Prevalence of obstructive sleep apnea in patients with posttraumatic stress disorder and its impact on adherence to continuous positive airway pressure therapy: a meta-analysis

ObjectiveAlthough some authors have recently investigated the co-occurrence of posttraumatic stress disorder (PTSD) and obstructive sleep apnea (OSA), the topic remains insufficiently studied. The aim of this meta-analysis was to detect the pooled prevalence of OSA in PTSD and its impact on adherence to continuous positive airway pressure (CPAP) therapy.MethodsWe conducted a search for articles published until August 20, 2016, in PubMed, Embase, the Cochrane Library, and PsycINFO. The literature search identified 194 articles, and 12 studies were included in the meta-analysis.ResultsThe pooled prevalence rates of OSA based on different apnea–hypopnea index (AHI) criteria in PTSD patients was 75.7% (95% confidence interval [CI] = 44.1–92.5%) (AHI ≥5) and 43.6% (95% CI = 20.6–69.7%) (AHI ≥10), respectively. Subgroup analysis showed that there was a significant difference between the prevalence of OSA in veterans with PTSD compared to nonveterans or mixed samples. Patients with PTSD and OSA demonstrated significantly lower adherence to CPAP therapy (regular use: g = −0.658, 95% CI = −0.856 to −0.460; time of average use per night: g = −0.873, 95% CI = −1.550 to −0.196) compared with those with OSA alone.ConclusionsOSA is commonly seen in patients with PTSD. Given its negative impact on the adherence to CPAP therapy, the possibility of OSA should be monitored carefully in patients with PTSD.     

Continuous positive airway pressure treatment and anxiety in adults with coronary artery disease and nonsleepy obstructive sleep apnea in the RICCADSA trial

BackgroundAnxiety and obstructive sleep apnea (OSA) coexist among adults with coronary artery disease (CAD) following revascularization. Continuous positive airway pressure (CPAP) is the first line treatment of OSA patients with daytime sleepiness. The current study evaluated the effect of CPAP on anxiety in CAD patients with nonsleepy OSA.MethodsTwo hundred forty-four revascularized CAD patients with nonsleepy OSA (apnea-hypopnea index ≥15/h, Epworth Sleepiness Scale score <10) were randomly assigned to CPAP or no-CPAP between 2005 and 2010. Zung Self-rating Anxiety Scale (SAS) was administered at baseline and after 3 and 12 months with higher scores suggesting more anxiety.ResultsA total of 208 patients with complete SAS scores at baseline and 12-month follow-up were included (CPAP, n = 103; no-CPAP, n = 105). In the intention-to-treat analysis, CPAP had no significant effect on the SAS scores. On-treatment analysis revealed a significant increase in the median of delta SAS score (+3.75) after three months among the participants using the device 2.8 h/day or more while there was a decline in the median of delta SAS score (−1.25) in the non-adherent or no-CPAP group (p = 0.031). The increase in the SAS score (+1.25) in the adherent group, and the decline (−1.25 points) in the non-adherent/no-CPAP group remained significant after one year (p = 0.011). Baseline SAS score predicted non-adherence [adjusted odds ratio 1.11; 95% confidence interval (CI) 1.04–1.18; p = 0.003], and there was an association between the increase in the SAS scores and accumulated CPAP hours/day [standardized β = 0.144 (95% CI 0.005–0.695), p = 0.047].ConclusionOur results suggest that anxiety should be considered in the management of CAD patients with nonsleepy OSA following revascularization.Clinical trial registrationNCT00519597.     

Does CPAP treat depressive symptoms in individuals with OSA? An analysis of two 12-week randomized sham CPAP-controlled trials

