Effects of patient education and progressive muscle relaxation alone or combined on adherence to continuous positive airway pressure treatment in obstructive sleep apnea patients

Purpose

The purpose of this study is to explore the effects of patient education and progressive muscle relaxation (PMR) alone or combined on adherence to continuous positive airway pressure (CPAP) treatment in obstructive sleep apnea (OSA) patients.

Methods

One hundred and fifty-two Han Chinese OSA patients were randomly assigned to a control group (C), an education group (E), a PMR group (P), and an education?+?PMR group (E?+?P), with 38 patients each group. The adherence to CPAP was defined as 4 or more hours of CPAP usage per night and at least 9 of each 14 nights of ventilator use. The CPAP adherence rates, cumulative patient dropout rates, CPAP usage, and scores of daytime sleepiness, sleep quality, anxiety, and depression were compared among the groups at 4, 8, and 12?weeks of intervention.

Results

All study groups were comparable in baseline characteristics. Group E?+?P showed significant improvement in CPAP adherence, daytime sleepiness, and sleep quality compared with group C at 4, 8, and 12?weeks of intervention. Compared with group C, group E only showed significant improvement in CPAP adherence, daytime sleepiness, and sleep quality at 4?weeks of intervention, while group P showed no significant improvement over time. Scores of anxiety and depression were significantly improved in group E?+?P compared with group C at 12?weeks of intervention.

Conclusions

Combined intervention with patient education and PMR can significantly improve CPAP adherence in OSA patients for at least 12?weeks. The intervention paradigm may serve as an important reference for future studies on CPAP adherence.     

Nocturnal hypoxemia biomarker predicts sleepiness in patients with severe obstructive sleep apnea

Purpose

This study aims to assess the association between excessive daytime sleepiness (EDS) and variables extracted from the pulse-oximetry signal obtained during overnight polysomnography.

Methods

A cross-sectional design was used to study the relation between four hypoxemia variables and EDS as determined by Epworth Sleepiness Scale scores (ESSS) in 200 consecutive patients, newly diagnosed with obstructive sleep apnea (OSA), as defined by an apnea–hypopnea index (AHI)?≥?15. Hypoxemia measurements were compared between sleepy (ESSS?≥?10) and nonsleepy (ESSS?<?10) patients before and after dichotomizing the cohort for each hypoxemia variable (and for AHI) such that there were 35 (165) patients in each of the corresponding higher (lower) subcohorts. The hypoxemia variables were combined into a biomarker, and its accuracy for predicting sleepiness in individual patients was evaluated. We planned to interpret prediction accuracy above 80 % as evidence that hypoxemia predicted EDS.

Results

Hypoxemia was unassociated with sleepiness in OSA patients with AHI in the range of 15 to 50. In patients with AHI?>?50, the hypoxemia biomarker (but not individual hypoxemia variables) predicted sleepiness with 82 % accuracy.

Conclusion

Nocturnal hypoxemia as determined by a polyvariable biomarker reliably predicted EDS in patients with severe OSA (AHI?>?50), indicating that oxygen fluctuation had a direct role in the development of EDS in patients with severe OSA.     

Predicting uptake of continuous positive airway pressure (CPAP) therapy in obstructive sleep apnoea (OSA): a belief-based theoretical approach

Purpose

Obstructive sleep apnoea (OSA) is a common disorder, for which continuous positive airway pressure (CPAP) therapy is a standard treatment. Despite its well-established efficacy, many patients choose not to initiate CPAP treatment. The present study investigated the degree to which biological measures (e.g. Apnoea–Hypopnoea Index [AHI]), symptom experiences (e.g. fatigue) and illness representations (e.g. perceived consequences) predict the decision of individuals newly diagnosed with OSA to undergo a trial of CPAP therapy.

