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International Forum of Allergy &... Jul 2023Evaluation and interpretation of the literature on obstructive sleep apnea (OSA) allows for consolidation and determination of the key factors important for clinical... (Review)
Review
BACKGROUND
Evaluation and interpretation of the literature on obstructive sleep apnea (OSA) allows for consolidation and determination of the key factors important for clinical management of the adult OSA patient. Toward this goal, an international collaborative of multidisciplinary experts in sleep apnea evaluation and treatment have produced the International Consensus statement on Obstructive Sleep Apnea (ICS:OSA).
METHODS
Using previously defined methodology, focal topics in OSA were assigned as literature review (LR), evidence-based review (EBR), or evidence-based review with recommendations (EBR-R) formats. Each topic incorporated the available and relevant evidence which was summarized and graded on study quality. Each topic and section underwent iterative review and the ICS:OSA was created and reviewed by all authors for consensus.
RESULTS
The ICS:OSA addresses OSA syndrome definitions, pathophysiology, epidemiology, risk factors for disease, screening methods, diagnostic testing types, multiple treatment modalities, and effects of OSA treatment on multiple OSA-associated comorbidities. Specific focus on outcomes with positive airway pressure (PAP) and surgical treatments were evaluated.
CONCLUSION
This review of the literature consolidates the available knowledge and identifies the limitations of the current evidence on OSA. This effort aims to create a resource for OSA evidence-based practice and identify future research needs. Knowledge gaps and research opportunities include improving the metrics of OSA disease, determining the optimal OSA screening paradigms, developing strategies for PAP adherence and longitudinal care, enhancing selection of PAP alternatives and surgery, understanding health risk outcomes, and translating evidence into individualized approaches to therapy.
Topics: Adult; Humans; Sleep Apnea, Obstructive; Continuous Positive Airway Pressure; Polysomnography; Risk Factors
PubMed: 36068685
DOI: 10.1002/alr.23079 -
Nature Reviews. Cardiology Aug 2023Obstructive sleep apnoea (OSA), characterized by recurrent periods of upper airway obstruction and intermittent hypoxaemia, is prevalent in patients with cardiovascular... (Review)
Review
Obstructive sleep apnoea (OSA), characterized by recurrent periods of upper airway obstruction and intermittent hypoxaemia, is prevalent in patients with cardiovascular disease (CVD), and is therefore important to consider in the prevention and management of CVD. Observational studies indicate that OSA is a risk factor for incident hypertension, poorly controlled blood pressure, stroke, myocardial infarction, heart failure, cardiac arrhythmias, sudden cardiac death and all-cause death. However, clinical trials have not provided consistent evidence that treatment with continuous positive airway pressure (CPAP) improves cardiovascular outcomes. These overall null findings might be explained by limitations in trial design and low levels of adherence to CPAP. Studies have also been limited by the failure to consider OSA as a heterogeneous disorder that consists of multiple subtypes resulting from variable contributions from anatomical, physiological, inflammatory and obesity-related risk factors, and resulting in different physiological disturbances. Novel markers of sleep apnoea-associated hypoxic burden and cardiac autonomic response have emerged as predictors of OSA-related susceptibility to adverse health outcomes and treatment response. In this Review, we summarize our understanding of the shared risk factors and causal links between OSA and CVD and emerging knowledge on the heterogeneity of OSA. We discuss the varied mechanistic pathways that result in CVD that also vary across subgroups of OSA, as well as the potential role of new biomarkers for CVD risk stratification.