BackgroundDepression is common in patients with obstructive sleep apnea (OSA). Whether treating OSA with continuous positive airway pressure (CPAP) improves depressive symptoms remains inconclusive. We examined the impact of CPAP on depressive symptoms in OSA patients compared to sham CPAP.MethodsA sub-analysis of two previous randomized sham-controlled trials was conducted. 126 male OSA patients (age = 51 ± 11 years; BMI = 32.0 ± 5.1 kg/m²; apnea hypopnea index = 42.4 ± 22.6 events/hour) were randomised either to therapeutic CPAP (n = 65) or sham CPAP (n = 61). Depressive symptoms were measured using the Depression, Anxiety and Stress Scale (DASS). The main outcome was the change in the DASS depression score (DASSD) after three months between the therapeutic and sham CPAP arms.ResultsThe change in DASSD at three months did not differ between therapeutic and sham CPAP (mean difference: 0.5, 95% CI -3.6 to 4.6, p = 0.80). There was no significant between-group differences within the sub-groups of adherent users (device usage≥4hrs/day), or those with baseline depression (DASSD>9). In a secondary analysis of patients with baseline depression, adherent therapeutic CPAP use was associated with a greater reduction in DASSD scores compared to non-adherers (−10.0, 95% CI -18.3 to −1.8, p = 0.019). Conclusions: Overall, three months of CPAP did not significantly improve depression scores in OSA patients. Adherent use of therapeutic CPAP in patients with baseline depressive symptoms was associated with a reduction in symptom score. Future trials involving OSA patients with higher depressive symptoms will enable us to understand the complex interaction between OSA and depression.     

Low-frequency oscillations and vasoreactivity of cortical vessels in obstructive sleep apnea during wakefulness: A near infrared spectroscopy study

ObjectivesEffective nasal continuous positive airway pressure (CPAP) therapy reduces the cardiovascular outcomes associated with obstructive sleep apnea (OSA), but the mechanism behind this effect is unclear. We investigated if OSA patients during wakefulness showed signs of increased sympathetic activity and decreased vasoreactivity in cerebral cortical vessels as measured with near-infrared spectroscopy (NIRS), and if this may be reversed by CPAP treatment.Subjects and methods23 OSA patients (mean age, 55 y) naive to CPAP were included in a prospective interventional study. The OSA patients received CPAP therapy for at least two months. Cortical low-frequency oscillation (LFO) amplitudes and vasoreactivity during a breath hold test were measured with NIRS and were compared between baseline and after CPAP treatment. Baseline values also were compared to 13 healthy controls (mean age, 52 y).ResultsWe found a decrease in LFO amplitudes after CPAP therapy (P = 0.022) in OSA patients. We found no differences in LFO amplitudes between OSA patients and healthy controls (P = 0.934). There were no differences in peak vascular response following breath hold tests in OSA patients before and after CPAP therapy (P = 0.158) or compared to healthy controls (P = 0.740).ConclusionOur NIRS study revealed a decrease in LFO amplitude following two months of CPAP treatment in OSA patients, which may reflect a decrease in sympathetic activity affecting cortical vessels.     

Does CPAP treatment in mild obstructive sleep apnea affect blood pressure?

ObjectivesObstructive sleep apnea (OSA) is associated with significant cardiovascular (CV) morbidity. Continuous positive airway pressure (CPAP) is the standard treatment for moderate to severe OSA, resulting in a reduction in CV morbidity. No studies have compared CV outcomes between CPAP and no CPAP in mild OSA (5 ? AHI < 15).MethodsRetrospective cohort study of subjects (age ? 18) with mild OSA diagnosed between 2004 and 2006. Subjects with a history of hypertension, angina, stroke and smoking were excluded. Subjects were stratified into two groups: CPAP (n = 93) or no CPAP (n = 162). The mean blood pressures (MBP) were compared 2 years after the diagnosis of OSA was established.ResultsUnmatched for covariates (age, sex, BMI, neck circumference, AHI, arousal index and family h/o CV disorders), subjects with mild OSA on CPAP had a 1.97 point reduction, and no CPAP resulted in a 9.61 point elevation (p < 0.0001) in MBP. With propensity score matching for covariates, the mean difference in MBP was ?1.97 (95% CI: ?14.03, ?9.92; p < 0.0001) with a sensitivity analysis of 2.646.ConclusionThis study shows an elevation of the MBP in mild OSA patients who were not treated with CPAP. CPAP treatment in mild OSA patients decreased the MBP over a 2-year period.     

