Diagnosis and management of obstructive sleep apnoea in adults.

Obstructive sleep apnoea is the most common form of sleep-disordered breathing. It is characterised by recurrent occlusion of the airway during sleep. Ensuing apnoeas terminate in arousal from sleep and lead to non-restorative sleep, excessive daytime sleepiness and adverse cardiovascular and neurocognitive effects. A sleep study should be offered to patients reporting witnessed apnoeas or symptoms related to non-restorative sleep. It should also be considered in the presence of predisposing factors for obstructive sleep apnoea (e.g. obesity, tonsillar hypertrophy, retrognathia, refractory hypertension). Treatment should aim to improve symptoms and reduce cardiovascular and neurocognitive risk. The treatment approach should consider the symptom burden, severity, anatomical factors, and patient preference. Positive airway pressure is the most effective treatment option, although intolerance and non-adherence are common. Other options include positional therapy, oral appliances and upper airway surgery. Weight loss and optimisation of cardiovascular disease risk should be considered in selected patients.

Beyond Counting Sheep: Exploring the Link between Polycystic Ovary Syndrome and Sleep Health.

Polycystic ovary syndrome (PCOS) is a common hormonal condition with reproductive, metabolic, and psychological sequelae that affects 8 to 13% of reproductive-aged women and 3 to 11% of adolescent girls. Sleep is often compromised in women with PCOS due to increased rates of sleep problems, with the most established problem being obstructive sleep apnea (OSA). OSA is highly prevalent in reproductive-aged adult women with PCOS, but not so in adolescence. The international evidence-based PCOS guideline to improve health outcomes in women with PCOS indicated routine screening to identify and alleviate symptoms of OSA. The guidelines, however, did not weigh other multidimensional constructs of sleep health such as sleep disturbances (e.g., sleep quality and quantity), beyond OSA. This is perhaps due to the lack of research and existing mixed findings in the area of PCOS and sleep health. This narrative review summarizes the current knowledge about OSA and expands further to include the limited knowledge about other sleep problems in PCOS among reproductive-aged women and adolescent girls. We broadly cover the prevalence, risk factors, and mechanisms of sleep problems in PCOS and their relationship with cardiometabolic and psychological health. A brief summary on treatment and intervention strategies for sleep problems in PCOS and future recommendations will be deliberated.

Validation of a single-use and reusable home sleep apnea test based on peripheral arterial tonometry compared to laboratory polysomnography for the diagnosis of obstructive sleep apnea.

STUDY OBJECTIVES: The objective of this study was to independently validate a disposable and a reusable home sleep apnea test (HSAT) recording on peripheral arterial tonometry, compared to laboratory polysomnography (PSG), for the diagnosis of obstructive sleep apnea (OSA). METHODS: 115 participants undergoing PSG for suspected OSA were recruited and fitted with the two study devices (NightOwl, Ectosense, Belgium). After exclusions were applied and device failures were removed, data from 100 participants were analyzed. HSAT-derived apnea-hypopnea index (AHI), OSA severity category, total sleep time, and oxygen desaturation index 3% were compared to PSG. RESULTS: Both study devices demonstrated satisfactory levels of agreement with minimal mean bias for determination of AHI and oxygen desaturation index 3% (disposable: AHI mean bias 2.04 events/h [95% limits of agreement -20.9 to 25.0], oxygen desaturation index 3% mean bias -0.21/h [-18.1 to 17.7]; reusable: AHI mean bias 2.91 events/h [-16.9 to 22.7], oxygen desaturation index 3% mean bias 0.77/h [-15.7 to 17.3]). Level of agreement diminished at higher AHI levels although misclassification for severe OSA occurred infrequently. Total sleep time level of agreement for the reusable HSAT was also satisfactory with minimal mean bias (4.18 minutes, -125.1 to 112.4), but the disposable HSAT was impacted by studies with high signal rejection (23.7 minutes, -132.7 to 180.1). Categorization of OSA severity demonstrated moderate agreement with laboratory PSG, with a kappa of 0.52 and 0.57 for the disposable and reusable HSATs respectively. CONCLUSIONS: The two HSAT devices were comparable and performed well compared to laboratory PSG for the diagnosis of OSA. CLINICAL TRIAL REGISTRATION: Registry: Australian New Zealand Clinical Trials Registry; Identifier: ANZCTR12621000444886. CITATION: Lyne CJ, Hamilton GS, Turton ARE, et al. Validation of a single-use and reusable home sleep apnea test based on peripheral arterial tonometry compared to laboratory polysomnography for the diagnosis of obstructive sleep apnea. J Clin Sleep Med. 2023;19(8):1429-1435.

