Effectiveness of mirtazapine in the treatment of sleep apnea/hypopnea syndrome (SAHS)

Several drugs have been described as possible treatments for Sleep Apnea/Hypopnea Syndrome (SAHS) but the data available does not support their use. In an animal model of central apnea the use of mirtazapine produced a significant reduction of apneas. We present a male patient, 82 years old, with excessive daytime sleepiness and loud snoring during at least 10 years. An overnight polysomnography (PSG) revealed an apnea/hypopnea index of 54.9 events per hour of sleep with a minimum pulse oximetric saturation (SaO(2)) of 78% and an arousal index of 40.4 per hour. A nasal CPAP titration in the second half of the night showed suppression of apneas with a CPAP level of 8 cmH(2)O. The patient refused to use the CPAP device and began with 15 mg of mirtazapine at bedtime. A second PSG performed after 3 months of mirtazapine showed a significant reduction in the apnea/hypopnea index (9.3 events per hour of sleep; 81% minimal oxygen saturation (SaO(2))). Clinically, the patient and his wife reported a clear reduction of excessive daytime sleepiness and an improvement in self-reported functioning and well-being without any important side effects. This successful case appears to be the first report with mirtazapine in human SAHS and supports the need for an appropriate clinical trial with this drug.     

Assessment of a wrist-worn device in the detection of obstructive sleep apnea

OBJECTIVE: To assess the accuracy of a wrist-worn device (Watch_PAT100) to diagnose obstructive sleep apnea (OSA). METHODS: Thirty adult subjects with and without suspected OSA simultaneously had a standard in-laboratory polysomnogram (PSG) and wore the Watch_PAT100 during a full-night recording. PSG sleep and respiratory events were scored according to standard criteria. Watch_PAT data were analyzed with an automated computerized algorithm which calculated the frequency of respiratory events per hour of actigraphy measured sleep using a combination of peripheral arterial tonometry (PAT) signal attenuation, desaturation on pulse oximetry, and changes in heart rate. This yielded a PAT apnea hypopnea index (AHI). RESULTS: Mean age was 47.0+/-14.8 years, mean body mass index 31.0+/-7.6 kg/m(2), mean PSG AHI 23+/-23.9 events per hour, and mean PAT AHI 23+/-15.9 events per hour. There was a significant correlation between PAT AHI and AHI by PSG (r=0.87, P<0.001). To assess sensitivity and specificity of Watch_PAT, we constructed receiver operator characteristic curves using a variety of AHI threshold values (10, 15, 20, and 30 events per hour). Optimal combinations of sensitivity and specificity for the various thresholds were 82.6/71.4, 93.3/73.3, 90.9/84.2, and 83.3/91.7, respectively. CONCLUSIONS: The Watch_PAT is a device that can detect OSA with reasonable accuracy. Thus, the Watch_PAT may be a useful method to diagnose OSA.     

A case of sleep choking syndrome improved by the Kampo extract of Hange-koboku-to

A case of sleep choking syndrome with typical symptoms is presented. A 44-year-old Japanese male suffered from multiple episodes of choking, which suddenly appeared with fear of impending death about 30 min after falling asleep almost every night. Overnight polysomnography showed an apnea index of 0.92 events/h, an apnea-hypopnea index of 2.77 events/h, and normal respiration during sleep with the exception of the episodes of apnea and hypopnea. No choking episode occurred in the sleep laboratory. The administration of 500 mg of acetazolamide was ineffective, but the choking episode improved after the administration of Kampo extract of Hange-koboku-to (Ban-xia-hou-pu-tang). Hange-koboku-to may be effective in treating choking sensation during sleep as well as during wakefulness.     