Methods

Four hundred forty-nine individuals (316 males) newly diagnosed with OSA. Epworth sleepiness scale (ESS), Fatigue Severity Scale, Depression Anxiety Stress Scale and Illness Perception Questionnaire-Revised (IPQ-R) were administered at time of sleep study. These, patient demographics and sleep study variables were used to determine factors predicting patient decision to proceed with a trial of CPAP.

Results

The participants were most likely to attribute their OSA to unchangeable and psychological factors. For those with moderate OSA (AHI, 15 to 30) IPQ-R illness consequence was predictive of decision to initiate CPAP (p = 0.002). For severe OSA (AHI >30) age, ESS and IPQ illness causal beliefs were predictive of decision to initiate CPAP (p < 0.001).

Conclusions

Illness beliefs are important determinants of the choice of recently diagnosed OSA patients whether or not to undertake a trial of CPAP therapy. Concerns about illness consequences were important in those with moderate OSA. In severe OSA, sleepiness symptoms are more prominent and a more significant determinant of CPAP uptake along with age and causal beliefs.     

Self-efficacy contributes to individual differences in subjective improvements using CPAP

Purpose  

Continuous positive airway pressure (CPAP) improves depressive symptoms and daytime sleepiness in patients with obstructive sleep apnea (OSA). However, there is variability in response to CPAP. This study examined individual differences in the daily associations between CPAP use and improvements in affect and sleepiness patients beginning CPAP.     

Nocturnal pulse rate and symptomatic response in patients with obstructive sleep apnoea treated with continuous positive airway pressure for one year

Background

Obstructive sleep apnoea (OSA) is the most common form of sleep-disordered breathing and a known risk factor for cardiovascular disease. We hypothesised that in patients with OSA the characteristics of nocturnal pulse rate (PR) are associated with changes in blood pressure and daytime sleepiness, following commencement of continuous positive airway pressure (CPAP) therapy.

Methods

Pulse oximetry data, demographics, daytime sleepiness and blood pressure were recorded at baseline and at one year follow up. Patients with OSA were grouped according to positive and negative changes in the PR (ΔPR) response during the first night of pulse oximetry before commencement of CPAP.

Results

A total of 115 patients (58 with OSA and 57 matched subjects without OSA) were identified and included in the analysis. The scale of improvement in daytime sleepiness could be predicted by a negative or positive ΔPR, as recorded in the initial screening pulse oximetry [ΔESS –5.8 (5.1) vs. –0.8 (7.2) points, P<0.05]. A negative correlation was observed between mean nocturnal PR and changes in systolic blood pressure (SBP) after one year of CPAP treatment (r=–0.42, P<0.05).

Conclusions

Mean nocturnal PR prior to CPAP initiation was associated with changes in SBP at one year follow up. A descending nocturnal PR in patients with OSA, prior to CPAP initiation, might help to identify a symptomatic response from long term CPAP treatment.     

Randomized, double-blind, placebo-controlled crossover trial of modafinil in the treatment of residual excessive daytime sleepiness in the sleep apnea/hypopnea syndrome

Some patients with the sleep apnea/hypopnea syndrome (SAHS) remain subjectively and objectively sleepy despite using effective continuous positive airway pressure (CPAP) therapy. The aim of this single center study was to determine the efficacy and safety of the novel wake-promoting medication modafinil in the treatment of CPAP-resistant daytime sleepiness. Thirty sleep apneics receiving effective CPAP therapy (objective use, 6.5 +/- 1.1 h/night) received daily single doses of 400 mg modafinil or placebo for 2 wk in a double-blind randomized crossover design. Outcome measures were assessed at baseline and at the end of both 2-wk treatment periods. Treatment periods were separated by a 1-wk washout. Modafinil had no effect on sleepiness as measured by the Epworth Sleepiness Scale or the Multiple Sleep Latency Test (p > 0.1); however, significant improvements in alertness were found with the Maintenance of Wakefulness Test (modafinil 18.3 +/- 3.9 min; placebo, 16.6 +/- 5.0 min; p < 0.02). No significant treatment-related improvements in cognitive performance or quality of life were found with modafinil (all p > 0.05). There was a significant reduction in CPAP use on modafinil compared to placebo (6.3 +/- 1 h/ night; 6.5 +/- 1, p = 0.03). This study suggests that modafinil may improve some aspects of alertness in patients with SAHS who remain sleepy during CPAP therapy, but further studies are required to assess the significance of the reduction in CPAP use.     

