sleep stage-related sleep disordered breathing.

STUDY OBJECTIVES: To evaluate mouth opening during sleep and the possible correlations between mouth opening and specific patient characteristics. METHODS: A total of 55 patients consecutively referred to assess snoring and suspected obstructive sleep apnea (OSA) were included. Sensors to record mouth opening were attached to each patient's face and synchronized with a standard polysomnogram. Mouth opening data were evaluated for each sleep stage as a percentage of maximum mouth opening. The patients were divided into 2 groups: patients with REM apnea hypopnea index (AHI) > NREM AHI (REM-dependent group = RD group), and patients with NREM AHI > REM AHI (NREM-dependent group = ND group). RESULTS: A total of 42 patients (male 69.0%, mean age 51.4 ± 12.9 years) underwent successful data collection. The amount of mouth opening during stage 1 (18.8% ± 14.6%) was significantly smaller than stage 2 (23.7% ± 16.4%, p < 0.01) and REM (29.2% ± 20.3%, p < 0.01). Age, body mass index (BMI), Epworth Sleepiness Scale (ESS) score, and AHI exhibited no correlation with mouth opening. The RD and the ND groups exhibited similar age, BMI, ESS, and AHI variables, but the ND group opened their mouths significantly more than the RD group during total sleep time (28.3% ± 13.6% vs 17.8% ± 17.3%, p < 0.01), stage 1 (23.2% ± 13.5% vs 12.9% ± 14.3%, p < 0.01), stage 2 (28.1% ± 17.9% vs 17.9% ± 17.4%, p < 0.01), and REM (34.7% ± 19.2% vs 21.9% ± 19.8%, p < 0.05). CONCLUSIONS: The ND patients opened their mouths wider than the RD patients during most sleep stages. The relationship between REM-dependent AHI and the amount of mouth opening may be a factor in the pathogenesis of OSA.

Canadian Sleep Society/Canadian Thoracic Society position paper on the use of portable monitoring for the diagnosis of obstructive sleep apnea/hypopnea in adults.

The present position paper on the use of portable monitoring (PM) as a diagnostic tool for obstructive sleep apnea/hypopnea (OSAH) in adults was based on consensus and expert opinion regarding best practice standards from stakeholders across Canada. These recommendations were prepared to guide appropriate clinical use of this new technology and to ensure that quality assurance standards are adhered to. Clinical guidelines for the use of PM for the diagnosis and management of OSAH as an alternative to in-laboratory polysomnography published by the American Academy of Sleep Medicine Portable Monitoring Task Force were used to tailor our recommendations to address the following: indications; methodology including physician involvement, physician and technical staff qualifications, and follow-up requirements; technical considerations; quality assurance; and conflict of interest guidelines. When used appropriately under the supervision of a physician with training in sleep medicine, and in conjunction with a comprehensive sleep evaluation, PM may expedite treatment when there is a high clinical suspicion of OSAH.

The impact of CPAP on cardiovascular biomarkers in minimally symptomatic patients with obstructive sleep apnea: a pilot feasibility randomized crossover trial.

BACKGROUND: Previous, largely uncontrolled studies demonstrated the substantial effects of continuous positive airway pressure ventilation (CPAP) on a variety of physiologic and biochemical markers known to be risk factors for cardiovascular disease in patients with obstructive sleep apnea (OSA). In this pilot crossover study, we assessed (1) the feasibility of using CPAP in a group of minimally symptomatic patients with OSA, assessed through patient compliance and (2) CPAP therapy's effect on biomarkers in these patients. METHODS: We studied patients with minimal daytime sleepiness who were referred to the University of British Columbia's Hospital Sleep Clinic with suspected OSA and an apnea-hypopnea index (AHI) > 15 events/h. Patients were randomized to either CPAP or no therapy for 4 weeks followed by a washout of 4 weeks, and then a crossover to the other intervention. Fasting morning blood and urine, 24-h blood pressure (BP) measurements, and endothelial function (peak flow-mediated dilation to nitroglycerin-mediated dilation ratio) were assessed before and after each study intervention. RESULTS: Nine adult male and four female patients were studied. Mean (SD) age was 55 (7) years, mean AHI = 27.9/h, mean Epworth Sleepiness Score = 6.8 (11/13 had a score < 10), and mean BMI = 31.1 kg/m(2). Mean compliance with CPAP therapy was 5.53 h/night. Compared to no therapy, potential improvements were observed with CPAP for urinary microalbumin, norepinephrine, and epinephrine to creatinine ratios (decreased by 3.51 mg/mmol, 1.70 nmol/mmol, and 0.95 nmol/mmol, respectively); 24-h BP (systolic decreased by 3.60 mmHg, diastolic by 0.70 mmHg); homeostasis model for insulin resistance score (decreased by 1.11); and endothelial function (increased by 7.4%). However, none of the above differences was significant (p > 0.10). CONCLUSION: In this pilot study there were potential improvements in a variety of cardiovascular biomarkers with CPAP. CPAP compliance was reasonably good even though patients were not particularly sleepy. Accordingly, larger randomized controlled trials in this area appear feasible and warranted.

Evaluation of a portable recording device (ApneaLink) for case selection of obstructive sleep apnea.