Polysomnographic and urodynamic changes in a case of obstructive sleep apnea syndrome with enuresis

A 53-year-old female patient with obstructive sleep apnea syndrome was reported. She had complained of enuresis as well as a 15-year history of snoring, but she had no complaint of sleep and awake disturbance. Polysomnographic study showed repeated obstructive apnea and hypopnea with an apnea/hypopnea index of 52.6, and severe oxygen desaturation during sleep. On cystometography during sleep, the changing amplitude of the spike wave corresponds to the changes of respiratory efforts against a closed upper airway. The patient was treated successfully with imipramine and acetazolamide for the obstructive sleep apnea and enuresis. Apnea/hypopnea index, nocturnal oxygen desaturation, and sleep architecture were improved, and enuresis completely disappeared. Cystometrography during sleep showed that the average amplitude of the spike wave tended to be low. Percentage urinary volume during sleep compared with 24 h volume was significantly reduced. We considered that the enuresis was mainly related to increased intra-abdominal pressure produced by respiratory efforts and enhanced nocturnal urine production.     

阻塞型睡眠呼吸暂停低通气综合征对急性缺血性卒中患者脑血管反应性的影响

目的 探讨阻塞型睡眠呼吸暂停低通气综合征（obstructive sleep apnea hypopnea syndrome,OSAHS） 对急性缺血性卒中患者脑血管反应性（cerebrovascular reactivity,CVR）的影响。 方法 前瞻性连续入组2017年10月-2020年8月住院治疗的急性缺血性卒中患者,入院2周内完善多 导睡眠监测,根据是否合并OSAHS及呼吸暂停低通气指数（apnea hypopnea index,AHI）将患者分为非 OSAHS组、轻度OSAHS组（AHI 5～15次/小时）和中重度OSAHS组（AHI>15次/小时）。在完成多导睡眠 监测后24 h内对患者进行TCD检查,检测CVR指标包括平静呼吸时、屏气后大脑中动脉的平均血流速 度（Vm）,计算屏气指数（breath holding index,BHI）。比较三组间CVR指标的差异,并在中重度OSAHS组 中分析CVR指标与入院时和发病3个月时NIHSS评分的相关性。 结果 共纳入228例急性缺血性卒中患者,男性140例（61.4%）,其中非OSAHS组49例,轻度OSAHS 组42例,中重度OSAHS组137例。中重度OSAHS组BMI、高血压比例、3个月时NIHSS评分均高于非OSAHS 组,差异有统计学意义。中重度OSAHS组平静呼吸时Vm低于非OSAHS组（57.4±10.6 cm/s vs 62.1±12.2 cm/s,P =0.010）和轻度OSAHS组（57.4±10.6 cm/s vs 59.6±11.2 cm/s,P =0.007）,BHI 低于非OSAHS组 （1.4%±0.6% vs 1.7%±0.7%,P =0.002）和轻度OSAHS组（1.4%±0.6% vs 1.5%±0.6%,P =0.001）。中重 度OSAHS组发病3个月时NIHSS评分与平静呼吸时Vm（r =-0.696,P＜0.001）和BHI（r =-0.832,P＜0.001） 呈负相关。 结论 伴中重度OSAHS的急性缺血性卒中患者CVR明显下降,而且CVR的下降可能与急性缺血性卒中 患者的预后不良有关。     

Sleep apnea as a feature of bulbar stroke

Medullary disorders can be associated with a sleep apnea syndrome. The present patient developed a sleep apnea syndrome with approximately 25 episodes of apnea or hypopnea during each hour of sleep following a lateral medullary infarction. The presence of predisposing factors and involvement of respiratory centers in the area of the medullary lesion may determine the appearance of sleep apnea with brainstem infarction. Investigation of breathing during sleep may be helpful in such cases.     