Determinants of continuous positive airway pressure adherence in a sleep clinic cohort of South Florida Hispanic veterans

Purpose

There are little existing data on continuous positive airway pressure (CPAP) adherence in US Hispanic veterans with obstructive sleep apnea (OSA). Our aim was to describe determinants of 1-month adherence in a sleep clinic cohort of South Florida Hispanic veterans.

Methods

Hispanic veterans referred to the Miami VA sleep clinic were recruited and completed questionnaires about sleep apnea risk, sleep quality, insomnia symptoms, sleepiness, depression/anxiety, acculturation, personality traits, and cognitions about OSA and CPAP. Individuals at risk for OSA were scheduled for baseline polysomnography (PSG), followed by in-lab CPAP titration or a trial of auto-CPAP. Participants with OSA accepting CPAP therapy were asked to return after 7 and 30 days of treatment for adherence verification and to repeat questionnaires.

Results

One hundred twenty-four participants (94 % men) were enrolled with 114 completing overnight PSG. Eighty-six out of 95 participants (91 %) with sleep apnea syndrome or moderate to severe OSA accepted CPAP treatment. Fifty-nine participants completed both follow-up visits with a mean CPAP use at 30 days of 3.6?±?2.0 h. The only independent predictor of 7-day mean daily CPAP use was the baseline Insomnia Severity Index while the best predictor of 30-day mean daily CPAP use was the 7-day mean daily use.

Conclusions

Our study suggests that South Florida Hispanic veterans with OSA evaluated in a sleep clinic show poor CPAP adherence. Insomnia and poor early use predicted poor adherence overall. Larger prospective studies with other race–ethnic groups are needed to determine the role of ethnicity and race in CPAP adherence among US veterans with OSA.     

Left ventricular hypertrophy is a common echocardiographic abnormality in severe obstructive sleep apnea and reverses with nasal continuous positive airway pressure

STUDY OBJECTIVES: To determine cardiac structural abnormalities by echocardiography in subjects with severe obstructive sleep apnea (OSA), and to determine the long-term effects of nasal continuous positive airway pressure (CPAP) on such abnormalities. DESIGN: Polysomnography was conducted on oximetry-screened patients who showed a desaturation index > 40/h and > or = 20% cumulative time spent below 90%. From these, 25 patients with severe OSA but without daytime hypoxemia underwent echocardiography prior to, then 1 month and 6 months following initiation of CPAP treatment. SETTING: Outpatient sleep disorders center. RESULTS: Of the 25 patients, 13 patients (52%) had hypertension by history or on physical examination. Baseline echocardiograms showed that severe OSA was associated with numerous cardiovascular abnormalities, including left ventricular hypertrophy (LVH) [88%], left atrial enlargement (LAE) [64%], right atrial enlargement (RAE) [48%], and right ventricular hypertrophy (16%). In all patients (intent to treat) as well as those patients compliant with CPAP therapy (84% > 3 h nightly), there was a significant reduction in LVH after 6 months of CPAP therapy as measured by interventricular septal distance (baseline diastolic mean, 13.0 mm; 6-month mean after CPAP, 12.3 mm; p < 0.02). RAE and LAE were unchanged after CPAP therapy. CONCLUSIONS: LVH was present in high frequency in subjects with severe OSA and regressed after 6 months of nasal CPAP therapy.     

