Comparison of sleep characteristics during the first and second period of restrictive measures due to COVID-19 pandemic in Greece.

OBJECTIVE: The first wave of coronavirus pandemic and concomitant restrictive measures affected sleep. We slept more than usual, but the quality was worse. As the pandemic continues, a second period of restrictive measures was initiated, and no data exist about their impact on sleep. The aim of this study was to compare quantity and quality of sleep between the two periods of restrictive measures, due to the Coronavirus Disease-19 (COVID-19) pandemic in Greece. MATERIALS AND METHODS: A web-based survey using a short 13-item questionnaire was created and was distributed online. This included information about demographic and professional data, quantitative and qualitative characteristics of sleep, degree of abidance in lockdown measures, and data about COVID-19 infection or close contact with active confirmed cases. RESULTS: A total of 1,078 questionnaires were evaluated (first period, n=963; second period, n=115). Sleep duration was shorter during the second lockdown (mean difference -0.51h; 95% confidence interval, (CI), -0.82, -0.19, p=0.002). Compared to usual habits, sleep increased in first wave (mean difference +0.37h; 95% CI, 0.26, 0.47; p<0.001) and decreased in second wave (mean difference -0.35h; 95% CI, -0.60, -0.09; p=0.009). Regarding quality of sleep, less participants reported good quality of sleep during the second wave compared to the first (p=0.006). Finally, compliance to restriction measures was lower and the prevalence of confirmed illness or close contact with COVID-19 cases among participants was higher during the second period than during the first one (p<0.001 and p=0.028, respectively). CONCLUSIONS: Our data showed that sleep duration increased during the first lockdown and decreased in the second one, when compared to usual habits. Moreover, sleep quality progressively deteriorated, as the restrictive measures due to coronavirus pandemic continued.

Feasibility and safety of treatment switch from Pirfenidone to Nintedanib in patients with idiopathic pulmonary fibrosis: a real-world observational study.

OBJECTIVE: Idiopathic Pulmonary Fibrosis is a disease characterized by a devastating fibrosing process. Two anti-fibrotic agents, pirfenidone and nintedanib, have been found to alter the disease progression. In this study, we sought to determine whether switching treatment to nintedanib is feasible and safe in patients that had to discontinue treatment with pirfenidone due to side effects. PATIENTS AND METHODS: We analyzed patients that had to discontinue pirfenidone due to side effects. Patients were prospectively enrolled for treatment with nintedanib between March 2015 and June 2019. Side effects and Pulmonary Function Tests were recorded. RESULTS: 12 patients received nintedanib after discontinuing treatment with pirfenidone. Side-effects that led to discontinuation were diarrhea (33.3%), nausea (16.6%), photosensitivity (33.3%) and difficulty adhering to pirfenidone's dosage scheme (16.6%). After the initiation of nintedanib, diarrhea was the most common side effect (66.6%). Four patients of these patients could not tolerate the full dose of 300 mg daily and had to reduce it to 200 mg daily. No patient has had experienced liver damage. During the last twelve months of treatment with pirfenidone, mean ΔFCV was +2.47 ± 3.69%, mean ΔDLco was -0.36 ± 2.64% and mean difference of the distance walked during the 6MWT was 5 ± 56.48 meters. During the first year of treatment with nintedanib, mean ΔFCV was -1.32 ± 1.12% (p=0.68), mean ΔDLco was -1.59 ± 3.45% (p=0.54) and mean difference of the distance walked during the 6MWT was 14.17 ± 59 meters (p=0.078). 50% of patients had stable disease under pirfenidone (6-month FVC decline < 5% and/or 6-month DLco decline < 10%) vs. 50% under nintedanib, 33.3% had marginal 6-month decline (5% ≤ 6-month FVC ≤ 10% and/or (≤ 10% 6- month DLco decline ≤15%) under pirfenidone vs. 33.3% under nintedanib and 16.6% had disease progression (6-month FVC decline > 10% and/or 6-month DLco decline > 15%) under pirfenidone vs. 16.6% under nintedanib. CONCLUSIONS: These results suggest that nintedanib is a safe option for the treatment of patients that had to discontinue pirfenidone due to adverse reactions. Further studies with greater patient numbers are needed for accurate results concerning efficacy.