Neural network analysis of nocturnal SpO2 signal enables easy screening of sleep apnea in patients with acute cerebrovascular disease

Current diagnostics of sleep apnea relies on the time-consuming manual analysis of complex sleep registrations, which is impractical for routine screening in hospitalized patients with a high probability for sleep apnea, e.g. those experiencing acute stroke or transient ischemic attacks (TIA). To overcome this shortcoming, we aimed to develop a convolutional neural network (CNN) capable of estimating the severity of sleep apnea in acute stroke and TIA patients based solely on the nocturnal oxygen saturation (SpO₂) signal.The CNN was trained with SpO₂ signals derived from 1379 home sleep apnea tests (HSAT) of suspected sleep apnea patients and tested with SpO₂ signals of 77 acute ischemic stroke or TIA patients. The CNN's performance was tested by comparing the estimated respiratory event index (REI) and oxygen desaturation index (ODI) with manually obtained values.Median estimation errors for REI and ODI in patients with stroke or TIA were 1.45 events/hour and 0.61 events/hour, respectively. Furthermore, based on estimated REI and ODI, 77.9% and 88.3% of these patients were classified into the correct sleep apnea severity categories. The sensitivity and specificity to identify sleep apnea (REI > 5 events/hour) were 91.8% and 78.6%, respectively. Moderate-to-severe sleep apnea was detected (REI > 15 events/hour) with sensitivity of 92.3% and specificity of 96.1%.The CNN analysis of the SpO₂ signal has great potential as a simple screening tool for sleep apnea. This novel automatic method accurately detects sleep apnea in acute cerebrovascular disease patients and facilitates their referral for a differential diagnostic HSAT or polysomnography evaluation.     

Effectiveness of prosthetic mandibular advancement for obstructive sleep apnea:Analysis by sleep position

Abstract Fifteen patients with obstructive sleep apnea were treated using prosthetic mandibular advancement (PMA). Each patient was evaluated in the supine and lateral decubitus positions with and without PMA. After PMA treatment, the mean intraesophageal pressure (Peso) in the supine position improved from -42.6 to -27.3 cmH₂O and the mean apnea + hypopnea index (AHI) decreased from 48.8/h to 23.7/h. The mean Peso in the lateral decubitus position improved from -27.9 to -18.6 cmH₂O and the mean AHI decreased from 9.6/h to 6.6/h. With PMA, respiratory disturbance during sleep further improved by changing the body position from the supine to lateral decubitus position.     

Sleep bruxism related to obstructive sleep apnea: the effect of continuous positive airway pressure

Several studies have reported that sleep bruxism rarely occurs in isolation. Recently, in an epidemiological study of sleep bruxism and risk factors in the general population, it was found that among the associated sleep symptoms and disorders obstructive sleep apnea (OSA) was the highest risk factor for tooth grinding during sleep. The purpose of this report was to evaluate the effect of continuous positive airway pressure (CPAP) on sleep bruxism in a patient with both severe OSA and sleep tooth grinding. Two polysomnographic (PSG) recordings were carried out. The first showed 67 events of sounded tooth grinding, most of them appearing as an arousal response at the end of apnea/hypopnea events in both the supine and lateral postures. During the CPAP titration night most breathing abnormalities were eliminated and a complete eradication of the tooth grinding events was observed. The results of this study suggest that when sleep bruxism is related to apnea/hypopneas, the successful treatment of these breathing abnormalities may eliminate bruxism during sleep.     

Clinical efficacy of prosthetic mandibular advancement on obstructive sleep apnea syndrome

In order to clarify the efficacy and indication of prosthetic mandibular advancement (PMA) on obstructive sleep apnea syndrome (OSAS), we made a comparison of both the polysomnographic findings and the upper airway configuration between before and during PMA on 19 OSAS patients. During PMA, there was a significant decreased apnea hypopnea index compared to before treatment. The changes in magnetic resonance imaging of the upper airway during sleep with PMA indicated that the treatment is regarded to be the first choice for OSAS patients with glossopharyngeal obstruction. In addition to that, the treatment might be considered for use in velopharyngeal obstruction.     