Nocturnal Wakefulness and Suicide Risk in the Australian Population.

Objective: Temporal patterns for suicide over a 24-hour period have shown mixed results among prior studies. However, analyses of 24-hour temporal patterns for wakeful actions including suicidal behavior should adjust for expected sleep requirements that inherently skew such activities to conventional wakeful times. This study analyzed the time-of-day for suicide cases from the Australian population for the year 2017, adjusting for expected sleep patterns. Identification of time-of-day trends using this methodology may reveal risk factors for suicide and potentially modifiable contributors.Methods: The Australian National Coronial Information System database was accessed, and data for completed suicide were extracted for the most recent completed year (2017). Time of suicide was allocated to one of four 6-hourly time bins across 24 hours, determined from time last seen alive and time found subsequently. Prevalence of suicide for each time bin was adjusted for the likelihood of being awake for each bin according to sleep-wake norms published from a large Australian community survey. Observed prevalence of suicide was compared to expected values predicted from likelihood of being awake across each time bin calculated as a standardized incidence ratio (SIR).Results: For the year 2017, there were 2,808 suicides, of which 1,417 were able to be allocated into one of four 6-hourly time bins. When compared to expected values, suicides were significantly more likely to occur in the overnight bin (2301-0500; SIR = 3.93, P < .001).Conclusions: Higher-than-expected rates of suicide overnight associated with nocturnal wakefulness may represent a modifiable risk factor for triggering suicide events.

Fit-Tested N95 Masks Combined With Portable High-Efficiency Particulate Air Filtration Can Protect Against High Aerosolized Viral Loads Over Prolonged Periods at Close Range.

BACKGROUND: Healthcare workers (HCWs) are at risk from aerosol transmission of severe acute respiratory syndrome coronavirus 2. The aims of this study were to (1) quantify the protection provided by masks (surgical, fit-testFAILED N95, fit-testPASSED N95) and personal protective equipment (PPE), and (2) determine if a portable high-efficiency particulate air (HEPA) filter can enhance the benefit of PPE. METHODS: Virus aerosol exposure experiments using bacteriophage PhiX174 were performed. An HCW wearing PPE (mask, gloves, gown, face shield) was exposed to nebulized viruses (108 copies/mL) for 40 minutes in a sealed clinical room. Virus exposure was quantified via skin swabs applied to the face, nostrils, forearms, neck, and forehead. Experiments were repeated with a HEPA filter (13.4 volume-filtrations/hour). RESULTS: Significant virus counts were detected on the face while the participants were wearing either surgical or N95 masks. Only the fit-testPASSED N95 resulted in lower virus counts compared to control (P = .007). Nasal swabs demonstrated high virus exposure, which was not mitigated by the surgical/fit-testFAILED N95 masks, although there was a trend for the fit-testPASSED N95 mask to reduce virus counts (P = .058). HEPA filtration reduced virus to near-zero levels when combined with fit-testPASSED N95 mask, gloves, gown, and face shield. CONCLUSIONS: N95 masks that have passed a quantitative fit-test combined with HEPA filtration protects against high virus aerosol loads at close range and for prolonged periods of time.

Pulmonary actinomycosis and polymicrobial empyema in a patient with ABPA and bronchocoele.

