Zolpidem and Eszopiclone Pre-medication for PSG: Effects on Staging, Titration, and Adherence.

Introduction: The non-benzodiazepine sedative hypnotic (NBSH) eszopiclone improves polysomnography (PSG) quality and continuous positive airway pressure (CPAP) adherence. It is unclear whether zolpidem has the same effect and neither NBSH has been studied in populations with milder forms of obstructive sleep apnea. Materials and Methods: We performed a retrospective analysis on patients undergoing level I PSG at our institution. Patients are pre-medicated with NBSHs at the discretion of the sleep physician. We compared PSG/CPAP titration quality and subsequent CPAP adherence for patients receiving NBSHs or no pre-study medication. We adjusted for obstructive sleep apnea pre-test probability (PTP), arousal threshold, and other factors showing differences at baseline. Results: Data on 560 patients were analyzed. Mean age and body mass index were 42.2 ± 10.1 and 28.8 ± 4.5, respectively. Median apnea hypopnea index was 12.9 (6.4-25.3), 100 (18.0%) patients had normal studies, 97 (17.3%) were split, and 457 (81.6%) had a respiratory low-arousal threshold. After adjusting for differences at baseline, neither NBSH was associated with sleep efficiency, wake after sleep onset, or total sleep time on PSG. After adjustment, patients receiving eszopiclone had a higher apnea hypopnea index at the final CPAP pressure (ß = 14.2; 95% confidence intervals (CI) 7.2-21.2; p < 0.001) and were more likely to have an unacceptable titration (odds ratio (OR) = 6.6; 95% CI 2.0-21.0; p = 0.002). When only split-night studies were examined, there were no differences in any adherence variables across or between categories. Conclusions: In a population with predominantly mild obstructive sleep apnea, NBSHs did not improve PSG or CPAP titration quality and did not increase CPAP adherence. There was no difference in effect between eszopiclone and zolpidem.

A mobile, web-based system can improve positive airway pressure adherence.

SleepMapper is a mobile, web-based system that allows patients to self-monitor their positive airway pressure therapy, and provides feedback and education in real time. In addition to the usual, comprehensive support provided at our clinic, we gave the SleepMapper to 30 patients initiating positive airway pressure. They were compared with patients initiating positive airway pressure at our clinic without SleepMapper (controls) to determine whether SleepMapper affected adherence. A total of 61 patients had polysomnographic and adherence data analysed, 30 were given SleepMapper and 31 received our standard of care. The two groups were well matched at baseline to include no significant differences in age, apnea-hypopnea index, percentage receiving split-night polysomnographs and starting pressures. Patients in the control group received significantly more non-benzodiazepine sedative hypnotics the night of their polysomnography and during positive airway pressure initiation. At 11 weeks, patients in the SleepMapper group had a greater percentage of nights with any use (78.0 ± 22.0 versus 55.5 ± 24.0%; P < 0.001) and >4 h positive airway pressure use (78.0 ± 22.0 versus 55.5 ± 24.0%; P = 0.02). There was a trend toward more patients in the SleepMapper group achieving >4 h of use for at least 70% of nights [9/30 (30%) versus 3/31 (9.7%); P = 0.06]. In multivariate linear regression, the SleepMapper remained significantly associated with percentage of nights >4 h positive airway pressure use (ß coefficient = 0.18; P = 0.02). Added to our usual, comprehensive programme to maximize positive airway pressure adherence in new users, the SleepMapper was independently associated with an 18% increase in nights >4 h of use.

Does zolpidem enhance the yield of polysomnography?

STUDY OBJECTIVES: An uncomfortable environment or continuous positive airway pressure (CPAP) intolerance may cause poor sleep efficiency during polysomnography and result in a poor-quality study. Unsatisfactory polysomnograms often must be repeated. Nonbenzodiazepine hypnotics may improve sleep efficiency without disruption of sleep architecture. We hypothesized that premedication with zolpidem improves polysomnogram quality and decreases the need to restudy. METHODS: We retrospectively reviewed 200 consecutive polysomnograms. Zolpidem premedication was not standardized and was prescribed at the discretion of consulting sleep physicians, who were unaware of this study. We compared the quality of polysomnograms between patients who received zolpidem 10 mg prior to polysomnography and those who did not. A poor-quality polysomnogram was defined as having insufficient sleep time to allow for diagnosis, incomplete CPAP titration with a resulting apnea-hypopnea index > 10 on the highest level of CPAP achieved, or complete CPAP intolerance. RESULTS: Of 200 records reviewed, 54 patients (27%) received zolpidem. Demographics did not differ between groups. Premedication with zolpidem resulted in improved sleep latency (11.8 +/- 9.5 minutes vs 26.0 +/- 19.9 minutes, p = .002) and sleep efficiency (89.5% +/- 5.6% vs 78.8 +/- 12.3, p < .0001). Zolpidem premedication resulted in significantly fewer studies meeting criteria for poor quality (7.4% vs 33.6%, p = .005). Of the 49 studies meeting criteria for poor quality, 21 were repeated using zolpidem, showing significant improvements in sleep latency (10.8 +/- 7.1 minutes vs 42.8 +/- 30.5 minutes, p = .0004) and sleep efficiency (89.5% +/- 4.9% vs 61.8% +/- 13.7%, p < .0001). No study repeated with zolpidem met criteria for poor quality. CONCLUSIONS: Pretreatment with zolpidem significantly improved polysomnographic quality and may decrease the need to repeat polysomnograms.