HHT based cardiopulmonary coupling analysis for sleep apnea detection

Study objectivesTo validate the feasibility of the Hilbert–Huang transform (HHT) based cardiopulmonary coupling (CPC) technique in respiratory events detection and estimation of the severity of apnea/hypopnea.MethodsThe HHT-CPC sleep spectrogram technique was applied to a total of 69 single-lead ECG signals downloaded from the Physionet Sleep Apnea Database. Sleep spectrograms generated by both the original and the improved CPC method were compared on the structure distribution and time–frequency resolution. The performance of respiratory events detection by using the power of low frequency coupling (pLFC) in the new method was estimated by receiver operating characteristic analysis. Furthermore, correlation between HHT-CPC index (temporal Variability of Dominant Frequency, TVDF) and conventional OSAHS scoring was computed.ResultsThe HHT-CPC spectrum provides much finer temporal resolution and frequency resolution (8 s and 0.001 Hz) compared with the original CPC (8.5 min and 0.004 Hz). The area under the ROC curve of pLFC was 0.79 in distinguishing respiratory events from normal breathing. Significant differences were found in TVDF among groups with different severities of OSAHS (normal, mild, moderate, and severe, p < 0.001). TVDF has a strong negative correlation with the apnea/hypopnea index (AHI, correlation coefficient ?0.71).ConclusionsThe HHT-CPC spectrum could exhibit more detailed temporal-frequency information about cardiopulmonary coupling during sleep. As two spectrographic markers, pLFC and TVDF can be used to identify respiratory events and represent the disruption extent of sleep architecture in patients with sleep apnea/hypopnea, respectively. The proposed technique might serve as a complementary approach to enhance diagnostic efforts.     

Comparative efficacy of CPAP,MADs, exercise-training,and dietary weight loss for sleep apnea: a network meta-analysis

Study objectiveTo synthesize evidence from available studies on the relative efficacies of continuous positive airway pressure (CPAP), mandibular advancement device (MAD), supervised aerobic exercise training, and dietary weight loss in patients with obstructive sleep apnea (OSA).DesignNetwork meta-analysis of 80 randomized controlled trials (RCTs) short-listed from PubMed, SCOPUS, Web of science, and Cochrane register (inception – September 8, 2015).PatientsIndividuals with OSA.InterventionsCPAP, MADs, exercise training, and dietary weight loss.ResultsCPAP decreased apnea–hypopnea index (AHI) the most [by 25.27 events/hour (22.03–28.52)] followed by exercise training, MADs, and dietary weight loss. While the difference between exercise training and CPAP was non-significant [−8.04 (−17.00 to 0.92), a significant difference was found between CPAP and MADs on AHI and oxygen desaturation index (ODI) [−10.06 (−14.21 to −5.91) and −7.82 (−13.04 to −2.59), respectively]. Exercise training significantly improved Epworth sleepiness scores (ESS) [by 3.08 (0.68–5.48)], albeit with a non-significant difference compared to MADs and CPAP.ConclusionsCPAP is the most efficacious in complete resolution of sleep apnea and in improving the indices of saturation during sleep. While MADs offer a reasonable alternative to CPAP, exercise training which significantly improved daytime sleepiness (ESS) could be used as adjunctive to the former two.     

Schizophrenia, obesity, and obstructive sleep apnea

BACKGROUND: This study evaluated the risk factors for obstructive sleep apnea in psychiatric patients. METHOD: The subjects were 364 patients referred to a sleep disorders consultation service from an inpatient psychiatric hospital. Seventy-eight percent underwent polysomnographic testing. Rates of obstructive sleep apnea in different diagnostic groups (established by clinical DSM-III-R diagnosis) were retrospectively assessed. RESULTS: Logistic regression demonstrated significant independent effects of age (p = .046), gender (p = .002), body mass index (p < .001), and chronic neuroleptic use (p = .012) on the presence of obstructive sleep apnea (defined as more than 20 instances of apnea and/or hypopnea per hour of sleep). Patients with schizophrenia were significantly heavier and had higher rates of sleep apnea than did other psychiatric patients. CONCLUSION: Obesity, male gender, and chronic neuroleptic administration are risk factors for obstructive sleep apnea in psychiatric patients. Since patients with schizophrenia are often on long-term neuroleptic treatment, they may have high rates of obstructive sleep apnea, mediated via the weight gain produced by such medications. Overweight psychiatric patients and those on chronic neuroleptic treatment (e.g., patients with schizophrenia) should be evaluated for sleep apnea if signs and symptoms of this disorder are present.     