Topics: Humans; Cardiovascular Diseases; Cardiovascular System; Hypertension; Sleep Apnea, Obstructive; Heart; Hypoxia
PubMed: 36899115
DOI: 10.1038/s41569-023-00846-6 -
Revue Neurologique Oct 2023Narcolepsy type 1 (NT1) and type 2 (NT2), also known as narcolepsy with and without cataplexy, are sleep disorders that benefited from major scientific advances over the... (Review)
Review
Narcolepsy type 1 (NT1) and type 2 (NT2), also known as narcolepsy with and without cataplexy, are sleep disorders that benefited from major scientific advances over the last two decades. NT1 is caused by the loss of hypothalamic neurons producing orexin/hypocretin, a neurotransmitter regulating sleep and wake, which can be measured in the cerebrospinal fluid (CSF). A low CSF level of hypocretin-1/orexin-A is a highly specific and sensitive biomarker, sufficient to diagnose NT1. Orexin-deficiency is responsible for the main NT1 symptoms: sleepiness, cataplexy, disrupted nocturnal sleep, sleep-related hallucinations, and sleep paralysis. In the absence of a lumbar puncture, the diagnosis is based on neurophysiological tests (nocturnal and diurnal) and the presence of the pathognomonic symptom cataplexy. In the revised version of the International Classification of sleep Disorders, 3rd edition (ICSD-3-TR), a sleep onset rapid eye movement sleep (REM) period (SOREMP) (i.e. rapid occurrence of REM sleep) during the previous polysomnography may replace the diurnal multiple sleep latency test, when clear-cut cataplexy is present. A nocturnal SOREMP is very specific but not sensitive enough, and the diagnosis of cataplexy is usually based on clinical interview. It is thus of crucial importance to define typical versus atypical cataplectic attacks, and a list of clinical features and related degrees of certainty is proposed in this paper (expert opinion). The time frame of at least three months of evolution of sleepiness to diagnose NT1 was removed in the ICSD-3-TR, when clear-cut cataplexy or orexin-deficiency are established. However, it was kept for NT2 diagnosis, a less well-characterized disorder with unknown clinical course and absence of biolo biomarkers; sleep deprivation, shift working and substances intake being major differential diagnoses. Treatment of narcolepsy is nowadays only symptomatic, but the upcoming arrival of non-peptide orexin receptor-2 agonists should be a revolution in the management of these rare sleep diseases.
Topics: Humans; Cataplexy; Orexins; Sleepiness; Narcolepsy; Sleep
PubMed: 37634997
DOI: 10.1016/j.neurol.2023.08.001 -
Continuum (Minneapolis, Minn.) Aug 2023This article provides an overview of the current definitions, diagnostic tools, and overall management of insomnia.
OBJECTIVE
This article provides an overview of the current definitions, diagnostic tools, and overall management of insomnia.
LATEST DEVELOPMENTS
The treatment of insomnia has shifted over time, with a growing emphasis on nonpharmacologic therapies as a first-line intervention and the leveraging of technology to aid in the dissemination of these therapies. With this evolution, the definition of insomnia has changed to reflect a common treatment pathway. As pharmacologic treatment options have increased, so has concern about the dangerous short-term and long-term adverse effects of these treatment options.
ESSENTIAL POINTS
Insomnia is a common disorder, frequently overlapping with other neurologic and psychiatric disorders, which can cause significant distress and disruption to patients' lives. Nonpharmacologic therapies are highly effective and are now considered first-line treatments. Although efficacy is variable, numerous pharmacologic interventions are available, and many options come with considerable concern about adverse effects, particularly in populations over 65 years old.
Topics: Humans; Aged; Sleep Initiation and Maintenance Disorders; Drug-Related Side Effects and Adverse Reactions
PubMed: 37590828
DOI: 10.1212/CON.0000000000001283 -
Primary Care Jun 2024Sleep significantly impacts health. Insomnia, characterized by difficulty with sleep onset, maintenance, and subsequent daytime symptoms, is increasingly prevalent and... (Review)
Review
Sleep significantly impacts health. Insomnia, characterized by difficulty with sleep onset, maintenance, and subsequent daytime symptoms, is increasingly prevalent and increases the risk of other medical comorbidities. The pathophysiology involves hyperarousal during non-REM sleep and altered sleep homeostasis. The 3P model explains the development and persistence of insomnia. Assessment is primarily clinical and based on appropriate history while distinguishing from other sleep disorders. "Somnomics" suggests a personalized approach to management. Cognitive behavioral therapy for insomnia is the first-line treatment in addition to other nonpharmacological strategies. Medications are a secondary option with weak supporting evidence.
Topics: Humans; Sleep Initiation and Maintenance Disorders; Cognitive Behavioral Therapy; Primary Health Care; Hypnotics and Sedatives
PubMed: 38692776
DOI: 10.1016/j.pop.2024.02.002 -
Revue Neurologique Oct 2023Insomnia is more prevalent in neurological disorders compared to the general population, with rates ranging from 11 to 74.2% in neurodegenerative disorders, 20 to 37% in... (Review)
Review
Insomnia is more prevalent in neurological disorders compared to the general population, with rates ranging from 11 to 74.2% in neurodegenerative disorders, 20 to 37% in vascular diseases, 13.3 to 50% in inflammatory diseases, 28.9 to 74.4% in epilepsy, and nearly 70% in migraines. Insomnia in neurological disorders stems from a variety of factors, encompassing physical and neuropsychiatric factors, behavioral patterns, and disruptions in the biological clock and circadian rhythm. There are bidirectional connections between neurological disorders and insomnia. Insomnia in neurological disorders worsens symptoms, resulting in heightened depressive symptoms, elevated mortality rates, reduced quality of life, and intensified acute symptoms. Managing comorbid sleep disorders, especially in the presence of psychiatric comorbidities, is crucial. Cognitive behavioral therapy for insomnia (CBT-I) is the first-line recommendation for insomnia management in neurological disorders. Other treatments are second-line strategies. Melatonin may demonstrate effectiveness in addressing insomnia, with soporific and chronobiotic effects. Furthermore, it has the potential to alleviate "sundowning" and behavioral disturbances, while generally being well-tolerated. Other treatment options that may be of interest include morning bright light therapy, sedative antidepressants, new orexin dual antagonists and levodopa specifically indicated for Parkinson's disease. Benzodiazepines and z-drugs can be used primarily during acute phases to prevent pharmacotolerance and minimize side effects. However, they should be avoided in patients with neurological disorders and not used in patients over 75 years old due to the risk of falls and confusion. In neurological disorders, insomnia has a profound impact on daytime functioning, making its management crucial. Effective treatment can result in improved outcomes, and additional research is necessary to investigate alternative therapeutic options and enhance patient care.