Obstructive sleep apnea,CPAP therapy and Parkinson's disease motor function: A longitudinal study

IntroductionWe aimed to assess, in patients with Parkinson's disease (PD), the association between obstructive sleep apnea (OSA), progression of motor dysfunction and the effect of OSA treatment.MethodsData were analysed from a prospective cohort study of idiopathic PD patients from a movement disorders clinic. Patients found to have OSA on polysomnography (apnea-hypopnea index [AHI] ≥15 events/h, OSA+) were offered treatment using continuous positive airway pressure (CPAP). CPAP+ was defined as an average ≥ 2 h/night use at each follow-up. Motor symptoms were assessed using the motor section of the Movement Disorder Society Unified Parkinson's Disease Rating Scale (mUPDRS) and the Timed-Up-And-Go (TUG). Follow-up times were 3, 6 and 12 months. Mixed models were constructed, adjusting for age, sex, body mass index, levodopa equivalent dose and comorbidities.ResultsWe studied 67 individuals (61.2% male) of mean age 64.7 years (SD = 10.1). Baseline mUPDRS was higher in OSA+ compared to OSA- (24.5 [13.6] vs. 16.2 [7.2], p < 0.001). Motor dysfunction increased at comparable rates in OSA- and OSA+CPAP-. However, in OSA+CPAP+, mUPDRS change was significantly lower compared to OSA- (β = −0.01 vs. 0.61, p = 0.03; p = 0.12 vs. OSA+CPAP- [β = 0.39]) and TUG change was lower compared to OSA+CPAP- (β = −0.01 vs. 0.13, p = 0.002; p = 0.05 vs. OSA- [β = 0.02]).ConclusionsIn this PD cohort, OSA was associated with higher baseline mUPDRS. In those with OSA, CPAP use was associated with stabilization of motor function (mUPDRS and TUG) over 12 months. These observations support further research to clarify the role of OSA in PD pathophysiology and motor dysfunction.     

Seasonal effects on the continuous positive airway pressure adherence of patients with obstructive sleep apnea

ObjectiveThis study examined seasonal differences in continuous positive airway pressure (CPAP) therapy adherence among patients with obstructive sleep apnea (OSA).MethodsPatients aged ≥20 years with OSA who had used CPAP devices on the automatic setting for >12 consecutive months (n = 141) were included in this retrospective study from December 2015–2016. The information of CPAP use (pressure, hours of actual use) was extracted from database downloaded from patients’ CPAP devices. Patients were divided into adherent and non-adherent groups using the cutoff point of 70% CPAP use for ≥4 h daily over the 1-year study period. CPAP use data were averaged for each season.ResultsPatients in the adherent group were significantly older than those in the non-adherent group (p < 0.001). In the adherent group, the rate of ≥4 h daily CPAP use was significantly lower, the daily duration of CPAP use was significantly shorter, and the residual apnea–hypopnea index (AHI; events/hour) was significantly higher in summer than in other seasons (all p < 0.001). In the non-adherent group, the duration of daily CPAP use and the AHI differed significantly between winter and summer (p = 0.008 and p < 0.001, respectively).ConclusionsSeasonal changes were associated with the CPAP adherence of patients with OSA. The study findings suggest that there is possibility of increasing the duration of CPAP use by adjusting the bedroom environment in hot and humid seasons.     

The association between atrial fibrillation and stroke in patients with obstructive sleep apnea: A population-based case-control study

BackgroundObstructive sleep apnea (OSA) has been shown to be an independent risk factor for ischemic stroke and may increase the risk of atrial fibrillation (AF) by up to fourfold. Given these relationships, it is possible that OSA may provide a link between stroke and AF. A case-control study was conducted to examine the association between AF and stroke in patients with OSA.MethodsOlmsted County, MN, USA, residents with a new diagnosis of OSA based on polysomnography (PSG) between 2005 and 2010 (N = 2980) who suffered a first-time ischemic stroke during the same period were identified as cases. Controls with no history of stroke were randomly chosen from the same database. Univariate and multiple logistic regression analyses were performed with age, gender, body mass index (BMI), smoking, hypertension, hyperlipidemia, diabetes mellitus, apnea–hypopnea index (AHI) and coronary artery disease (CAD) as co-variates, with the diagnosis of AF as the variable of interest.ResultsA total of 108 subjects were studied. Mean age of cases (n = 34) was 73 ± 12 years and 53% were men. Among controls (n = 74), mean age was 61 ± 16 years and 55% were male. On univariate analyses, AF was significantly more common in the cases than among controls (50.0% vs 10.8%, p < 0.01). On multivariate regression analyses, the association between AF and stroke was significant after controlling for age, BMI, coronary artery disease, hypertension, diabetes mellitus, hyperlipidemia and smoking status (corrected odds ratio (OR): 5.34; 95% confidence interval (CI): 1.79–17.29).ConclusionsPatients with OSA who had a stroke had higher rates of AF even after accounting for potential confounders.     