The effect of modafinil following acute CPAP withdrawal: a preliminary study

Daytime symptoms resulting from obstructive sleep apnea (OSA) include impaired neurobehavioural performance and increased sleepiness. Continuous positive airway pressure (CPAP) reduces these symptoms. However, even compliant users may temporarily withdraw from CPAP treatment resulting in an immediate return of OSA. It has been hypothesised that these treatment “holidays” may be associated with neurobehavioural decline. Acute administration of a wakefulness promoter during such treatment “holidays” may help maintain neurobehavioural functioning. We examined the effects of 200 mg modafinil on neurobehavioural performance in a placebo-controlled crossover trial including N = 12 OSA patients acutely removed from CPAP. Sleep–wake activity was assessed for four consecutive days on CPAP and one night off CPAP using actigraphy. During the night off, CPAP patients wore a single channel nasal airflow diagnostic device. On the morning after CPAP withdrawal, patients reported to the laboratory and were administered either modafinil (200 mg) or placebo. At 2 h post-administration, patients completed a single simulated drive of approximately 30 min with simultaneous administration of a divided attention task (STISIM™), critical flicker fusion (CFF) test and subjective sleepiness scales. After a 14-day washout, participants repeated the protocol. CPAP withdrawal was associated with a worsening of sleep efficiency and the movement and fragmentation index (MFI), compared to the on-CPAP nights (all p ≤ 0.02). Modafinil did not result in a superior driving simulator performance or CFF responses the morning after CPAP withdrawal but did result in better subjective sleepiness (both p ≤ 0.04) compared to placebo. These data do not support the use of modafinil for the maintenance of daytime functioning in patients with OSA who are acutely withdrawn from CPAP.     

Long‐term use of continuous positive airway pressure therapy in coronary artery disease patients with nonsleepy obstructive sleep apnea

Background

Excessive daytime sleepiness is a frequent symptom of obstructive sleep apnea (OSA) and has been proposed as a motivator for adherence to continuous positive airway pressure (CPAP) therapy. However, excessive daytime sleepiness is absent in many patients with coronary artery disease (CAD) and concomitant OSA. We evaluated long‐term use of CPAP and predictors of CPAP use in nonsleepy and sleepy OSA patients from a CAD cohort.

Hypothesis

Long‐term CPAP use is lower in CAD patients with nonsleepy OSA vs sleepy OSA.

Methods

Nonsleepy (Epworth Sleepiness Scale [ESS] score < 10) OSA patients randomized to CPAP (n = 122) and sleepy (ESS ≥10) OSA patients offered CPAP (n = 155) in the RICCADSA trial in Sweden were included in this substudy. The median follow‐up was 4.8 years for the main trial, with a predefined minimum follow‐up of 2 years.

Results

The probability of remaining on CPAP at 2 years was 60% in nonsleepy patients and 77% in sleepy patients. Multivariate analyses indicated that age and hours of CPAP use per night at 1 month were independently associated with long‐term CPAP use in nonsleepy patients. In the sleepy phenotype, body mass index, acute myocardial infarction at baseline, and hours of CPAP use per night at 1 month were predictors of long‐term CPAP use.

Conclusions

Long‐term use of CPAP is likely to be challenging for CAD patients with nonsleepy OSA. Early CPAP use is an important predictor of continued long‐term use of CPAP, so optimizing patients' initial experience with CPAP could promote adherence.

     

Obstructive sleep apnea

Purpose

Attempts to understand the causes of cognitive impairment in obstructive sleep apnea (OSA) are complicated by the overlap among clinical and demographic factors that may impact cognition. The goal of the current study was to isolate the contribution of hypoxemia to cognitive impairment in OSA.

Methods

Two groups of 20 patients with newly diagnosed OSA were compared. The groups differed on severity of hypoxemia but not other demographic (e.g., age, gender, education, estimated premorbid IQ) or clinical (e.g., sleep related respiratory disturbances, daytime sleepiness, depressive symptoms) variables. Participants completed polysonmography and cognitive assessment.