Cardiovascular Disease in Patients with Chronic Obstructive Pulmonary Disease, Obstructive Sleep Apnoea Syndrome and Overlap Syndrome.

Chronic obstructive pulmonary disease (COPD) and obstructive sleep apnoea syndrome (OSAS) are among the most prevalent chronic respiratory disorders. Accumulating data suggest that there is a significant burden of cardiovascular disease (CVD) in patients with COPD and OSAS, affecting negatively patients' quality of life and survival. Overlap syndrome (OS), i.e. the co-existence of both COPD and OSAS in the same patient, has an additional impact on the cardiovascular system multiplying the risk of morbidity and mortality. The underlying mechanisms for the development of CVD in patients with either OSAS or COPD and OS are not entirely elucidated. Several mechanisms, in addition to smoking and obesity, may be implicated, including systemic inflammation, increased sympathetic activity, oxidative stress and endothelial dysfunction. Early diagnosis and proper management of these patients might reduce cardiovascular risk and improve patients' survival. In this review, we summarize the current knowledge regarding epidemiological aspects, pathophysiological mechanisms and present point-to-point specific associations between COPD, OSAS, OS and components of CVD, namely, pulmonary hypertension, coronary artery disease, peripheral arterial disease and stroke.

Sleep quality and associated factors in the context of COVID-19, among prehospital emergency personnel, in North-Eastern Greece.

BACKGROUND: The stressful conditions that emerged during the Coronavirus disease 2019 (COVID-19) pandemic have had a negative impact on sleep quality in large part of the healthcare worker population. This study aimed to assess the self-reported quality of sleep among members of the Emergency Ambulance Service personnel of the National Emergency Center in the region of Thrace, Northeastern Greece, and to investigate its associations with perceived stress, feelings, and perceptions of well-being during the COVID-19 pandemic. METHODS: The study was conducted from March to May 2021 using an online structured questionnaire, and the collected data included: socio-demographic characteristics, occupational and medical history, distress and mental health issues due to COVID-19 and the following self-administrated instruments: Pittsburgh Sleep Quality Index (PSQI), WHO-5 Well-Being Index (WHO-5), and Perceived Stress Scale-14 items (PSS-14). RESULTS: Among the 74 participants, 71 % were poor sleepers (i.e., PSQI >5). The majority (83 % of the sample) reported feelings of stigma due to their occupation, with the proportion being higher among women (100 % vs 78 % in men, p =0.05) and poor sleepers (95 % vs 65 % in good sleepers, p =0.03). Poor sleepers had significantly lower WHO-5 scores than good sleepers (13.8 ± 4.9 vs 16.9 ± 5.8, p =0.04) and were experiencing significantly more anxiety and/or sadness at the time they answered the questionnaire (69.1 % vs 35.3 %, p =0.02). Perceived stress was significantly positively correlated with the "Latency" dimension of the PSQI (p =0.03). CONCLUSIONS: Poor sleep quality and feelings of stigmatization were prevalent for most of the sample. Poor sleep quality was associated more frequently with reported feelings of stigmatization, anxiety and/or sadness, and impaired well-being. HIPPOKRATIA 2021, 25 (3):126-133.

Pre-diabetic patients with severe obstructive sleep apnea: novel parameters of hypoxia during sleep correlate with insulin resistance.