Continuous positive airway pressure deepens sleep in patients with Alzheimer’s disease and obstructive sleep apnea

ObjectivePatients with Alzheimer’s disease (AD) and obstructive sleep apnea (OSA) experience disrupted sleep. This study examined the effect of continuous positive airway pressure (CPAP) on sleep parameters in AD patients with OSA.MethodsA randomized placebo-controlled trial of 3 weeks of therapeutic CPAP (tCPAP) vs. 3 weeks placebo CPAP (pCPAP) followed by 3 weeks tCPAP in patients with AD and OSA. Polysomnography data from screening after one night and after 3 weeks of treatment were analyzed. Records were scored for percent of each sleep stage, total sleep time (TST), sleep efficiency (SE), sleep period (SP), time in bed (TIB), sleep onset (SO), wake time after sleep onset (WASO), and arousals. A randomized design comparing one night of pCPAP to tCPAP and a paired analysis combining 3 weeks of tCPAP were performed.ResultsFifty-two participants (mean age = 77.8 years, SD = 7.3) with AD and OSA were included. After one treatment night, the tCPAP group had significantly less % Stage 1 (p = 0.04) and more % Stage 2 sleep (p = 0.02) when compared to the pCPAP group. In the paired analysis, 3 weeks of tCPAP resulted in significant decreases in WASO (p = 0.005), % Stage 1 (p = 0.001), arousals (p = 0.005), and an increase in % Stage 3 (p = 0.006).ConclusionIn mild to moderate AD patients with OSA, the use of tCPAP resulted in deeper sleep after just one night, with improvements maintained for 3 weeks.     

Severity of nocturnal hypoxia and daytime hypercapnia predicts CPAP failure in patients with COPD and obstructive sleep apnea overlap syndrome

BackgroundObstructive sleep apnea (OSA) and chronic obstructive pulmonary disease (COPD) are independent risk factors for cardiovascular diseases. In patients with OSA and concurrent COPD, continuous positive airway pressure (CPAP) therapy improves survival. Nevertheless, a significant proportion of such patients do not tolerate CPAP. The aim of the present study was to analyze early predictors of CPAP failure in patients with OSA and concurrent COPD, and to evaluate the effects of bilevel positive airway pressure (BiPAP) in this high-risk group of patients.MethodsA post hoc analysis from the database of 2100 patients diagnosed with OSA between 2012 and 2014 identified 84 subjects as having concomitant COPD and meeting inclusion criteria. Demographic data, pulmonary function tests, OSA parameters, blood gases, response to CPAP and BiPAP titration, and two months of therapy were collected. A multivariate model was generated to find determinants of CPAP failure.ResultsPrimary CPAP failure was found in 23% of patients who were more obese (p = 0.018), had worse lung function, lower PO₂ (p = 0.023) and higher PCO₂ while awake (p < 0.001), and more sleep time with an SpO₂ < 90% (CT90%) (p < 0.001) compared to those who responded to CPAP. In multivariate analysis, PCO₂ while awake [odds ratio (OR) 29.5, confidence interval (CI) 2.22–391, p = 0.010] and CT90% (OR 1.06, CI 1.01–1.11, p = 0.017) independently predicted CPAP failure after adjustments for covariates. The BiPAP therapy was well tolerated and effectively alleviated hypercapnia in all patients with primary CPAP failure.ConclusionsDaytime hypercapnia and nocturnal hypoxia are independent predictors of early CPAP failure in patients with the OSA–COPD overlap syndrome.     