Results

We compared patients with high and low hypoxemia on measures of memory, attention, executive functioning, and motor coordination using independent sample t-tests. The high hypoxemia group performed significantly better on immediate recall (Hopkins Verbal Learning Test — Revised; t?=??2.50, p?<?0.02) than the low hypoxemia group. No group differences were observed on other neuropsychological measures.

Conclusions

This study is one of the first to compare the cognitive performance of patients with high and low hypoxemia after controlling for demographic factors and aspects of OSA severity that could confound the relationship. In our carefully matched sample, we observed an unexpected advantage of higher hypoxemia on memory. These preliminary findings are discussed in the context of basic science literature on the protective effects of adaptation to intermittent hypoxemia. Our data suggest that the association between hypoxemia and cognition may not straightforward. Future research targeting the effects of hypoxemia on cognition controlling for other clinical factors in large groups of patients with OSA will be important.     

Modafinil as adjunct therapy for daytime sleepiness in obstructive sleep apnea: a 12-week, open-label study

STUDY OBJECTIVES: The purpose of this 12-week study was to evaluate the efficacy and safety of adjunct modafinil to treat excessive sleepiness in patients with obstructive sleep apnea (OSA) who experience residual sleepiness despite regular nasal continuous positive airway pressure (nCPAP) use. DESIGN: Twelve-week, open-label trial. SETTING: Twenty-two centers in the United States. PATIENTS: We studied 125 patients with moderate-to-severe OSA (ie, respiratory disturbance index > or =15) before nCPAP therapy and residual daytime sleepiness (Epworth sleepiness scale [ESS] score > or =10) despite effective and regular nCPAP therapy. Patients were studied after completing a 4-week, double-blind, placebo-controlled trial of nCPAP plus modafinil for the treatment of residual daytime sleepiness. Interventions and measurements: Patients received individually titrated doses of modafinil (200 to 400 mg qd). Sleepiness was assessed using the ESS, quality of life was evaluated using the Functional Outcomes of Sleep Questionnaire (FOSQ), and the overall clinical effect was indexed using the clinical global impression of change scale. Adverse events, nCPAP use, and vital sign measurements were also recorded. RESULTS: The significant improvements in daytime wakefulness and sleep-related functional status observed with modafinil treatment during the 4-week, double-blind study were maintained throughout 12 weeks of open-label treatment: week 12 ESS, 7.8 (4.7) vs 14.4 (3.1) at double-blind baseline; week 12 FOSQ, 3.3 (0.6) vs 14.4 (2.7) at double-blind baseline (mean [SD]). The percentage of patients rated as clinically improved increased from 83% after 1 week to > or =93% after 2 to 12 weeks of open-label treatment. Mean (SD) nCPAP use decreased from 6.3 (1.3) h/night at baseline to 5.9 (1.4) h/night (p = 0.004) during open-label treatment. The most common adverse events were headache (28%), anxiety (16%), and nervousness (14%). CONCLUSIONS: Modafinil remained effective and well tolerated as an adjunct therapy for residual daytime sleepiness even after 12 weeks of daily dosing in patients with OSA receiving nCPAP therapy.     

One night’s CPAP withdrawal in otherwise compliant OSA patients: marked driving impairment but good awareness of increased sleepiness

Purpose

Obstructive sleep apnoea (OSA) patients effectively treated by and compliant with continuous positive air pressure (CPAP) occasionally miss a night??s treatment. The purpose of this study was to use a real car interactive driving simulator to assess the effects of such an occurrence on the next day??s driving, including the extent to which these drivers are aware of increased sleepiness.

Methods

Eleven long-term compliant CPAP-treated 50?C75-year-old male OSA participants completed a 2-h afternoon, simulated, realistic monotonous drive in an instrumented car, twice, following one night: (1) normal sleep with CPAP and (2) nil CPAP. Drifting out of road lane (??incidents??), subjective sleepiness every 200?s and continuous electroencephalogram (EEG) activities indicative of sleepiness and compensatory effort were monitored.