Effect of below-the-knee compression stockings on severity of obstructive sleep apnea

BackgroundOvernight fluid shift from the legs to the neck may narrow the upper airway and contribute to obstructive sleep apnea (OSA) pathogenesis. We hypothesized that below-the-knee compression stockings will decrease OSA severity in a general OSA population by decreasing daytime leg fluid accumulation and overnight fluid shift and increasing upper-airway size.MethodsPatients with OSA (apnea–hypopnea index ≥10) were randomized to wear compression stockings during the daytime or to a control group for 2 weeks. Overnight polysomnography with measurement of leg and neck fluid volumes and upper-airway cross-sectional area before and after sleep was performed at baseline and follow-up. The primary outcome was change in the apnea–hypopnea index.ResultsTwenty-two patients randomized to compression stockings and 23 to control completed the study. The apnea–hypopnea index decreased significantly more in the compression stockings than in the control group (from 32.4 ± 20.0 to 23.8 ± 15.5 vs. from 31.2 ± 25.0 to 30.3 ± 23.8, p = 0.042), in association with a significantly greater reduction in the overnight decrease in leg fluid volume (p = 0.028), and a significantly greater increase in morning upper-airway cross-sectional area (p = 0.006). Overnight change in neck fluid volume was unchanged.ConclusionThese observations suggest that in, a general OSA population, below-the-knee compression stockings decrease OSA severity modestly via attenuation of overnight fluid shift and consequent upper-airway dilatation.     

Is obstructive sleep apnea a problem in Parkinson’s disease?

BackgroundParkinson’s disease (PD) is associated with sleep disorders and daytime sleepiness. Upper airway dysfunction in PD may promote obstructive sleep apnea. However, the frequency and clinical relevance of sleep-disordered breathing in PD remains unclear.MethodsSleep apnea symptoms, cardiovascular events and treatment were collected in 100 patients with PD (50 unselected, consecutive patients matched for age, sex and body mass index with 50 patients referred for sleepiness) and 50 in-hospital controls. The motor and cognitive status was evaluated in patients with PD. The 150 subjects underwent a video-polysomnography.ResultsSleep apnea (defined as an apnea–hypopnea index greater than 5) was less frequent in the PD group (27% patients, including 6% with mild, 11% with moderate and 10% with severe sleep apnea) than in the control group (40% in-hospital controls, p < 0.002). Sleep apnea was not associated with increased sleepiness, nocturia, depression, cognitive impairment and cardiovascular events in patients with PD. Sleep apnea was more frequent and severe in the most disabled patients. Patients with PD did not display sleep hypoventilation, stridor and abnormal central sleep apnea. In patients with REM sleep behavior disorders, snoring and obstructive sleep apnea occurred during REM sleep, although the chin muscle tone was maintained.ConclusionObstructive sleep apnea does not seem to be a clinically relevant issue in PD. Daytime sleepiness, nocturia and cognitive impairment are mostly caused by other, non-apneic mechanisms. The maintenance of chin muscle tone during REM sleep behavior disorder has no influence on the frequency of apneic events.     

Evaluation of the auto continuous positive airway pressure efficacy by upper airway pressure measurement

The efficacy of auto continuous positive airway pressure (CPAP) was prospectively evaluated in 11 obstructive sleep apnea cases by the upper airway pressure measurement. Their apnea plus hypopnea index decreased from 68.3+/-20.2/h to 0.5+/-0.9/h during manually adjusted and 9.6+/-14.5/h during auto CPAP The intraesophageal pressure decreased from -88.0+/-34.0 cm H2O to 11.9+/-7.2 cm H2O during manually adjusted and -26.0+/-13.7 cm H2O during auto CPAP. The manually adjusted CPAP level was 9.1+/-1.7 cm H2O and the maximum pressure of the auto CPAP was 9.4+/-2.0 cm H2O. Auto CPAP could automatically detect the optimal CPAP level. However, the efficacy of the auto CPAP was less than that of the manually adjusted CPAP.     