The effect of continuous positive airway pressure therapy on arterial stiffness and endothelial function in obstructive sleep apnea: a randomized controlled trial in patients without cardiovascular disease

BackgroundObstructive sleep apnea (OSA) is associated with increased cardiovascular morbidity and mortality which may be mediated by increased arterial stiffness and endothelial dysfunction. Continuous positive airway pressure (CPAP) therapy improves excessive daytime somnolence (EDS), but its effect on vascular function in patients without preexisting cardiovascular disease (CVD) is unclear.MethodsFifty-three patients with OSA defined as an apnea–hypopnea index (AHI) of ⩾15 and without CVD were recruited into a double-blind, randomized, placebo-controlled, crossover trial of 12 weeks of CPAP therapy, of whom 43 participants completed the study protocol. Arterial stiffness was assessed by measuring the augmentation index (AIx) and pulse wave velocity (PWV) by applanation tonometry and cardiovascular magnetic resonance imaging to determine aortic distensibility. Endothelial function was assessed by measuring vascular reactivity after administration of salbutamol and glyceryl trinitrate.ResultsCPAP therapy lowered systolic blood pressure (SBP) (126 mmHg [standard deviation {SD}, 12] vs 129 mmHg [SD, 14]; P = .03), with a trend towards reduced AIx (15.5 [SD, 11.9] vs 16.6 [SD, 11.7]%; P = .08) but did not modify endothelial function. When subjects with (n = 24) and without (n = 19) EDS were separately examined, no effect of CPAP therapy on vascular function was seen.ConclusionsIn patients without overt CVD, CPAP therapy had a nonsignificant effect on AIx and did not modify endothelial function.     

Predictors of CPAP adherence following stroke and transient ischemic attack

ObjectiveContinuous positive airway pressure (CPAP) has been shown to improve functional, motor and cognitive outcomes in post-stroke obstructive sleep apnea (OSA). However, rates of CPAP adherence are often low and factors impacting CPAP adherence remain under-explored. Our objective was to determine predictors of CPAP adherence in patients who had a stroke or transient ischemic attack (TIA).MethodsWe screened 313 stroke/TIA patients for OSA using in-hospital polysomnography or the ApneaLink home sleep apnea test. Potential predictors were recorded at baseline and adherence to CPAP was recorded during a six-month follow-up visit. Selected variables from our univariate analyses were included in multivariate regression models to determine predictors of CPAP adherence. For our logistic regression analyses, CPAP adherence (CPAP use of ≥4 h per night) was the dependent outcome variable. In our linear regression analyses, total CPAP use per week (recorded in hours) was the dependent outcome variable.ResultsEighty-eight patients (mean age 67.81 ± 13.09 years, 69.32% male, mean body mass index 27.93 ± 5.23 kg/m²) were diagnosed with OSA, prescribed CPAP, and assessed for adherence at a six-month follow-up visit. In these 88 patients, 46 (52.27%) were adherent with CPAP therapy. From our regression models, two significant predictors of CPAP adherence were identified: greater functional status (p = 0.04) and not endorsing daytime tiredness (p = 0.047) post-stroke/TIA.ConclusionPatients with greater functional capacity and those with less daytime fatigue demonstrated stronger adherence to CPAP therapy. Our findings may facilitate future treatment strategies for enhancing CPAP adherence in the vulnerable stroke/TIA population.     

Effects of CPAP for patients with OSA on visual sensitivity and retinal thickness