Topics: Humans; Aged; Sleep Initiation and Maintenance Disorders; Prevalence; Quality of Life; Sleep; Hypnotics and Sedatives
PubMed: 37620177
DOI: 10.1016/j.neurol.2023.08.008 -
JAMA Dec 2023The utility of adenotonsillectomy in children who have habitual snoring without frequent obstructive breathing events (mild sleep-disordered breathing [SDB]) is unknown. (Comparative Study)
Comparative Study Randomized Controlled Trial
IMPORTANCE
The utility of adenotonsillectomy in children who have habitual snoring without frequent obstructive breathing events (mild sleep-disordered breathing [SDB]) is unknown.
OBJECTIVES
To evaluate early adenotonsillectomy compared with watchful waiting and supportive care (watchful waiting) on neurodevelopmental, behavioral, health, and polysomnographic outcomes in children with mild SDB.
DESIGN, SETTING, AND PARTICIPANTS
Randomized clinical trial enrolling 459 children aged 3 to 12.9 years with snoring and an obstructive apnea-hypopnea index (AHI) less than 3 enrolled at 7 US academic sleep centers from June 29, 2016, to February 1, 2021, and followed up for 12 months.
INTERVENTION
Participants were randomized 1:1 to either early adenotonsillectomy (n = 231) or watchful waiting (n = 228).
MAIN OUTCOMES AND MEASURES
The 2 primary outcomes were changes from baseline to 12 months for caregiver-reported Behavior Rating Inventory of Executive Function (BRIEF) Global Executive Composite (GEC) T score, a measure of executive function; and a computerized test of attention, the Go/No-go (GNG) test d-prime signal detection score, reflecting the probability of response to target vs nontarget stimuli. Twenty-two secondary outcomes included 12-month changes in neurodevelopmental, behavioral, quality of life, sleep, and health outcomes.
RESULTS
Of the 458 participants in the analyzed sample (231 adenotonsillectomy and 237 watchful waiting; mean age, 6.1 years; 230 female [50%]; 123 Black/African American [26.9%]; 75 Hispanic [16.3%]; median AHI, 0.5 [IQR, 0.2-1.1]), 394 children (86%) completed 12-month follow-up visits. There were no statistically significant differences in change from baseline between the 2 groups in executive function (BRIEF GEC T-scores: -3.1 for adenotonsillectomy vs -1.9 for watchful waiting; difference, -0.96 [95% CI, -2.66 to 0.74]) or attention (GNG d-prime scores: 0.2 for adenotonsillectomy vs 0.1 for watchful waiting; difference, 0.05 [95% CI, -0.18 to 0.27]) at 12 months. Behavioral problems, sleepiness, symptoms, and quality of life each improved more with adenotonsillectomy than with watchful waiting. Adenotonsillectomy was associated with a greater 12-month decline in systolic and diastolic blood pressure percentile levels (difference in changes, -9.02 [97% CI, -15.49 to -2.54] and -6.52 [97% CI, -11.59 to -1.45], respectively) and less progression of the AHI to greater than 3 events/h (1.3% of children in the adenotonsillectomy group compared with 13.2% in the watchful waiting group; difference, -11.2% [97% CI, -17.5% to -4.9%]). Six children (2.7%) experienced a serious adverse event associated with adenotonsillectomy.
CONCLUSIONS
In children with mild SDB, adenotonsillectomy, compared with watchful waiting, did not significantly improve executive function or attention at 12 months. However, children with adenotonsillectomy had improved secondary outcomes, including behavior, symptoms, and quality of life and decreased blood pressure, at 12-month follow-up.