Obstructive sleep apnea (OSA) is an increasingly prevalent sleep disorder with estimated prevalence of moderate to severe sleep apnea ranging between 6-13% in the adult population. Nocturnal intermittent hypoxia has been associated with an increased risk of developing type 2 diabetes and insulin resistance (IR). The existing indices of hypoxia, used in polysomnography (PSG), cannot express accurately the influence of the mild desaturations precisely during sleep. In the present study, 73 subjects without other comorbidities were examined by PSG. Hypoxia parameters were analyzed, in the intervals with low values of SpO2 signal. The thresholds were set at 94% and 92% and the average value (M) of the SpO2 signal, in areas below thresholds, were calculated. The desaturations were analyzed together with their duration within the recording in terms of SpO2 signal parameters. Blood samples were taken for biochemical analysis. A total of 50 subjects were diagnosed with OSAS with mean AHI of 56.11±27.70/h and 23 subjects had no sleep apnea with mean AHI of 3.47±0.6/h. The amount of desaturations was significantly correlated with insulin levels (r=0.301, p=0.034) and the percentage of desaturation events (Dev) that were longer than 6 points (2 sec) (r=0.301, p=0.034). In addition, mean duration of desaturations was significantly correlated with IR as expressed by HOMA index (r=0.289, p=0.047), as well as with total duration of desaturation of SpO2 (r=0.322, p =0.025) and percentage of Dev that were long than 6 points (2 sec) (r=0.292, p=0.044). A strong correlation was also revealed between total duration of desaturations and fasting glucose (r=0.887, p=0.000). Results suggest that hypoxia parameters derived from SpO2 signal analysis, are strongly correlated with IR and fasting glucose levels, implying a role of hypoxia in the pathogenesis of diabetes.

Vitamin D Levels in Middle-Aged Patients with Obstructive Sleep Apnoea Syndrome.

BACKGROUND: Vitamin D (Vit D) insufficiency has been implicated in the pathophysiology of numerous diseases. Obstructive sleep apnoea syndrome (OSAS), a disorder associated with increased cardiovascular and cerebrovascular morbidity, has been associated with decreased Vit D levels, but reports are inconclusive. AIM: To evaluate the association between serum 25-hydroxyvitamin D [25(OH)D], a marker of Vit D status, with anthropometric and sleep characteristics of OSAS patients and to compare those levels between OSAS patients and non-apnoeic controls. METHOD: Consecutive subjects who had undergone polysomnography and pulmonary function testing were divided into controls (apnoea-hypopnea index, AHI <5/h) and OSAS group (AHI ≥5/h). RESULTS: A total of 169 subjects (135 men) were included. OSAS patients (n=139) significantly differed from non-apnoeic controls in terms of age (53.9±12.8 vs. 44.9±12.8 years, p=0.002) and body mass index (BMI) (35.9±6.9 vs. 29.9±6.8 kg/m2, p<0.001). Serum 25(OH)D levels were lower in OSAS patients (17.8±7.8 vs. 23.9±12.4 ng/ml, p=0.019). In OSAS patients, levels of serum 25(OH)D were negatively correlated with sleep stage transitions (r=-0.205, p=0.028), AHI (r=-0.187, p=0.045), oxygen desaturation index (r=-0.234, p=0.011) and percentage of time with oxyhaemoglobin saturation <90% (r=-0.172, p=0.041). In contrast, they were positively correlated with average oxyhaemoglobin saturation during sleep (r=0.179, p=0.033), forced expiratory volume in 1 sec (r=0.207, p=0.037) and oxygen partial pressure (r=0.197, p=0.029). CONCLUSION: Vit D levels were lower in OSAS patients compared with non-apnoeic controls. Several indices of OSAS severity also correlated with Vit D levels.

Validation of the Greek version of the Severe Respiratory Insufficiency questionnaire.

BACKGROUND: The Severe Respiratory Insufficiency (SRI) questionnaire is a multidimensional, well-validated tool for the assessment of health-related quality of life (HRQL) in patients with severe chronic respiratory failure (CRF), due to a variety of underlying disorders. The aim of this study was to validate the SRI questionnaire in the Greek language (Gr-SRI). METHODS: Reliability and validity analyses were performed for the Gr-SRI using data of 136 consecutive patients with CRF, due to chronic obstructive pulmonary disease (COPD) or non-COPD respiratory diseases (kyphoscoliosis, obesity-hypoventilation, and post-tuberculosis sequelae). Sixty-three patients (46.3 %) were under long-term oxygen therapy (LTOT), while 73 (53.7 %) under long-term non-invasive mechanical ventilation at home (HMV), either with or without LTOT. RESULTS: Cronbach's alpha was high for the Summary Score of the SRI (0.86) showing high internal consistency, comparable to that of the original German version. The results of the principal component analysis on the SRI Summary Score produced a one-factor construct with a variance of 54 %, which confirmed a single Summary Score for the Greek SRI also. The highest and the lowest scores were detected in Respiratory Complaints and Physical Functioning subscales, respectively. The SRI was capable of discriminating COPD patients and non-COPD patients, with COPD patients having lower mean SRI scores, but no difference was observed between COPD patients under HMV or LTOT. CONCLUSIONS: Greek SRI has high psychometric properties qualifying its use for HRQL assessment in patients with CRF. HIPPOKRATIA 2017, 21(4): 186-190.