ObjectiveObstructive sleep apnea/hypopnea syndrome (OSA) could compromise oxygenation of the optic nerve and cause glaucomatous optic neuropathy; there has been no study to investigate the microstructure changes of the optic nerve and retina in OSA patients before and after continuous positive airway pressure (CPAP) therapy. In this study, we assess whether treatment with CPAP might improve visual sensitivity and retinal thickness in patients with OSA.MethodsPatients with OSA were prospectively recruited and referred for ophthalmologic evaluation at baseline and three months after CPAP treatment. Each patient underwent an ophthalmological exam, standard automated perimetry (SAP), and optical coherence tomography (OCT) exam. Peripapillary retinal nerve fiber layer (RNFL) and macular layer (ML) thickness parameters were measured. The SAP, RNFL, and ML thickness parameters before and after treatment were compared.ResultsA total of 32 OSA patients were consecutively enrolled. At baseline, the mean deviation (MD) of SAP was −2.15 ± 1.90 dB (dB). After CPAP treatment, the MD was −1.38 ± 1.37 dB (p = 0.017). Regarding the OCT parameters, the inferior quadrant and nasal-inferior sector of RNFL thickness significantly improved after treatment (p = 0.025 and 0.004, respectively). The ML thickness in the superior-inner sector, inferior-outer sector, nasal-outer sector, superior hemisphere, and inferior hemisphere were also significantly improved after treatment. Improvement of ML thickness in the superior-inner sector positively correlated with the apnea/hypopnea index (r = 0.405, p = 0.022) and desaturation index (r = 0.473, p = 0.006) on pre-treatment polysomnography.ConclusionThe treatment of CPAP could improve visual sensitivity and increase retinal thickness in patients with OSA.     

Comparative effects of CPAP and mandibular advancement splint therapy on blood pressure variability in moderate to severe obstructive sleep apnoea

BackgroundObstructive sleep apnoea (OSA) is associated with increased blood pressure variability (BPV) and are risk factors for cardiovascular disease. We aimed to assess the comparative effects of two OSA therapies, continuous positive airway pressure (CPAP) and mandibular advancement splint (MAS), on BPV.MethodsThis is a secondary analysis of data collected as part of a previously published randomised crossover trial of one month each of CPAP and MAS therapy. BPV was determined from 24-h-ambulatory blood pressure recordings in 92 patients with moderate to severe OSA at baseline and after one month of optimised treatment with each modality. BPV was assessed by three measures: Standard deviation of the mean (SD), Coefficient of variation (CoV), and the Average Real Variability (ARV) index.ResultsNeither CPAP nor MAS therapy improved BPV, with no difference between treatments. BPV did not change in hypertensive OSA patients, however, there was a reduction in ARV of diastolic blood pressure in the effectively treated compared to ineffectively treated CPAP patients, Δ ARV 24-h-DBP (mmHg), −0.72 ± 2.14, 0.34 ± 1.52, P = 0.02, respectively. There was no difference between effective versus ineffective MAS treatment, Δ ARV 24-h-DBP (mmHg), −0.04 ± 2.4, 0.02 ± 1.9, P = 1.00, respectively.ConclusionsOne month of optimised CPAP or MAS therapy did not improve short term BPV in patients with moderate to severe OSA. The subgroup of patients on effective CPAP showed some improvement in BPV with CPAP but not MAS. Further work on the effect of OSA therapy on BPV following long-term therapy is needed.     

Effect of CPAP treatment on residual depressive symptoms in patients with major depression and coexisting sleep apnea: Contribution of daytime sleepiness to residual depressive symptoms

BackgroundAlthough extensive studies have indicated a relationship between obstructive sleep apnea (OSA) and depressive symptoms, the effect of continuous positive airway pressure (CPAP) treatment on residual depressive symptoms in patients with both major depressive disorder (MDD) and coexisting OSA has not been examined.MethodsSeventeen patients with continued MDD despite pharmacotherapy such as antidepressants and/or benzodiazepines, who also had comorbid OSA, were required to complete the Beck Depression Inventory (BDI), Hamilton Rating Scale for Depression (HRSD), and Epworth sleepiness scale (ESS) at the commencement of the study and then again after 2 months of CPAP treatment.ResultsBDI and HRSD scores decreased from 19.7 to 10.8 and 16.7 to 8.0 after 2 months of CPAP treatment (both p < 0.01). We also found significant correlations among the improvement rates in BDI, HRSD and ESS scores (R = 0.86 and 0.75, both p < 0.01). The mixed effect model demonstrated a significant ESS effect on BDI and HRSD.ConclusionsThe results suggest that MDD patients with residual depressive symptoms despite pharmacotherapy who also have symptoms of suspected OSA, such as loud snoring, obesity, and daytime sleepiness, should be evaluated for sleep apnea by polysomnography and treated with an appropriate treatment such as CPAP. CPAP treatment may result in a significant improvement of residual depressive symptoms due to the improvement of daytime sleepiness in these patients.     

