Sleep complaints: snoring and daytime sleepiness in pregnant and pre-eclamptic women

BACKGROUND AND PURPOSE: To examine whether snoring and sleepiness are linked in pregnancy and pre-eclampsia. PATIENTS AND METHODS: We recruited 167 healthy and 82 pre-eclamptic women in the third trimester of pregnancy and 160 non-pregnant women. Subjects and their partners completed a sleep questionnaire. Height, weight, neck circumferences and blood pressure were recorded for all. RESULTS: Pregnant and pre-eclamptic women were (mean +/-SD) 36+/-3.6 and 36+/-3 weeks pregnant, respectively. Age and height did not differ significantly between groups (P>0.2), but pre-eclamptic women were heavier than pregnant and non-pregnant women and had higher BMI than pregnant women before pregnancy (all P<0.05). Thirty-two percent of control, 55% of pregnant and 85% of pre-eclamptic women snored (P<0.001), but pre-pregnancy snoring rates (pre-eclamptic=36%, healthy pregnant women=27%) were similar to those in non-pregnant women (32%) (P>0.7). Sleepiness was reported by 12% of non-pregnant, 23% of pregnant and 15% of pre-eclamptic women (P<0.04), but non-pregnant women had lower mean Epworth Sleepiness scores than both pregnant and pre-eclamptic groups (P<0.001). Snoring was correlated with (P=0.002), but explained only <2%, of the variance in sleepiness. CONCLUSION: Snoring and sleepiness increased in the third trimester of pregnancy, particularly in patients with pre-eclampsia. However, the study suggests that sleepiness in pregnancy is largely due to factors other than snoring or breathing pauses.     

A questionnaire survey among Turkish physicians about sleep disorders

We aimed to assess the knowledge of Turkish physicians about sleep disorders and the attitude of the physicians towards sleep medicine. We prepared a 24-item-questionnaire, 7 of the questions were about the attitudes of the physicians and 17 of them were about the knowledge of the physicians. We applied the questionnaire in all university and educational hospitals in Ankara, which is the capital city and the second largest city of Turkey. Two-hundred-fifteen medical doctors from 5 different specialties accepted to answer the questionnaire, and 168 (78%) of them completed the questionnaire. 47% of the physicians rated themselves as they had little knowledge about sleep disorders, and 45% as they had enough knowledge about sleep disorders, however, the overall score was not high. They answered only 45.3% of the questions correctly. In the light of this survey, we concluded that medical education on sleep disorders should be extended both in length and in content to improve the quality of sleep disorders medicine in Turkey.     

Adaptation of functional outcomes of sleep questionnaire (FOSQ) to Turkish population

Turkish version of functional outcomes of sleep questionnaire (FOSQ.tr) was examined for its psychometric properties in patients with obstructive sleep apnoea hypopnoea syndrome (OSAHS). The FOSQ was translated into Turkish using a forward-backward translation. For the psychometric evaluation, 73 consecutive patients were selected along with 73 control subjects. Internal consistency, test-retest reliability, concurrent and discriminant validity were investigated. Values of Cronbach's alpha for the total FOSQ.tr (alpha= 0.92) and its sub-scales (alpha= 0.76-0.80) suggest that the questionnaire was consistent internally. Test-retest reliability of the FOSQ.tr was significant for the total score (r= 0.7) and the sub-scales apart from social outcome (r= 0.5 to 0.8, all p< 0.01). FOSQ.tr correlated moderately with Epworth sleepiness scale (ESS), with coefficients ranging from r= -0.5 to -0.62, (all p< 0.05) for the sub-scales, and r= -0.64 (p< 0.01) for total score. Discriminant analysis showed that FOSQ.tr could significantly distinguish the patients from normal subjects (p< 0.03). The psychometric properties of the FOSQ.tr suggest that it is a valid and reliable instrument for the assessment of the impact of disorders of excessive sleepiness on daily behaviour.     

Obstructive sleep apnea in pregnancy: performance of a rapid screening tool

Purpose

The Sleep Apnea Symptom Score (SASS) has been commonly used to assess obstructive sleep apnea (OSA). The aim of this study was to examine the psychometric properties of the SASS and the predictive value of SASS incorporating bedpartner-reported information in identifying OSA in pregnant women.