Insulin Sensitivity and Insulin Resistance in Non-Diabetic Middle-Aged Patients with Obstructive Sleep Apnoea Syndrome.

BACKGROUND: Obstructive sleep apnoea syndrome (OSAS) has been linked with abnormal glucose metabolism, insulin resistance (IR) and development of diabetes mellitus. METHODS: Non-diabetic patients (n=69) with OSAS, diagnosed by polysomnography, were prospectively recruited. To evaluate IR among OSAS patients, the Homeostasis Model Assessment of Insulin Resistance (HOMA-IR) and Insulin sensitivity by Quantitative Insulin sensitivity Check Index (QUICKI) were used. RESULTS: HOMA-IR was positively associated with body-mass index (BMI) (ρ=0.364, p=0.002), time with oxyhaemoglobin saturation <90% (ρ=0.291, p=0.015), arousal index (ρ=0.268, p=0.027), Epworth sleepiness scale (ESS) score (ρ=0.293, p=0.019) and negatively with average oxyhaemoglobin saturation (ρ=-0.398, p=0.001) and minimum oxyhaemoglobin saturation (ρ=-0.327, p=0.006). QUICKI was positively associated with forced vital capacity (r=0.301, p=0.014), average oxyhaemoglobin saturation (r=0.443, p<0.001), minimum oxyhaemoglobin saturation (ρ=0.318, p=0.008), and negatively associated with sleep stage transitions (r=-0.266, p=0.032), oxygen desaturation index (r=-0.404, p=0.005), time with oxyhaemoglobin saturation <90% (r=-0.311, p=0.019), arousal index (r=-0.344, p=0.004) and ESS score (r=-0.299, p=0.016). After adjustment for age and BMI, HOMA-IR was associated with sleep stage transitions, time with oxyhaemoglobin saturation <90%, average oxyhaemoglobin saturation, minimum oxyhaemoglobin saturation and arousal index. QUICKI was associated with oxygen desaturation index, sleep stage transitions, ESS score, minimum oxyhaemoglobin saturation and arousal index. CONCLUSIONS: An independent association between OSAS and IR in patients without pre-existing diabetes mellitus was observed. Recurrent hypoxia and sleep fragmentation in OSAS are associated with IR in these patients.

Mean Platelet Volume as a Surrogate Marker for Platelet Activation in Patients With Idiopathic Pulmonary Fibrosis.

BACKGROUND: Idiopathic pulmonary fibrosis (IPF) is associated with a prothrombotic state. AIM: To study mean platelet volume (MPV) and Platelet Distribution Width (PDW) as markers of platelet activation and their potential association with lung function in patients with recently diagnosed IPF. MATERIALS AND METHODS: This study included 56 patients with IPF (age 64.9±7.4 years) and 79 controls (age 64.2 ± 5.9 years). RESULTS: An inverse relation was demonstrated between platelet count and MPV in the control group but not among patients with IPF. Platelet count was significantly lower in patients with IPF compared with controls (230 ± 60 vs 256 ± 75 × 10(3)/µL, P = .038). Conversely, MPV was higher in patients versus controls (10.3 ± 1.2 vs 9.8 ± 1.2 fl, P = .024), while there was no difference between the groups in PDW. Respiratory function was, as expected, significantly impaired in patients with IPF versus controls in terms of forced expiratory volume in first second (FEV1; 67.2 ± 23.1 vs 102.6 ± 15.9% of predicted value, P < .001), forced vital capacity (FVC; 65.3 ± 21 vs 95.2 ± 16.1% of predicted value, P < .001), FEV1/FVC (83.1 ± 15 vs 87.5 ± 6.4%, P = .041) and partial pressure of oxygen in arterial blood (PaO2; 67.1 ± 10.3 vs 81.5 ± 15.2 mm Hg, P < .001). No significant correlation was seen between MPV and FVC (r = -.1497, P = .275), MPV and lung diffusion capacity for carbon monoxide (r = .035, P = .798) and total lung capacity (r = .032, P = .820). CONCLUSIONS: Patients with IPF exhibit higher MPV values and lower platelet count. Further studies are needed to assess the clinical implications of these findings.