Sleep maintenance insomnia complaints predict poor CPAP adherence: A clinical case series

BackgroundAlthough CPAP is a highly efficacious treatment for obstructive sleep apnea (OSA), low adherence presents a significant challenge for sleep medicine clinicians. The present study aimed to evaluate the relationship between insomnia symptoms and CPAP use. We hypothesized that pre-treatment insomnia complaints would be associated with poorer CPAP adherence at clinical follow-up.MethodsThis was a retrospective chart review of 232 patients (56.5% men, mean age = 53.6 ± 12.4 years) newly diagnosed with OSA (mean AHI = 41.8 ± 27.7) and prescribed CPAP in the Johns Hopkins Sleep Disorder Center. Difficulty initiating sleep, difficulty maintaining sleep, and early morning awakening were measured via three self-report items. CPAP use was measured via objective electronic monitoring cards.ResultsThirty-seven percent of the sample reported at least one frequent insomnia complaint, with 23.7% reporting difficulty maintaining sleep, 20.6% reporting early morning awakening and 16.6% reporting difficulty initiating sleep. After controlling for age and gender, sleep maintenance insomnia displayed a statistically significant negative relationship with average nightly minutes of CPAP use (p < .05) as well as adherence status as defined by the Centers for Medicaid and Medicare Services (p < .02).ConclusionsTo our knowledge, these are the first empirical data to document that insomnia can be a risk factor for poorer CPAP adherence. Identifying and reducing insomnia complaints among patients prescribed CPAP may be a straightforward and cost-effective way to increase CPAP adherence.     

The relationships between improvements in daytime sleepiness,fatigue and depression and psychomotor vigilance task testing with CPAP use in patients with obstructive sleep apnea

ObjectiveThe purpose of this study was to determine if the subjective improvements in daytime sleepiness, fatigue and depression experienced by patients with obstructive sleep apnea (OSA) with continuous positive airway pressure (CPAP) therapy predict an objective improvement in vigilance, and whether patients with mild-to-moderate OSA differ from patients with severe OSA in this regard.MethodsA total of 182 patients underwent psychomotor vigilance task (PVT) testing and measurements of subjective daytime sleepiness, fatigue and depression at baseline and after a minimum of one month of adherent CPAP use at an adequate pressure.ResultsPatients with both mild-to-moderate (n = 92) and severe (n = 90) OSA experienced improvements in subjective daytime sleepiness, fatigue and depression, but objective improvement in vigilance was only seen in patients with severe OSA. In patients with severe OSA, while a correlation was found between improvements in daytime sleepiness and some PVT parameters, changes in subjective daytime sleepiness, fatigue and depression scores were not predictive of objective improvement in vigilance while controlling for all these subjective symptoms and for age, gender, body mass index, apnea-hypopnea index/respiratory event index and total sleep time/total recording time with pulse oximetry below 90%.ConclusionsWe found no predictive relationship between subjective improvements in daytime sleepiness, fatigue and depression and objective vigilance with CPAP use in patients with OSA. These results suggest that subjective complaints of daytime impairment and objective measures of vigilance in patients with OSA should be assessed separately while evaluating the efficacy of CPAP therapy on daytime functioning.     

Obstructive sleep apnea (OSA) and outcomes from coronavirus disease 2019 (COVID-19) pneumonia: a systematic review and meta-analysis