Methods

A cohort of healthy pregnant women completed the SASS and Pittsburgh Sleep Quality Index. Participants underwent overnight laboratory polysomnography (PSG) monitoring. Reliability and validity of the SASS were evaluated. A multivariable predictive model, incorporating the SASS score along with BMI, age, and bedpartner-reported information, was developed to assess the risk for OSA (AHI?≥?5 events/h). Receiver operating characteristic curves for OSA were constructed to evaluate the sensitivity and specificity of the predictive model.

Results

A total of 126 and 105 participants completed the PSG during the first and third trimester, respectively. The SASS demonstrated adequate validity and acceptable reliability (Cronbach’s α?=?0.72 during the third trimester). When the combined model consisting of SASS, age, BMI, and bedpartner-reported information was used, the area under the curve for AHI?≥?5 for the first and third trimester was 0.781 (95%CI 0.648, 0.914) and 0.842 (95%CI 0.732, 0.952), respectively; the sensitivity/specificity was 76.9%/72.4% and 82.4%/78.0%, respectively.

Conclusions

The SASS alone has acceptable reliability and validity, but limited predictive values. A new tool, combining the SASS and other patient characteristics (i.e., age, BMI, and bedpartner-reported snoring and breathing pauses), demonstrated improved sensitivity and specificity, and thus may have greater utility in clinical practice for predicting OSA in pregnant women.

     

Acoustic reflection for nasal airway measurement in patients with obstructive sleep apnea-hypopnea syndrome

STUDY OBJECTIVE: To measure nasal dimensions and explore relationships between these and patients' use of continuous positive airway pressure (CPAP) in patients with obstructive sleep apnea-hypopnea syndrome (OSAHS). DESIGN: Prospective single-blind study. SETTING: A tertiary-care, sleep disorders referral center. Patients: Sixty OSAHS patients (52 men, mean age 51 years, body mass index (BMI) 36.1 +/- 9.4 kg/m2). MEASUREMENTS: After in-vitro validation, acoustic reflection was used to measure the nasal minimal cross-sectional area (MCSA), mean area, and volume in OSAHS patients receiving CPAP treatment. Variables from sleep studies included the apnea-hypopnea index (AHI), titration pressure, and CPAP use (hours per night) after 3 months. Median MCSA was used to categorize subjects into small and large MCSA groups. Correlation and regression analyses were conducted to investigate the relationship between results of polysomnography and nasal acoustic reflection. RESULTS: At baseline the small and large MCSA groups were not different (P > .05) in BMI, age, mask type, or previous nasal stuffiness, but there were more women in the smaller MCSA group (P = .02). CPAP use was significantly lower in the small MCSA group (P = .007), but apnea-hypopnea index and titration pressure were indistinguishable between the 2 groups. Furthermore, CPAP use correlated significantly and positively with MCSA (r = 0.34, P = .008), mean area (r = 0.27, P = .04), and volume (r = 0.28, P = .03). Step-wise multiple regression models revealed that MCSA was a predictor of the CPAP compliance (R2 = 0.16, P = .002), and MCSA (P = .001) and age (P = .04) were predictive factors of CPAP compliance (R2= 0.22). Nasal dimensions were not related to subjective nasal stuffiness. CONCLUSIONS: CPAP use in patients with smaller nasal passages was lower than in those with larger passages. Objective measurement of nasal dimension may be more reliable than subjective self-report of nasal symptoms in identifying patients with OSAHS who might struggle with CPAP therapy.     

Sleep-disordered breathing and daytime napping are associated with maternal hyperglycemia

Objectives

Sleep disturbances in pregnancy may impair glucose mechanism. This study aimed to examine associations of sleep-disordered breathing, sleep, and nap duration with 1-h glucose challenge test (GCT) levels in pregnant women after controlling for known risk factors for gestational diabetes.

Methods

This is a case–control study of 104 pregnant women. All women underwent full polysomnography and a GCT and completed the multivariable apnea prediction and Pittsburgh Sleep Quality indexes. The primary outcome was maternal hyperglycemia measured by GCT. Bivariate and multivariable logistic regression analyses were performed.