Is there evidence of early vascular disease in patients with obstructive sleep apnoea without known comorbidities? Preliminary findings.

We evaluated early atherosclerotic lesions in 20 non-smokers with newly diagnosed Obstructive Sleep Apnoea (OSA) and without known comorbidities by measuring common carotid artery intima media thickness (CCA-IMT), transcranial Doppler ultrasound (TCD), and ankle brachial index (ABI). These were compared with 20 healthy age- and BMI-matched controls. In OSA patients, CCA-IMT was not significantly higher vs. controls (0.74±0.17 vs. 0.66±0.12 mm, p=0.201) and it was positively correlated with neck circumference (r=0.466, p=0.039), arousal index (r=0.663, p=0.001), gamma-glutamyl transpeptidase activity (r=0.474, p=0.035) while it was negatively correlated with Forced Expiratory Volume in 1 sec (r=-0.055, p=0.012). No difference was noted between patients and controls in terms of vascular stenosis on TCD examination, while asymptomatic peripheral artery disease was found in one patient with OSA. In conclusion, OSA patients without known comorbidities exhibit a non-significant increase in CCA-IMT without further evidence of vascular disease, but additional experience in a larger patient series is needed.

Unilateral pulmonary artery agenesis: a case series.

BACKGROUND: Unilateral pulmonary artery agenesis (UPAA) is a rare congenital anomaly due to a malformation of the sixth aortic arch of the affected side during embryogenesis. The diagnosis is usually set at adolescence, however it can remain asymptomatic and late diagnosis is possible. DESCRIPTION: We present a case series of three female patients, aged 18, 49 and 68 years old, with history of recurrent respiratory tract infections, to whom the diagnosis of UPAA was set. They were admitted, due to hemoptysis and productive cough (case 1) or progressive dyspnea on exertion (cases 2 and 3). Chest X-ray was abnormal in all three cases, depicting shift of the mediastinal structures to the left and hypoplasia of the left lung while chest CT demonstrated absence of the left pulmonary artery. CONCLUSION: UPAA can remain asymptomatic and diagnosis in adult age is possible, usually after an abnormal chest radiograph. A number of additional imaging techniques are available to aid the diagnosis. Physicians should consider the possibility of undiagnosed UPAA in adults.

Mean platelet volume and platelet distribution width in patients with chronic obstructive pulmonary disease: the role of comorbidities.

We evaluated mean platelet volume (MPV; an indicator of vascular risk) and platelet distribution width in patients with stable chronic obstructive pulmonary disease (COPD; n = 85). We also included a control group of 34 smokers without airflow limitation. Mean platelet volume was significantly higher in patients with COPD (10.69 ± 1.0 vs 9.96 ± 1.10 fL, P < .001) than in the smoker controls. White blood cell (WBC) count was also significantly higher in patients with COPD than in the smoker controls (10,642 ± 1247 vs 7136 ± 1887/µL, P < .001). There was a correlation between MPV and WBC in patients with COPD, especially in those at stage III (r = .530, P = .004) and IV (r = .389, P = .023). Mean platelet volume did not correlate with any indices of COPD severity. In patients with COPD, MPV and WBC levels are higher than those of smokers with normal pulmonary function and are significantly correlated. Whether these effects relate to vascular risk in patients with COPD remain to be established.