Results

Withdrawal of CPAP markedly increased sleep disturbance and led to significantly more incidents, a shorter ??safe?? driving duration, increased alpha and theta EEG power and greater subjective sleepiness. However, increased EEG beta activity indicated that more compensatory effort was being applied. Importantly, under both conditions, there was a highly significant correlation between subjective and EEG measures of sleepiness, to the extent that participants were well aware of the effects of nil CPAP.

Conclusions

Patients should be aware that compliance with treatment every night is crucial for safe driving.     

Impact of continuous positive airway pressure on C-reactive protein in patients with obstructive sleep apnea: a meta-analysis

Purpose

C-reactive protein (CRP) is associated with the development of obstructive sleep apnea (OSA) and cardiovascular diseases. Continuous positive airway pressure (CPAP) is an effective treatment for OSA, but the impact of CPAP therapy on CRP levels in patients with OSA remains unclear. To obtain this information, we performed a meta-analysis to determine whether effective CPAP therapy could reduce serum CRP levels.

Methods

A comprehensive literature search was performed to identify studies that examined the impact of CPAP on serum CRP levels in OSA patients who were treated with CPAP for at least 4 weeks. Standardized mean difference (SMD) was used to analyze the summary estimates for CPAP therapy.

Results

Fourteen self-control design studies involving 1199 patients with OSA met the inclusion criteria. Meta-analysis indicated that the overall SMD for the CRP levels was 0.64 units (95 % confidence interval (CI) 0.40 to 0.88) before and after CPAP therapy; test for overall effect z?=?5.27 (P?=?0.000). Subgroup analysis showed that evolution of CRP decreased non-significantly in less than 3 months (SMD, 0.26, 95 % CI ?0.08 to 0.60, P?=?0.138), significantly decreased after 3 months (SMD, 0.68, 95 % CI 0.34 to 1.02, P?=?0.000), and further declined after 6 months (SMD, 0.74, 95 % CI 0.43 to 1.05, P?=?0.000).

Conclusions

The systemic inflammation, as measured by CRP, was present and significantly reduced by effective CPAP therapy in patients with OSA. The use of CRP levels may be clinically recognized as a valuable predictor for OSA treatment monitoring.     

A pathway underlying the impact of CPAP adherence on intimate relationship with bed partner in men with obstructive sleep apnea

Purpose

Our aim was to determine the pathway underlying the effects of continuous positive airway pressure (CPAP) adherence on intimate relationship with bed partner in men with obstructive sleep apnea (OSA). We hypothesized that CPAP with good adherence affected the intimate relationship with bed partner directly and indirectly, and it was mediated through daytime sleepiness and activity level in men with OSA.

Methods

Data were obtained from an education program for enhancing CPAP adherence. Men who were newly diagnosed of OSA and CPAP therapy naïve were recruited in a tertiary teaching hospital.

Results

Self-reported quality of life [Functional Outcomes of Sleep Questionnaire], daytime sleepiness [Epworth Sleepiness Scale (ESS)], and negative emotion symptoms [depression, anxiety, stress scale] were assessed before and after CPAP treatment at 1-year assessment. Seventy-three men were included in the data analysis, with a mean?±?SD age of 52?±?10 years, body mass index of 29.0?±?5.2 kg/m², ESS of 9.5?±?5.6, and median [interquartile range(IR)] apnea and hypopnea index of 31 (21, 56) events/h. The median (IR) CPAP daily usage was 4.3(0, 6.1)?h/day. From the path analysis, CPAP therapy was shown to improve intimate relationship directly (ß?=?0.185) and indirectly (ß?=?0.050) by reducing daytime sleepiness and increasing activity level. However, negative emotion symptoms were not the mediators between CPAP adherence and the intimate relationship.