Results

Over 13 % subjects reported habitual snoring in the first trimester. Only 9.3 % women with normoglycemia (GCT?<?135) were habitual snorers, whereas 45.5 % women with hyperglycemia (GCT?≥?135) had habitual snoring (p?<?0.001). Sleep-disordered breathing symptoms (loud snoring, snorting/gasping, and apneas) (odds ratio (OR) 2.85; 95 % confidence interval (CI) 1.50–5.41; p?=?0.001) and total nap duration (OR 1.48; 95 % CI 0.96–2.28; p?=?0.08) were associated with hyperglycemia. After adjusting for confounders, sleep-disordered breathing symptoms (OR 3.37; 95 % CI 1.44–8.32; p?=?0.005) and nap duration (OR 1.64; 95 % CI 1.00–2.681.02; p?=?0.05) continued to be associated with hyperglycemia. However, the primary exposure measure, the apnea/hypopnea index in the first trimester was not significantly associated with hyperglycemia (OR 1.03; 95 % CI 0.83–1.28; p?=?0.77).

Conclusions

Sleep-disordered breathing symptoms and nap duration are associated with hyperglycemia. Sleep duration was not associated with hyperglycemia. Research is needed concerning whether women with sleep-disordered breathing and/or daytime napping are at risk for gestational diabetes.     

The upper airway in pregnancy and pre-eclampsia

Snoring is common in pregnancy, and snoring pregnant women have increased rates of pre-eclampsia. Patients with pre-eclampsia show upper airway narrowing during sleep. The present study aimed to compare upper airway dimensions in pregnant and nonpregnant women and in patients with pre-eclampsia. A total of 50 women in the third trimester of pregnancy and 37 women with pre-eclampsia were recruited consecutively from the antenatal service and matched with 50 nonpregnant women. Upper airway dimensions were measured using acoustic reflection. Comparisons were made by analysis of variance and Student-Newman-Keuls tests. Snoring was reported by 14% of nonpregnant women, 28% of pregnant women, and 75% of pre-eclamptic women (p < 0.001). When seated, pregnant women had wider upper airways than nonpregnant women (p < 0.02), but there was no difference when supine. Oropharyngeal junction area in the seated position was less (p < 0.01) in the women with pre-eclampsia (mean +/- SD: 0.9 +/- 0.1 cm2) than either nonpregnant (1.1 +/- 0.1 cm2) or pregnant women (1.3 +/- 0.1 cm2). Supine oropharyngeal junction area was less in the women with pre-eclampsia than in the nonpregnant women (0.8 +/- 0.1 versus 1.0 +/- 0.1 cm2; p = 0.01) but similar in women with pre-eclampsia and pregnant women (0.9 +/- 0.1 cm2; p > 0.3). The study showed that women with pre-eclampsia have upper airway narrowing in both upright and supine postures. These changes could contribute to the upper airway resistance episodes during sleep in patients with pre-eclampsia, which may further increase their blood pressure.     

Sleep duration versus sleep insufficiency as predictors of cardiometabolic health outcomes

ObjectiveThe objective of the present study was to investigate the relationship between sleep insufficiency and sleep duration, particularly regarding negative cardiometabolic health outcomes already considered to be affected by reduced sleep time.MethodsA total of N = 30,934 participants from the 2009 Behavioural Risk Factor Surveillance System (BRFSS) answered questions about their sleep duration as well as subjective feelings of sleep insufficiency. Outcomes included body mass index (BMI), obesity (BMI ? 30 kg m^?2) and history of hypertension, diabetes, hypercholesterolaemia, heart attack and stroke. Linear and logistic regression models examined whether cardiometabolic outcomes were associated with (1) sleep duration alone, (2) sleep insufficiency alone and (3) the combined effect of sleep duration and sleep insufficiency.ResultsResults indicated that, when examined alone, sleep duration <5 h (versus 7 h) was related to BMI (B = 2.716, p < 0.01), obesity (B = 2.080, p < 0.000001), diabetes (B = 3.162, p < 0.000001), hypertension (B = 2.703, p < 0.000001), hypercholesterolaemia (B = 1.922, p < 0.00001), heart attack (B = 4.704, p < 0.000001) and stroke (B = 4.558, p < 0.000001), and sleep insufficiency (days per week, continuous) was related to BMI (B = 0.181, p < 0.01), obesity (B = 1.061, p < 0.000001) and hypercholesterolaemia (B = 1.025, p < 0.01). All of these relationships remained significant after adjustment for covariates, except for diabetes and sleep duration. Also, after adjustment, a significant relationship between insufficient sleep and hypertension emerged (B = 1.039, p < 0.001). When evaluated together, after adjustment for covariates, significant relationships remained between sleep duration <5 h (versus 7 h) and BMI (B = 1.266, p < 0.05), obesity (B = 1.389, p < 0.05), hypertension (B = 1.555, p < 0.01), heart attack (B = 2.513, p < 0.01) and stroke (B = 1.807, p < 0.05). It should be noted that relationships between sleep duration >9 h (versus 7 h) were seen for heart attack (B = 1.863, p < 0.001) and stroke (B = 1.816, p < 0.01). In these models, sleep insufficiency was associated with hypercholesterolaemia (B = 1.031, p < 0.01) and hypertension (B = 1.027, p < 0.05).ConclusionsThese analyses show that both sleep duration and insufficiency are related to cardiometabolic health outcomes, and that when evaluated together, both variables demonstrate unique effects.     