BackgroundObstructive sleep apnea (OSA) is the most prevalent sleep-related breathing disorder which could impair someone's quality of life and is also associated with poor outcomes from many diseases. Currently, the evidence regarding the link between OSA and coronavirus disease 2019 (COVID-19) is still conflicting. This study aims to analyze the relationship between OSA and poor outcomes of COVID-19.Materials and methodsWe systematically searched the PubMed and Europe PMC database using specific keywords related to our aims until December 10th, 2020. All articles published on COVID-19 and OSA were retrieved. The quality of the study was assessed using the Newcastle–Ottawa Scale (NOS) tool for observational studies. Statistical analysis was done using Review Manager 5.4 software.ResultsA total of 21 studies with 54,276 COVID-19 patients were included in this meta-analysis. This meta-analysis showed that OSA was associated with composite poor outcome [OR 1.72 (95% CI 1.55–1.91), p < 0.00001, I² = 36%, random-effect modeling] and its subgroup which comprised of severe COVID-19 [OR 1.70 (95% CI 1.18–2.45), p = 0.005], ICU admissions [OR 1.76 (95% CI 1.51–2.05), p < 0.00001], the need for mechanical ventilation [OR 1.67 (95% CI 1.48–1.88), p < 0.00001], and mortality [OR 1.74 (95% CI 1.39–2.19), p < 0.00001].ConclusionsExtra care and close monitoring should be provided to patients with OSA to minimize the risk of infections. Simple questionnaires such as STOP-Bang questionnaire can be used for screening patients who may be at risk for severe adverse outcomes.     

Different scoring rules for respiratory event-related leg movements: effects on the prevalence of periodic limb movements during sleep and their association with depressive symptoms in patients with obstructive sleep apnea

BackgroundWe compared the prevalence of periodic leg movements during sleep (PLMS) according to two different scoring rules of the American Academy of Sleep Medicine (AASM) 2012 and World Association of Sleep Medicine (WASM) 2016 and determined their association with depressed mood in patients with obstructive sleep apnea (OSA).MethodsPLMS, defined as a periodic leg movements index of >15, were diagnosed on a diagnostic and continuous positive airway pressure (CPAP) titration polysomnography using the AASM 2012 and WASM 2016 rules. The Beck Depression Inventory (BDI) and Epworth Sleepiness Scale (ESS) were used, and multiple regression analyses were performed.ResultsAmong 160 OSA patients, the proportion with PLMS scored by the WASM 2016 criteria was significantly higher than that scored by the AASM 2012 criteria in a diagnostic study (20.6% vs. 16.3%, respectively; P = 0.016) but not in CPAP titration study and only in patients with severe OSA. In adjusted models, PLMS were positively associated with BDI scores and a BDI of ≥10 on both diagnostic and CPAP titration studies when scored by the WASM 2016. By contrast, when scored by the AASM 2012, PLMS were associated with BDI scores (but not BDI of ≥10) only in a CPAP titration study.ConclusionsThere are significant differences in the prevalence of PLMS and their association with depressed mood depending on the scoring rules in patients with OSA. The current AASM scoring criteria underestimate the prevalence of PLMS, and PLMS are more likely associated with depressed mood according to the WASM scoring criteria.     

Clinical and polysomnographic characteristics and response to continuous positive airway pressure therapy in obstructive sleep apnea patients with nightmares

ObjectiveTo assess the characteristics of obstructive sleep apnea (OSA) patients with nightmares and the effects of continuous positive airway pressure (CPAP) therapy on nightmares.MethodsConsecutive patients referred with a clinical suspicion of OSA underwent attended overnight sleep studies. OSA and nightmares were diagnosed according to the American Academy of Sleep Medicine (AASM) criteria, and CPAP titration was performed in accordance with the AASM guidelines. A follow-up visit was performed 3 months later, and the patients with nightmares were divided into two groups: group 1 used CPAP with good compliance, whereas group 2 refused CPAP treatment and did not use other alternative treatments for OSA.ResultsThe study included 99 patients who had been diagnosed with OSA with nightmares. Their mean age was 47.2 ± 11.2 years, and they had a mean apnea–hypopnea index (AHI) of 36.5 ± 34.3/h. Also included were 124 patients with OSA without nightmares. The mean age of these patients was 45.4 ± 13.9 years, and they had a mean AHI of 40.2 ± 35/h. The patients with nightmares had a significantly higher AHI during rapid eye movement sleep (REM) compared with the patients without nightmares (51.7 ± 28.1 vs 39.8 ± 31.9/h). Logistic regression analysis revealed that the REM-AHI and interrupted sleep at night were independent predictors of nightmares in the OSA patients. Nightmares disappeared in 91% of the patients who used CPAP compared with 36% of patients who refused to use CPAP (p < 0.001).ConclusionNightmares in OSA patients are associated with a higher REM-AHI. CPAP therapy results in a significant improvement in nightmare occurrence.