Obstructive sleep apnea syndrome: are we missing an at-risk population?

STUDY OBJECTIVES: While age and body-mass index (BMI) are well-established risk factors for obstructive sleep apnea syndrome (OSAS), this disorder occurs across a wide spectrum of ages and weights. Preconceptions regarding "classic" patients with OSAS may lead to underdiagnosis in at-risk populations, particularly younger nonoverweight individuals. We hypothesized that the severity of OSAS is independent of age and BMI in a younger less-obese population. METHODS: Prospective study of consecutive patients diagnosed with OSAS. Active-duty military, National Guardsmen, and civilians were compared to determine if age and BMI correlated with disease severity. RESULTS: Two hundred seventy subjects (120 active-duty, 80 National Guardsmen, 70 civilians) were included. Active-duty military members were significantly younger and less overweight than both National Guardsmen and civilians. Of the civilians, 64.3% and, of National Guardsmen, 48.8% were obese, whereas only 19.2% of active-duty had a BMI > or = 30 kg/m2 (p < .001). However, the prevalence of severe disease did not differ between groups. Disease severity showed no correlation with BMI among active-duty subjects (r = 0.09, p = .33). Of the active-duty subjects, 37.5% had severe disease, as compared with 42.5% of National Guard and 45.7% of civilian subjects (p = .18 and .09, respectively). BMI did not differ between active-duty subjects with severe disease and those with mild to moderate OSAS (26.7 kg/m2 versus 26.9 kg/m2, p = .40). There was a low but significant correlation between age and AHI (r = 0.21, p = .02) among all subjects. CONCLUSIONS: OSAS occurs in young nonobese individuals and should be considered in patients reporting excessive daytime sleepiness, regardless of age or BMI.

Breathing patterns in prepubertal children with sleep-related breathing disorders.

OBJECTIVE: To investigate abnormal breathing patterns during sleep in prepubertal children using nonstandard polysomnographic patterns in association with an apnea-hypopnea scoring technique. PATIENTS AND METHODS: Study participants included 400 children with suspected sleep-related breathing disorders and 60 control children. We analyzed clinical signs and symptoms at entry into the study and 3 months after otolaryngological treatment. We determined the frequency of predefined breathing patterns during sleep through blind analysis of polysomnograms obtained once in control subjects and twice in children referred to our clinic (before and after adenotonsillectomy), using the nasal cannula-pressure transducer system, mouth thermistor, esophageal manometry, microphone, and pulse oximetry. We also determined the relationship between breathing patterns during sleep and residual postsurgery symptoms. Further analysis was performed of symptoms and polysomnographic patterns in those children who underwent new treatment interventions due to persistence of symptoms and abnormal polysomnogram findings. RESULTS: Tachypnea, persistently elevated breathing effort, progressively increased breath effort, and discrete flattening of nasal airflow monitored with the nasal cannula-pressure transducer system without oxygen saturation decreases help determine disorder as much as apneas and hypopneas. Abnormal, nonstandard breathing patterns were associated with the same symptoms as those in children with apnea and hypopnea and were more commonly present when there was incomplete resolution of initial symptoms that led treating practitioners to request further treatment. CONCLUSION: Currently published polysomnographic scoring recommendations overlook common breathing abnormalities during sleep that are associated with clinical complaints.

Sleep disordered breathing: surgical outcomes in prepubertal children.

OBJECTIVE: To evaluate the treatment outcomes of sleep disordered breathing (SDB) in prepubertal children 3 months following surgical intervention. STUDY DESIGN: Retrospective investigation of 400 consecutively seen children with SDB who were referred to otolaryngologists for treatment. METHOD: After masking the identities and conditions of the children, the following were tabulated: clinical symptoms, results of clinical evaluation and polysomnography at entry, the treatment chosen by the otolaryngologists, and clinical and polysomnographic results 3 months after surgery. RESULTS: Treatment ranged from nasal steroids to various surgical procedures. Adenotonsillectomy was performed in only 251 of 400 cases (68%). Four cases included adenotonsillectomy in conjunction with pharyngoplasty (closure of the tonsillar wound by suturing the anterior and posterior pillar to tighten the airway). Persistent SDB was seen in 58 of 400 children (14.5%), and an additional 8 had persistent snoring. Best results were with adenotonsillectomy. CONCLUSION: SDB involves obstruction of the upper airway, which may be partially due to craniofacial structure involvement. The goal of surgical treatment should be aimed at enlarging the airway, and not be solely focused on treating inflammation or infection of the lymphoid tissues. This goal may not be met in some patients, thus potentially contributing to residual problems seen after surgery. The possibility of further treatment, including collaboration with orthodontists to improve the craniofacial risk factors, should be considered in children with residual problems.