Knowledge and attitude of primary care physicians towards obstructive sleep apnea in the Middle East and North Africa region

Background/objectives

Sleep disorders are highly prevalent in primary care. Obstructive sleep apnea (OSA) is one of the most common sleep disorders in the world, and it is estimated that only 10 to 20% of OSA cases are diagnosed. Primary care physicians (PCP) play an important role in screening for OSA. Knowledge of sleep disorders among PCP varies widely and has been generally reported as low. In this study, we aimed to assess the knowledge and attitudes towards OSA among primary care physicians in the Middle East and North Africa regions.

Methods

A cross-sectional study using the Obstructive Sleep Apnea Knowledge and Attitudes (OSAKA) self-administered questionnaire was distributed to PCP attending the Lebanese Society of Family Medicine annual conference, the Lebanese Society of Internal Medicine annual conference, and World Organization of Family Doctors (WONCA) East Mediterranean region conference.

Results

Of 300 physicians approached, 256 (85%) completed the questionnaires. The range of possible scores was 0 to 18. The mean total knowledge score with standard deviation (SD) was 12.6 (2.5). Internal medicine specialists showed a higher mean knowledge score of 14.1 (2.3) compared to general/family medicine specialists 12.4 (2.4) and other specialties 11.9 (2.8), p = 0.001. Though 78% of all physicians felt confident in identifying patients with OSA, only 26% felt confident in managing patients with continuous positive airway pressure. Overall, there was a weak positive correlation between knowledge and attitude.

Conclusion

There were gaps in knowledge and attitudes regarding managing patients with OSA. Training in managing patients with OSA is needed.

     

Reliability and validity studies of the Turkish version of the Epworth Sleepiness Scale

The Epworth Sleepiness Scale (ESS) is a self-administered eight-item questionnaire that is widely used in English speaking countries for assessment of daytime sleepiness in adults. The aim of this study was to investigate the reliability and validity of the ESS in the Turkish language. The Turkish version of the ESS (ESStr) was applied to 194 healthy controls and 150 consecutive subjects attending the sleep centre with symptoms of sleep-disordered breathing. Test–retest reliability of the ESStr was tested in a separate group of 30 subjects. The ESStr scores of 60 subjects with mild to severe obstructive sleep apnoea (OSA) were compared with the ESStr scores of 60 healthy controls matched for age, gender, and body mass index (BMI). Concurrent validity with the Functional Outcomes of Sleep Questionnaire (FOSQtr) was also assessed in 12 subjects. The questionnaire had a high level of internal consistency as measured by Cronbach’s alpha (≥0.86). The test–retest intraclass correlation coefficient was r  = 0.81 (95% confidence interval: 0.64–0.90) (p < 0.001) and Spearman’s correlation coefficient was r = 0.80 (p = 0.01). The control group had lower ESStr scores than subjects with sleep-disordered breathing (3.6 ± 3 vs 12.6 ± 6, respectively; p < 0.001). Subjects with mild sleep-disordered breathing also had lower scores of the ESStr than those with moderate and severe sleep-disordered breathing (10 ± 6.2 vs 14 ± 5. and 10 ± 6.2 vs 16 ± 5.4, respectively; both p < 0.05), but there were no significant differences between moderate and severe subjects with sleep apnoea. There were significant correlations between the ESStr and total FOSQtr and its subscales (r  = −0.22 to r = −0.92; all p  = 0.05). Factor analysis of item scores showed that the ESStr had only one factor. The ESStr is a reliable and valid measure of daytime sleepiness. These features and the simplicity of the ESStr make it a valuable measure for clinical management and research.