Conclusions

CPAP therapy with good adherence is related directly and indirectly to a better intimate relationship with bed partner in men with OSA. It was possibly attributed to reduced daytime sleepiness and increased activity level.

     

Correlation of daytime sleepiness with urine metabolites in patients with obstructive sleep apnea

Purpose

The apnea–hypopnea index (AHI) is closely related with the severity of daytime sleepiness, but excessive daytime sleepiness (EDS) is not presented on all patients with obstructive sleep apnea (OSA). It is unclear why daytime sleepiness is not always present in OSA patients even if their sleep is disrupted from the perspective of polysomnographic findings. This study aimed to analyze the correlation between sleepiness and urine metabolites of neurotransmitters involved in the arousal system.

Methods

On the basis of AHI in polysomnography, 49 consecutive OSA patients were included. According to their Epworth sleepiness scale (ESS), 23 non-sleepy patients (ESS <11) and 26 sleepy patients (ESS ≥11) were included. Urine samples were collected before and after polysomnography and analyzed by gas chromatography–mass spectrometry with selective ion monitoring. Six metabolites of dopamine, norepinephrine and serotonin were analyzed.

Results

The dopamine metabolites, homovanillic acid (r?=?0.366, P?=?0.017) and 3,4-dihydroxyphenylacetic acid (DOPAC; r?=?0.584, P?P?=?0.032).

Conclusion

Urine dopamine metabolites may identify sleepy patients with OSA. In particular, the overnight change of urine DOPAC may indicate OSA patients with EDS.     

Factors associated with excessive daytime sleepiness in patients with severe obstructive sleep apnea

Purpose

Although excessive daytime sleepiness (EDS) is one of the key symptoms of obstructive sleep apnea (OSA), associations between OSA and EDS have been inconsistent, even in patients with severe OSA. To that end, our goal was to investigate factors associated with EDS based on the Epworth Sleepiness Scale (ESS) score in a large clinical population with severe OSA (apnea–hypopnea index ≥30).

Methods

This cross-sectional study included 1,126 consecutive adult patients referred for their first in-laboratory polysomnogram for suspicion of OSA. All patients completed a routine questionnaire including demographics, race, co-morbidities, sleep history, ESS, short-form quality of life questionnaire-12 (SF-12), the Center for Epidemiologic Studies Depression scale, and medications used. Severe OSA was diagnosed in 498 patients. After excluding patients taking narcotics, hypnotics, benzodiazepines, antidepressants, or those with diagnosis of depression, 355 patients remained in the final analytic cohort. Patients were divided into quartiles based on the ESS and comparisons were made between the lowest quartile (ESS?≤?6; n?=?105) and highest quartile (ESS?≥?13; n?=?97).

Results

Compared to the ESS?≤?6 group, patients in the ESS?≥?13 group had a significantly higher 3 % oxygen desaturation index and a significantly lower oxygen saturation nadir during sleep (p?<?0.05). Moreover, patients with severe OSA in the highest quartile of ESS had higher depressive symptomatology.

Conclusions

In patients with severe OSA, intermittent hypoxemia and depressive symptoms are important contributing factors to EDS.     

Sleepiness and nocturnal hypoxemia in Peruvian men with obstructive sleep apnea

Purpose

To evaluate the intensity of nocturnal hypoxemia associated with sleepiness in Peruvian men with a diagnosis of obstructive sleep apnea (OSA).

Methods

We carried out a secondary data analysis based on a study which includes patients with OSA who were seen in a private hospital in Lima, Peru from 2006 to 2012. We included male adults who had polysomnographic recordings and who answered the Epworth sleepiness scale (ESE). The intensity of nocturnal hypoxemia (oxygen saturation ≤90 %) was classified in four new categories: 0, <1, 1 to 10 and >10 % total sleep time with nocturnal hypoxemia (NH). When the ESE score was higher than 10, we used the definitions presence or absence of sleepiness. We used Poisson regression models with robust variance to estimate crude and adjusted prevalence ratios (PR) for association between sleepiness and NH.