TRIAL REGISTRATION
ClinicalTrials.gov Identifier: NCT02562040.
Topics: Child; Female; Humans; Polysomnography; Quality of Life; Sleep Apnea Syndromes; Sleep Apnea, Obstructive; Snoring; Tonsillectomy; Male; Adenoidectomy; Watchful Waiting; Child, Preschool; Treatment Outcome; Follow-Up Studies
PubMed: 38051326
DOI: 10.1001/jama.2023.22114 -
Medicina (Kaunas, Lithuania) Aug 2023Obstructive sleep apnea syndrome (OSAS) is the most common breathing-related sleep disorder. It is characterized by recurrent episodes of partial or complete airway... (Review)
Review
Obstructive sleep apnea syndrome (OSAS) is the most common breathing-related sleep disorder. It is characterized by recurrent episodes of partial or complete airway obstruction during sleep, resulting in a reduction in or the total cessation of airflow, despite ongoing respiratory efforts, leading to oxygen desaturation and arousal. The purpose of this literature review is to evaluate the most common characteristics of this pathology, as well as to investigate the most effective treatment options, providing an update on the management of OSA patients.
Topics: Humans; Sleep; Sleep Apnea, Obstructive
PubMed: 37629749
DOI: 10.3390/medicina59081459 -
American Journal of Respiratory and... Oct 2023Obstructive sleep apnea is characterized by frequent reductions in ventilation, leading to oxygen desaturations and/or arousals. In this study, association of hypoxic...
Obstructive sleep apnea is characterized by frequent reductions in ventilation, leading to oxygen desaturations and/or arousals. In this study, association of hypoxic burden with incident cardiovascular disease (CVD) was examined and compared with that of "ventilatory burden" and "arousal burden." Finally, we assessed the extent to which the ventilatory burden, visceral obesity, and lung function explain variations in hypoxic burden. Hypoxic, ventilatory, and arousal burdens were measured from baseline polysomnograms in the Multi-Ethnic Study of Atherosclerosis (MESA) and the Osteoporotic Fractures in Men (MrOS) studies. Ventilatory burden was defined as event-specific area under ventilation signal (mean normalized, area under the mean), and arousal burden was defined as the normalized cumulative duration of all arousals. The adjusted hazard ratios for incident CVD and mortality were calculated. Exploratory analyses quantified contributions to hypoxic burden of ventilatory burden, baseline oxygen saturation as measured by pulse oximetry, visceral obesity, and spirometry parameters. Hypoxic and ventilatory burdens were significantly associated with incident CVD (adjusted hazard ratio [95% confidence interval] per 1 SD increase in hypoxic burden: MESA, 1.45 [1.14, 1.84]; MrOS, 1.13 [1.02, 1.26]; ventilatory burden: MESA, 1.38 [1.11, 1.72]; MrOS, 1.12 [1.01, 1.25]), whereas arousal burden was not. Similar associations with mortality were also observed. Finally, 78% of variation in hypoxic burden was explained by ventilatory burden, whereas other factors explained only <2% of variation. Hypoxic and ventilatory burden predicted CVD morbidity and mortality in two population-based studies. Hypoxic burden is minimally affected by measures of adiposity and captures the risk attributable to ventilatory burden of obstructive sleep apnea rather than a tendency to desaturate.
Topics: Male; Humans; Obesity, Abdominal; Sleep Apnea Syndromes; Sleep Apnea, Obstructive; Polysomnography; Cardiovascular Diseases; Hypoxia; Atherosclerosis; Sleep
PubMed: 37418748
DOI: 10.1164/rccm.202209-1808OC -
Australian Journal of General Practice Sep 2023Restless legs syndrome (RLS) is a common sensorimotor disorder causing significant distress and is commonly seen in the primary care setting.
BACKGROUND
Restless legs syndrome (RLS) is a common sensorimotor disorder causing significant distress and is commonly seen in the primary care setting.
OBJECTIVE
This article outlines the epidemiology, pathophysiology, diagnosis and management of RLS, with a focus on the primary care setting.
DISCUSSION
RLS is a clinical diagnosis, although mimics exist. Brain iron deficiency, dopaminergic dysfunction and genetics underpin the poorly understood pathophysiology of this common condition. After repleting iron stores, reviewing any exacerbating medications and attending to non-pharmacological management options, there are pharmacological options that prove to be effective, although with class-specific effects that need to be considered.
Topics: Humans; Restless Legs Syndrome; Dopamine; Iron Deficiencies
PubMed: 37666782
DOI: 10.31128/AJGP-02-23-6722