Gender Issues in Obstructive Sleep Apnea.

Obstructive sleep apnea has historically been considered a male disease. Although most studies have shown male predominance, obstructive sleep apnea is highly prevalent in women, increasing with age and varying with physiologic status among other factors. Obstructive sleep apnea is associated with significant symptoms and health consequences in women yet remains underdiagnosed in women in part due to differences in presenting symptoms, differences in polysomnographic findings, and/or sociocultural factors. This review will discuss the epidemiology, pathophysiology, clinical presentation, diagnostic findings, and treatment of obstructive sleep apnea, focusing on sex and gender differences.

Progressive Dyspnea and Hypoxemia With Diffuse Pulmonary Infiltrates in a Previously Healthy Woman.

CASE PRESENTATION: A 50-year-old woman presented with 3 months of cough, dyspnea, and fatigue. She also reported new fevers, night sweats, and a rash on her face and torso. On presentation she was tachycardic and tachypneic, with oxygen saturation of 81% on 2 L/min of oxygen. She was in mild respiratory distress. Results of the physical examination were remarkable for tender left cervical and axillary adenopathy and bibasilar pulmonary crackles. She had an acneiform rash on her face, chest, and back, consisting of multiple nonblanching erythematous or violaceous macules and papules (Fig 1) and had conjunctival edema. Admission laboratory test results were significant for a WBC count of 56,000, of which 79.5% were lymphocytes. Hemoglobin and platelet levels were normal. She was admitted for further management.

Sleep-Disordered Breathing in Neuromuscular and Chest Wall Diseases.

Neuromuscular and chest wall diseases include a diverse group of conditions that share common risk factors for sleep-disordered breathing, including respiratory muscle weakness and/or thoracic restriction. Sleep-disordered breathing results from both the effects of normal sleep on ventilation and the additional challenges imposed by the underlying disorders. Patterns of sleep- disordered breathing vary with the specific diagnosis and stage of disease. Sleep hypoventilation precedes diurnal respiratory failure and may be difficult to recognize clinically because symptoms are nonspecific. Polysomnography has a role in both the diagnosis of sleep-disordered breathing and in the titration of effective noninvasive positive-pressure ventilation.

Patient-centered care in obstructive sleep apnea: A vision for the future.

Obstructive sleep apnea is a common condition, with multiple potential neurocognitive, cardiovascular, and metabolic consequences. Efficacious treatment is available, but patient engagement is typically required for treatment to be effective. Patients with sleep apnea are phenotypically diverse and have individual needs, preferences, and values that impact treatment decisions. There has been a shift in obstructive sleep apnea management from diagnosis to chronic care management. Making treatment decisions that incorporate an individual patient's values and preferences and are personalized for that patient's biology has the potential to improve patient outcomes. A patient-centered care approach in obstructive sleep apnea is reviewed including 1) determining patient-specific needs to guide treatment decisions, 2) understanding patient values, preferences, and other factors impacting treatment decisions and using shared decision-making, 3) enhancing patient education and support to improve treatment adherence, 4) promoting patient engagement, 5) optimizing care coordination, continuity of care, and access to care, and 6) determining and assessing patient-centered outcomes.

Can periodic limb movement disorder be diagnosed without polysomnography? A case-control study.

OBJECTIVES: (1) To determine whether clinical information can predict the presence of periodic limb movement disorder (PLMD). (2) To examine whether clinical data correlate with PLMD severity. METHODS: Sixty-one adult patients (48 males and 13 females, aged 55.1+/-14.1 years) with PLMD (without a clinical diagnosis of restless legs syndrome) were compared with 61 control patients without PLMD (43 males and 18 females, aged 49.6+/-16.1 years) in this case-control study. All patients completed a detailed questionnaire which included (1) demographics, (2) sleep complaints, (3) medical disorders, (4) use of medication, nicotine, and caffeine, and (5) history of nocturnal motor/sensory leg symptoms. All patients underwent standard polysomnography. RESULTS: The PLMD and control groups were similar in the prevalence of insomnia, hypersomnia, diabetes, peripheral neurologic disorders, anemia, spinal disease, antidepressant medication use, smoking, caffeine intake, and leg pain. Compared with the control group, the PLMD group reported more leg kicks (28% vs. 5%, P<0.001) and more crawling or aching sensations in legs (28% vs. 11%, P=0.023). The logistic regression analysis showed that only age (P=0.044), leg kicks (odds ratio (OR) 12.70, 95% confidence interval (CI) 2.80-57.63, P=0.001), and crawling or aching in legs (OR 5.23, 95% CI 1.16-23.44, P=0.029) were significantly related to the presence of PLMD. The positive predictive value of leg kicks in the diagnosis of PLMD was 85% and the negative predictive value was 57%. Within the PLMD group, only age correlated positively with the PLM-index (r=0.47, P<0.001). Both the PLM-index and the PLM arousal-index were negatively correlated with sleep efficiency on polysomnography (P=0.005 and P=0.006, respectively). CONCLUSIONS: Clinical data are not sufficiently predictive of the presence of PLMD to rule in or rule out the diagnosis. Polysomnography is required for establishing the diagnosis of PLMD in patients with insomnia or hypersomnia.

Continuous positive airway pressure: new generations.

Automatic positive airway pressure devices are the most technologically advanced positive airway pressure devices available for use in OSA. Although heterogeneous, they have in common the ability to detect and respond to changes in upper airway resistance. Data cannot necessarily be extrapolated from one device to another, and the field is rapidly advancing. Most studies of APAP have been performed in a supervised setting, or patients have been carefully selected to have a high likelihood of OSA uncomplicated by disorders such as alveolar hypoventilation or central apnea or technical problems such as mask leaks. Studies of APAP for the diagnosis of OSA have shown that APAP can diagnose severe OSA effectively, but the diagnosis of mild-moderate OSA is less reliable. APAP devices also can be effective therapy for selected patients with OSA, with overall similar results to conventional fixed CPAP in terms of respiratory disturbances, sleep quality, nocturnal oxygenation, and daytime sleepiness and performance, with less known or other long-term outcomes. In most studies, mean treatment pressures are lower, without change in side effect profile. Compliance and preference with APAP are similar to or somewhat better than CPAP in most studies. APAP also can be used in an attended setting to titrate an effective pressure for use in long-term conventional CPAP therapy, also with similar results to CPAP in many patients. APAP devices are more expensive than CPAP devices, but the cost may be outweighed if a group of patients who can be diagnosed, treated, or titrated safely in the unattended setting can be identified. Although diagnostic and therapeutic algorithms for APAP have been proposed, the best candidates for this modality must be defined better.