Mean Platelet Volume and Platelet Distribution Width in non-diabetic subjects with obstructive sleep apnoea syndrome: new indices of severity?

UNLABELLED: To evaluate Mean Platelet Volume (MPV) and Platelet Distribution Width (PDW) in non-diabetic subjects, according to obstructive sleep apnoea syndrome (OSAS) severity and the associations of these indices with anthropometric characteristics and parameters of breathing function during sleep. MATERIALS AND METHODS: We included 610 non-diabetic subjects with suspected OSAS, evaluated by polysomnography. According to their apnoea-hypopnoea index (AHI), patients were divided into Group A (n=148) with AHI<5/h; Group B (n=121) with AHI: 5-14.9/h; Group C (n=85) with AHI: 15-29.9/h and Group D (n=256) with AHI ≥ 30/h. MPV and PDW were measured using an automated blood cell counter. RESULTS: MPV was significantly higher in group D (mean value 12.1 ± 1.3 fl) than in groups A (9.8 ± 1.1 fl), B (9.8 ± 1.6 fl), and C (11.5 ± 1.3 fl) (p<0.001). The same pattern was observed in PDW values (15.9 ± 2.2 fl for group D and 13.2 ± 2.2 fl for group A, 14.1 ± 2.8 fl for group B, and 15 ± 2.2 fl for group C, p<0.001). Significant correlations were seen between MPV and AHI (p<0.001), average pulse oxygen saturation (SpO(2)) (p<0.001), minimum SpO(2) (p<0.001) and percent of the total sleep time with SpO(2) lower than 90% (t<90%) (p<0.001) during sleep, Arousal Index (p<0.001) and Epworth sleepiness scale (ESS) (p=0.028). Similarly, PDW was correlated with AHI (p<0.001), average SpO(2) (p=0.001), minimum SpO(2) (p<0.001), t<90% (p=0.002), and Arousal Index (p<0.001). CONCLUSIONS: MPV and PDW are higher in non-diabetic patients with severe OSAS and are correlated with different parameters of breathing function during sleep.

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.

Respiratory function in amyotrophic lateral sclerosis patients. The role of sleep studies.

BACKGROUND AND AIM: Respiratory function decline in association with sleep breathing abnormalities in Amyotrophic Lateral Sclerosis (ALS) patients are fully recognized as crucial manifestations in the natural course of the disease, severely affecting the prognosis. The aim of this study was to evaluate the respiratory function at daytime and during sleep in a population of ALS patients and investigate the necessity of sleep study performance for the appropriate management of the disease. PATIENTS AND METHODS: Twenty eight (10 male, 18 female) unselected patients with ALS, were evaluated in terms with their functional status by means of the ALS Functional Scale (ALSFSC). Baseline anthropometric measurements, pulmonary function tests and arterial blood gases analysis were performed, as well as evaluation of patients' perception of dyspnoea. A polysomnography was performed using a multichannel ambulatory recording. RESULTS: Nineteen patients had sleep disordered breathing with an RDI (Respiratory Disorder Index)>5/h (from 5.6/h to 83/h) and 10 patients had an RDI>15/h. All patients had impaired functional capacity by the ALSFSC and 11 patients (39.3%) reported mild to moderate dyspnoea. FVC was below 80% predictive value in 22 patients and in 8 patients hypoxaemia (PaO2<80 mmHg) and in 12 patients hypercapnia (PaCO2>40 mmHg) was present. There was no correlation found between spirometric values, maximum inspiratory and expiratory pressures and sleep study parameters. There was a significant correlation between PaCO2 and RDI (r=0.498, p<0.01), and PaO2 with nocturnal hypoxaemia (average SpO2, r=0.436,p<0.05). CONCLUSIONS: Sleep-breathing abnormality is common in ALS patients even in the absence of documented respiratory failure. Clinical evaluation and respiratory function tests alone may not be sufficient to predict sleep disordered breathing (SDB) and nocturnal breathing assessment should be included in the evaluation of respiratory function.