颅内肿瘤和睡眠呼吸暂停低通气综合征

目的 评估颅内肿瘤病人呼吸暂停低通气的类型以及肿瘤切除术在改善呼吸紊乱方面起的作用.方法 对30例颅内肿瘤病人(22例幕上,8例幕下)术前、术后进行睡眠呼吸检测.结果 术前平均呼吸暂停低通气指数为23.3,18例病人存在阻塞性呼吸暂停,3例病人存在阻塞性和中枢性呼吸暂停.术后平均呼吸暂停低通气指数降为9.6(P＜0.0...     

Usefulness of arousal for the diagnosis of sleep breathing disorder

Abstract We hypothesize that breathing disorder related arousal index (B-ArI) can differentiate sleep breathing disorder from simple snorer when apnea hypopnea index (AHI) is low. We studied 54 patients using polysomnography. Breathing disorder related arousal (B-Ar) was defined as arousal accompanied by apnea, hypopnea, desaturation or snort. Mean AHI was 44.2 ± 34.0/h, and B-ArI correlated significantly with AHI, desaturation index, percentage total sleep time with SpO₂ below 90%. Breathing disorder related arousal index was greater than AHI when AHI was below 20. In 11/54 patients, AHI was below 10, and B-ArI more than 10. Nasal continuous positive airway pressure was applied to six patients and showed reduced B-ArI. Breathing disorder related arousal index may be one of the useful indices for the diagnosis of sleep breathing disorder when AHI is less than 10.     

Obstructive sleep apnea and incident type 2 diabetes

ObjectivesTo determine whether severity of obstructive sleep apnea is associated with incident diabetes in middle-aged and older adults.MethodsA prospective analysis of 1453 non-diabetic participants of both the Atherosclerosis Risk in Communities Study and the Sleep Heart Health Study (mean age 63 years, 46% male) had in-home polysomnography (1996–1998) and was followed up for incident diabetes. Using the apnea–hypopnea index derived from home polysomnography, study participants were categorized as follows: <5.0 (normal), 5.0–14.9 (mild), 15.0–29.9 (moderate), and ≥30.0 events/h (severe). Incident diabetes was ascertained during annual follow-up telephone calls through 2013.ResultsDuring a median follow-up of 13 years, there were 285 incident diabetes cases among the 1453 participants. Participants with severe obstructive sleep apnea were at greater risk of incident diabetes compared to persons classified as normal after adjustment for confounders including body mass index and waist circumference (1.71 [1.08, 2.71]). The association between severe obstructive sleep apnea and incident diabetes was similar when analyses were restricted to obese individuals.ConclusionsSevere obstructive sleep apnea was associated with greater risk of incident diabetes, independent of adiposity in a community-based sample. Healthcare professionals should be cognizant of the high prevalence of OSA in the general population and the potential link to incident diabetes.     

Apnea burden: efficacy versus effectiveness in patients using positive airway pressure

BackgroundModern continuous positive airway pressure (PAP) machines track hours of use and residual respiratory events while on treatment. A substantial portion of sleep apnea patients are partially compliant, emphasizing the need to distinguish between PAP efficacy and PAP effectiveness in chronic management of patients with sleep apnea.MethodsWe used a combination of three data sources to estimate the sleep apnea burden in a convenience cohort of PAP users from our clinics that were compliant based on Medicare criteria: self-reported habitual total sleep time, and PAP usage times with residual apnea–hypopnea index (AHI) from compliance downloads.ResultsAssuming that the off-PAP time consists of baseline AHI severity, an estimated apnea burden was calculated to estimate PAP effectiveness. Whereas 70% of patients in our cohort showed machine AHI values <5/h, the apnea burden calculations revealed that only one-third of patients are predicted to have an effective AHI <5.ConclusionEstimating PAP effectiveness through the concept of apnea burden has implications for clinical care as well as research trials.