Results

518 male patients with OSA were evaluated. Four hundred and fifty-two (87 %) patients had NH and 262 (51 %) had sleepiness. Of the 142 (27.4 %) patients who had >10 % total sleep time with NH, 98 (69.0 %) showed sleepiness and had a greater probability of sleepiness prevalence, with a crude PR of 1.82 (95 % CI 1.31–2.53). This association persisted in the multivariate models.

Conclusions

We found an association between NH and sleepiness. Only patients with the major intensity of NH (over 10 % of the total sleep time) had a greater probability of sleepiness. This suggests that sleepiness probably occurs after a chronic process and after overwhelming compensatory mechanisms.     

Effects of exercise training associated with continuous positive airway pressure treatment in patients with obstructive sleep apnea syndrome

Purpose

The aim of this study was to evaluate the effects of a 2-month exercise training associated with continuous positive airway pressure (CPAP) treatment on the subjective and objective sleep measurements, quality of life, and mood in moderate to severe obstructive sleep apnea syndrome (OSAS) patients.

Methods

Male patients were randomized into two treatment groups: CPAP (n?=?19) and CPAP?+?exercise (n?=?13). All patients completed 1?month of sleep hygiene, 2?months of treatment (CPAP or CPAP?+?exercise), and 1?week of washout (no treatment). Fletcher and Luckett sleep questionnaire, Epworth sleepiness scale, sleep diaries, polysomnography, SF-36 inventory of quality of life, Profile of Mood States (POMS) questionnaire, neck circumference, and body composition were evaluated. CPAP?+?exercise group also underwent cardiopulmonary exercise test before and after treatment.

Results

Both treatments were effective in improving subjective sleepiness but CPAP?+?exercise treatment was more effective in maintaining this improvement after washout. No significant differences were found in most of the sleep parameters studied in both groups. CPAP?+?exercise group showed lower values of tension and fatigue on POMS and higher values of physical functioning, general health perception, and vitality on SF-36 after treatment.

Conclusions

A 2-month exercise training associated with CPAP treatment for OSAS patients has a positive impact on subjective daytime sleepiness, quality of life (physical functioning and general health perception), and mood state (tension and fatigue).     

Modafinil as adjunct therapy for daytime sleepiness in obstructive sleep apnea.

Patients with obstructive sleep apnea/hypopnea syndrome can experience residual daytime sleepiness despite regular use of nasal continuous positive airway pressure therapy. This randomized, double-blind, placebo-controlled, parallel group study assessed the efficacy and safety of modafinil for the treatment of residual daytime sleepiness in such patients. Patients received modafinil (n = 77) (200 mg/d, Week 1; 400 mg/d, Weeks 2 to 4) or matching placebo (n = 80) once daily for 4 wk. Modafinil significantly improved daytime sleepiness, with significantly greater mean changes from baseline in Epworth Sleepiness Scale scores at Weeks 1 and 4 (p < 0.001) and in multiple sleep latency times (MSLT) at Week 4 (p < 0.05). The percentage of patients with normalized daytime sleepiness (Epworth score < 10) was significantly higher with modafinil (51%) than with placebo (27%) (p < 0.01), but not for MSLT (> 10 min; 29% versus 25%). Headache (modafinil, 23%; placebo, 11%; p = 0.044) and nervousness (modafinil, 12%; placebo, 3%; p = 0.024) were the most common adverse events. During modafinil or placebo treatment, the mean duration of nCPAP use was 6.2 h/night, with no significant change from baseline observed between groups. Modafinil may be a useful adjunct treatment for the management of residual daytime sleepiness in patients with obstructive sleep apnea/hypopnea syndrome who are regular users of nasal continuous positive airway pressure therapy.