We present a 43-year-old woman, with a history of allergic bronchopulmonary aspergillosis and a chronic bronchocoele, who was admitted to hospital with an infection of the bronchocoele, progressing to a pulmonary abscess and polymicrobial empyema, following dental extraction and regular Lactobacillus probiotic ingestion. Interval chest imaging following this procedure demonstrated worsening right upper lobe opacities and a right-sided pleural effusion. Bronchoscopies identified copious mucoid secretions and an infected bronchocoele with a right upper lobe airways impaction. Oral cavity organisms including Actinomyces odontolyticus were cultured on bronchial washings. Streptococcus mitis and Lactobacillus rhamnosus were cultured in pleural fluid. Treatment with endoscopic mucoid secretion suctioning; intercostal catheter insertion and therapeutic drainage; and antibiotic, glucocorticoid and anti-IgE therapy resulted in clinical and radiological improvement. Our case illustrates the potential pulmonary complications from oral cavity organisms following tooth extraction and probiotic use in patients with chronic lung disease associated with mucoid lesions and airways obstruction.

Examining the impact of multilevel upper airway surgery on the obstructive sleep apnoea endotypes and their utility in predicting surgical outcomes.

BACKGROUND AND OBJECTIVE: Upper airway surgery for obstructive sleep apnoea (OSA) is an alternative treatment for patients who are intolerant of continuous positive airway pressure (CPAP). However, upper airway surgery has variable treatment efficacy with no reliable predictors of response. While we now know that there are several endotypes contributing to OSA (i.e., upper airway collapsibility, airway muscle response/compensation, respiratory arousal threshold and loop gain), no study to date has examined: (i) how upper airway surgery affects all four OSA endotypes, (ii) whether knowledge of baseline OSA endotypes predicts response to surgery and (iii) whether there are any differences when OSA endotypes are measured using the CPAP dial-down or clinical polysomnographic (PSG) methods. METHODS: We prospectively studied 23 OSA patients before and ≥3 months after multilevel upper airway surgery. Participants underwent clinical and research PSG to measure OSA severity (apnoea-hypopnoea index [AHI]) and endotypes (measured in supine non-rapid eye movement [NREM]). Values are presented as mean ± SD or median (interquartile range). RESULTS: Surgery reduced the AHITotal (38.7 [23.4 to 79.2] vs. 22.0 [13.3 to 53.5] events/h; p = 0.009). There were no significant changes in OSA endotypes, however, large but variable improvements in collapsibility were observed (CPAP dial-down method: ∆1.9 ± 4.9 L/min, p = 0.09, n = 21; PSG method: ∆3.4 [-2.8 to 49.0]%Veupnoea , p = 0.06, n = 20). Improvement in collapsibility strongly correlated with improvement in AHI (%∆AHISupineNREM vs. ∆collapsibility: p < 0.005; R2  = 0.46-0.48). None of the baseline OSA endotypes predicted response to surgery. CONCLUSION: Surgery unpredictably alters upper airway collapsibility but does not alter the non-anatomical endotypes. There are no baseline predictors of response to surgery.

Body position during laboratory and home polysomnography compared to habitual sleeping position at home.

STUDY OBJECTIVES: Supine-predominant obstructive sleep apnea (OSA) is highly prevalent. The proportion of time spent in the supine position may be overrepresented during polysomnography, which would impact on the apnea-hypopnea index (AHI) and have important clinical implications. We aimed to investigate the difference in body position during laboratory or home polysomnography compared to habitual sleep and estimate its effect on OSA severity. Secondary aims were to evaluate the consistency of habitual sleeping position and accuracy of self-reported sleeping position. METHODS: Patients undergoing diagnostic laboratory or home polysomnography were recruited. Body position was recorded using a neck-worn device. Habitual sleeping position was the average time spent supine over 3 consecutive nights at home. Primary outcomes were the proportion of sleep time spent supine (% time supine) and AHI adjusted for habitual sleeping position. RESULTS: Fifty-seven patients who underwent laboratory polysomnography and 56 who had home polysomnography were included. Compared to habitual sleep, % time supine was higher during laboratory polysomnography (mean difference 14.1% [95% confidence interval: 7.2-21.1]; P = .0002) and home polysomnography (7.1% [95% confidence interval 0.9-13.3]; P = .03). Among those with supine-predominant OSA, there was a trend toward lower adjusted AHI than polysomnography-derived AHI (P = .07), changing OSA severity in 31.6%. There was no significant between-night difference in % time supine during habitual sleep (P = .4). Self-reported % time supine was inaccurate (95% limits of agreement -49.2% to 53.9%). CONCLUSIONS: More time was spent in the supine position during polysomnography compared to habitual sleep, which may overestimate OSA severity for almost one-third of patients with supine-predominant OSA. CLINICAL TRIAL REGISTRATION: Registry: Australia and New Zealand Clinical Trials Registry (ANZCTR); Title: Sleeping position during sleep tests and at home; Identifier: ACTRN12618000628246; URL: https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=374873&isReview=true. CITATION: Yo SW, Joosten SA, Wimaleswaran H, et al. Body position during laboratory and home polysomnography compared to habitual sleeping position at home. J Clin Sleep Med. 2022;18(9):2103-2111.