OBJECTIVE: This study was designed to assess the sensitivity and specificity of a portable sleep apnea recording device (ApneaLink) using standard polysomnography (PSG) as a reference and to evaluate the possibility of using the ApneaLink as a case selection technique for patients with suspected obstructive sleep apnea (OSA). MATERIALS AND METHODS: Fifty patients (mean age 48.7 +/- 12.6 years, 32 males) were recruited during a 4-week period. A simultaneous recording of both the standard in-laboratory PSG and an ambulatory level 4 sleep monitor (ApneaLink) was performed during an overnight study for each patient. PSG sleep and respiratory events were scored manually according to standard criteria. ApneaLink data were analyzed either with the automated computerized algorithm provided by the manufacturer following the American Academy of Sleep Medicine standards (default setting DFAL) or The University of British Columbia Hospital sleep laboratory standards (alternative setting, ATAL). The ApneaLink respiratory disturbance indices (RDI), PSG apnea-hypopnea indices (AHI), and PSG oxygen desaturation index (ODI) were compared. RESULTS: The mean PSG-AHI was 30.0 +/- 25.8 events per hour. The means of DFAL-RDI and ATAL-RDI were 23.8 +/- 21.9 events per hour and 29.5 +/- 22.2 events per hour, respectively. Intraclass correlation coefficients were 0.958 between PSG-AHI and DFAL-RDI and 0.966 between PSG-AHI and ATAL-RDI. Receiver operator characteristic curves were constructed using a variety of PSG-AHI cutoff values (5, 10, 15, 20, and 30 events per hour). Optimal combinations of sensitivity and specificity for the various cutoffs were 97.7/66.7, 95.0/90.0, 87.5/88.9, 88.0/88.0, and 88.2/93.9, respectively for the default setting. The ApneaLink demonstrated the best agreement with laboratory PSG data at cutoffs of AHI >or= 10. There were no significant differences among PSG-AHI, DFAL-RDI, and ATAL-RDI when all subjects were considered as one group. ODI at 2%, 3%, and 4% desaturation levels showed significant differences (p < 0.05) compared with PSG-AHI, DFAL-RDI, and ATAL-RDI for the entire group. CONCLUSION: The ApneaLink is an ambulatory sleep monitor that can detect OSA and/or hypopnea with acceptable reliability. The screening and diagnostic capability needs to be verified by further evaluation and manual scoring of the ApneaLink. It could be a better choice than traditional oximetry in terms of recording respiratory events, although severity may be under- or overestimated.

Three-dimensional computer-assisted study model analysis of long-term oral-appliance wear. Part 1: Methodology.

INTRODUCTION: The aim of this study was to test a 3-dimensional (3D) computer-assisted dental model analysis system that uses selected landmarks to describe tooth movement during treatment with an oral appliance. METHODS: Dental casts of 70 patients diagnosed with obstructive sleep apnea and treated with oral appliances for a mean time of 7 years 4 months were evaluated with a 3D digitizer (MicroScribe-3DX, Immersion, San Jose, Calif) compatible with the Rhinoceros modeling program (version 3.0 SR3c, Robert McNeel & Associates, Seattle, Wash). A total of 86 landmarks on each model were digitized, and 156 variables were calculated as either the linear distance between points or the distance from points to reference planes. Four study models for each patient (maxillary baseline, mandibular baseline, maxillary follow-up, and mandibular follow-up) were superimposed on 2 sets of reference points: 3 points on the palatal rugae for maxillary model superimposition, and 3 occlusal contact points for the same set of maxillary and mandibular model superimpositions. The patients were divided into 3 evaluation groups by 5 orthodontists based on the changes between baseline and follow-up study models. RESULTS: Digital dental measurements could be analyzed, including arch width, arch length, curve of Spee, overbite, overjet, and the anteroposterior relationship between the maxillary and mandibular arches. A method error within 0.23 mm in 14 selected variables was found for the 3D system. The statistical differences in the 3 evaluation groups verified the division criteria determined by the orthodontists. CONCLUSIONS: The system provides a method to record 3D measurements of study models that permits computer visualization of tooth position and movement from various perspectives.

Three-dimensional computer-assisted study model analysis of long-term oral-appliance wear. Part 2. Side effects of oral appliances in obstructive sleep apnea patients.

INTRODUCTION: Oral appliances (OAs) are widely prescribed for the treatment of obstructive sleep apnea (OSA). The occlusal changes that occur after long term OA treatment have not been well described based on detailed computerized three-dimensional (3D) assessment. METHODS: Seventy patients with OSA (mean age, 50.0 years) who had been treated with an OA were identified for this study. A MicroScribe-3DX dental study model analysis system was used to make 3D measurements on baseline and follow-up (88.4 +/- 26.7 months) study models. RESULTS: The following dental measurements showed significant changes (P <0.05) with long-term use of an OA: mandibular arch width increased more than maxillary arch width, crowding decreased in both arches, the curve of Spee became flat in the premolar area, the mandibular canine to second molar segment moved forward in relation to the maxillary arch, the bite opened and the overjet decreased except in some molar areas. CONCLUSIONS: A variety of occlusal changes occur with long-term OA treatment for OSA. The changes could be regarded as either adverse or beneficial depending upon the baseline characteristics.