Sleep as a Major Determinant for Mental Health Outcomes in Elite Australian Football League (AFL) Athletes.

PURPOSE: The link between mental health and sleep is well documented in the general population, with the majority of mental health disorders involving some type of sleep disturbance. There is, however, limited research investigating this relationship in elite athlete populations. The aim of this study was to identify whether sleep and mental health outcomes are associated in elite athletes and, if so, what measures of sleep were the most predictive of mental health outcomes. METHODS: A comprehensive assessment of sleep was conducted using both objective and subjective methods in 68 Australian Football League athletes (male; mean age, 23.3 ± 3.4 yr; median, 23; range, 18-32 yr). Rest-activity patterns were recorded using wrist actigraphy for an average of 13.8 ± 3.6 d (a total of 884 d of data). Subjective sleep data were collected using daily sleep diaries and validated questionnaires. Validated mental health questionnaires were used to assess depression, anxiety, and stress symptoms. Multiple linear regression modeling was used to investigate the relationship between sleep and mental health. RESULTS: Using a combination of sleep variables, poor sleep predicted 51% of the variation in clinical depression, 42% of the variation in stress, and 31% in clinical anxiety. Self-reported insomnia symptoms (using the Insomnia Severity Index) were the strongest predictors of poor mental health outcomes, followed by objective sleep monitoring via actigraphy. Sleep diary measures were the weakest predictors of mental health. CONCLUSIONS: Our results present poor sleep as a major determinant of impaired mental health outcomes in a population that is constantly under pressure to perform at the highest level and may underreport mental health symptoms. These findings support the inclusion of sleep assessments as an initial screening tool as well as a core component of all routine health and rehabilitation programs.

Sleep disturbances may influence lifestyle behaviours in women with self-reported polycystic ovary syndrome.

Polycystic ovary syndrome (PCOS) is associated with a higher prevalence of sleep disturbances and obesity. Treatment of PCOS includes modifying lifestyle behaviours associated with weight management. However, poor sleep in the non-PCOS population has been associated with poorer lifestyle behaviours. The aim was to investigate whether sleep disturbance confounds or modifies the association between lifestyle factors and PCOS. This was a cross-sectional analysis from the Australian Longitudinal Study on Women's Health cohort aged 31-36 years in 2009 were analysed (n 6067, 464 PCOS, 5603 non-PCOS). Self-reported data were collected on PCOS, anthropometry, validated modified version of the Active Australia Physical Activity survey, validated FFQ and sleep disturbances through latent class analysis. Women with PCOS had greater adverse sleep symptoms including severe tiredness (P = 0·001), difficulty sleeping (P < 0·001) and restless sleep (P < 0·001), compared with women without PCOS. Women with PCOS also had higher energy consumption (6911 (sd 2453) v. 6654 (sd 2215) kJ, P = 0·017), fibre intake (19·8 (sd 7·8) v. 18·9 (sd 6·9) g, P = 0·012) and diet quality (dietary guidelines index (DGI)) (88·1 (sd 11·6) v. 86·7 (sd 11·1), P = 0·008), lower glycaemic index (50·2 (sd 4·0) v. 50·7 (sd 3·9), P = 0·021) and increased sedentary behaviour (6·3 (sd 2·8) v. 5·9 (sd 2·8) h, P = 0·009). There was a significant interaction between PCOS and sleep disturbances for DGI (P = 0·035), therefore only for women who had adequate sleep was PCOS associated with a higher DGI. For women with poorer sleep, there was no association between PCOS and DGI. The association between PCOS and improved diet quality may only be maintained if women can obtain enough good quality sleep.

The social and economic cost of sleep disorders.

STUDY OBJECTIVES: To estimate economic cost of common sleep disorders in Australia for 2019-2020. METHODS: Costs were estimated for obstructive sleep apnea (OSA), insomnia, and restless legs syndrome (RLS) using prevalence, financial, and nonfinancial data from national databases. These included: (1) financial costs associated with health care, informal care, productivity losses, non-medical accident costs, deadweight loss from taxation/welfare inefficiencies; and (2) nonfinancial costs associated with loss of well-being. They were expressed in U.S. dollars ($). RESULTS: Estimated overall cost of sleep disorders in Australia in 2019-2020 (population: 25.5 million) was $35.4 billion (OSA $13.1 billion; insomnia $13.3 billion, RLS $9.0 billion). Of this, the financial cost component was $10.0 billion, comprised of: health system costs $0.7 billion; productivity losses $7.7 billion; informal care $0.2 billion; other, mainly non-medical accident costs, $0.4 billion; and deadweight losses $1.0 billion. For moderate to severe OSA syndrome, insomnia unrelated to other conditions and RLS, financial costs represented $16,717, $21,982, and $16,624 per adult with the condition for the year, respectively. The nonfinancial cost was $25.4 billion. CONCLUSIONS: The economic costs associated with sleep disorders are substantial. The financial component of $10.0 billion is equivalent to 0.73% of Australian gross domestic product. The nonfinancial cost of $25.4 billion represents 3.2% of total Australian burden of disease for the year. Health system costs of these disorders are low relative to those associated with their consequences, suggesting greater expenditure on detection, treatment and prevention is warranted.

Poorer sleep quality predicts melatonin response in patients with traumatic brain injury: findings from a randomized controlled trial.

STUDY OBJECTIVES: A recent clinical trial demonstrated that melatonin treatment was effective in improving self-perceived sleep quality in patients with traumatic brain injury (TBI); however, it remains unclear which patients benefited from melatonin treatment. To that end, findings from the clinical trial were re-examined to identify possible predictors of treatment response. METHODS: Hierarchical multiple regression was used to identify patient characteristics, TBI injury characteristics, and self-report measures assessing sleep, fatigue, mood, and anxiety symptomatology that may uniquely explain a change in self-reported sleep quality scores (follow-up minus baseline score) as assessed by the Pittsburgh Sleep Quality Index (PSQI). RESULTS: After controlling for patient demographic and TBI injury-related variables, baseline self-report measures of sleep, fatigue, mood, and anxiety explained an additional 32% of the variance in change in PSQI scores. However, only baseline PSQI score made a unique and statistically significant contribution (ß = -0.56, P = .006). After controlling for patient and TBI characteristics, baseline PSQI scores further explained 27% of the variance in change in PSQI scores (R2 change = .27, F1, 27 change = 11.79, P = .002). The standardized ß for baseline PSQI score revealed a statistically significant negative relationship with change in PSQI score (ß = -0.54, P = .002), revealing that higher PSQI score at baseline was associated with better sleep outcomes. CONCLUSIONS: In a sample comprising predominantly severe TBI and comorbid insomnia, participants who report poorer sleep quality have the most to gain from melatonin treatment irrespective of time since injury, demographics, fatigue, daytimes sleepiness, mood, and anxiety symptomology. CLINICAL TRIAL REGISTRATION: Registry: Australian New Zealand Clinical Trials Registry; Name: Efficacy of Melatonin for Sleep Disturbance Following Traumatic Brain Injury; URL: https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=343083&showOriginal=true&isReview=true; Identifier: ACTRN12611000734965. CITATION: Grima NA, Rajaratnam SMW, Mansfield D, McKenzie D, Ponsford JL. Poorer sleep quality predicts melatonin response in patients with traumatic brain injury: findings from a randomized controlled trial. J Clin Sleep Med. 2021;17(8):1545-1551.

Viable virus aerosol propagation by positive airway pressure circuit leak and mitigation with a ventilated patient hood.

INTRODUCTION: Nosocomial transmission of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has been a major feature of the COVID-19 pandemic. Evidence suggests patients can auto-emit aerosols containing viable viruses; these aerosols could be further propagated when patients undergo certain treatments, including continuous positive airway pressure (PAP) therapy. Our aim was to assess 1) the degree of viable virus propagated from PAP circuit mask leak and 2) the efficacy of a ventilated plastic canopy to mitigate virus propagation. METHODS: Bacteriophage phiX174 (108 copies·mL-1) was nebulised into a custom PAP circuit. Mask leak was systematically varied at the mask interface. Plates containing Escherichia coli host quantified viable virus (via plaque forming unit) settling on surfaces around the room. The efficacy of a low-cost ventilated headboard created from a tarpaulin hood and a high-efficiency particulate air (HEPA) filter was tested. RESULTS: Mask leak was associated with virus contamination in a dose-dependent manner (χ2=58.24, df=4, p<0.001). Moderate mask leak (≥21 L·min-1) was associated with virus counts equivalent to using PAP with a vented mask. The highest frequency of viruses was detected on surfaces <1 m away; however, viable viruses were recorded up to 3.86 m from the source. A plastic hood with HEPA filtration significantly reduced viable viruses on all plates. HEPA exchange rates ≥170 m3·h-1 eradicated all evidence of virus contamination. CONCLUSIONS: Mask leak from PAP may be a major source of environmental contamination and nosocomial spread of infectious respiratory diseases. Subclinical mask leak levels should be treated as an infectious risk. Low-cost patient hoods with HEPA filtration are an effective countermeasure.

Obstructive sleep apnoea predicted by the STOP-BANG questionnaire is not associated with higher rates of post-operative complications among a high-risk surgical cohort.

PURPOSE: The purpose of this study is to establish if obstructive sleep apnoea (OSA) predicted by the STOP-BANG questionnaire would be associated with higher rates of post-operative cardiac, respiratory or neurological complications among a selected high-risk population with established major comorbidities undergoing major surgery. We hypothesise that a cohort selected for major comorbidities will show a higher post-operative complication rate that may power any potential association with co-existent OSA and identify an important target group for OSA screening and treatment pathways in preparation for major surgery. METHODS: Patients attending a high-risk preadmission clinic prior to major surgery from May 2015 to November 2015 were prospectively screened for OSA using the STOP-BANG questionnaire. Patients with treated OSA were excluded. Patient data and complications were attained from the pre-admission clinic and subsequent inpatient medical record at discharge. RESULTS: Three-hundred-and-ten patients were included in the study (age 68.6 ± 13.1 years, body mass index [BMI] 30.6 ± 7.4 kg/m2; 52.9% female). Sixty-four patients (20.6%) experienced 82 post-operative complications. Seventy-five percent of the cohort had a STOP-BANG ≥ 3. There was no association between the STOP-BANG score (unadjusted and adjusted for comorbidity) with the development of post-operative complications. CONCLUSIONS: OSA predicted by the STOP-BANG score was not associated with higher rates of post-operative complications in patients with major comorbidities undergoing high-risk surgery. As the findings from this cohort contrast with other observational studies, more definitive studies are required to establish a causative link between OSA and post-operative complications and determine whether treating OSA reduces this complication rate.

Recommendations for current and future countermeasures against sleep disorders and sleep loss to improve road safety in Australia.

The Australian National Road Safety Strategy 2011-2020 framed a 19-point action plan targeting a 30% reduction in road deaths by 2020. In achieving a 9% reduction to date, it is likely to fail this target. Sleep disorders and sleep loss did not feature prominently in this strategy, despite their high prevalence and effect on drowsiness and crashes. This article gathers sleep experts to provide recommendations addressing driver education and legislation to assist the response to this public health problem. Developments in drowsiness detection and sleep disorders management are also presented that offer innovative countermeasures that could enhance road safety beyond 2020.