Richard Staats

Diabetes Mellitus Prevalence and Control in Sleep-Disordered Breathing: The European Sleep Apnea Cohort (ESADA) Study

BACKGROUND OSA is associated with an increased risk of cardiovascular morbidity. A driver of this is metabolic dysfunction and in particular type 2 diabetes mellitus (T2DM). Prior studies identifying a link between OSA and T2DM have excluded subjects with undiagnosed T2DM, and there is a lack of population-level data on the interaction between OSA and glycemic control among patients with diabetes. We assessed the relationship between OSA severity and T2DM prevalence and control in a large multinational population. METHODS We performed a cross-sectional analysis of 6,616 participants in the European Sleep Apnea Cohort (ESADA) study, using multivariate regression analysis to assess T2DM prevalence according to OSA severity, as measured by the oxyhemoglobin desaturation index. Patients with diabetes were identified by previous history and medication prescription, and by screening for undiagnosed diabetes with glycosylated hemoglobin (HbA1c) measurement. The relationship of OSA severity with glycemic control was assessed in diabetic subjects. RESULTS T2DM prevalence increased with OSA severity, from 6.6% in subjects without OSA to 28.9% in those with severe OSA. Despite adjustment for obesity and other confounding factors, in comparison with subjects free of OSA, patients with mild, moderate, or severe disease had an OR (95% CI) of 1.33 (1.04-1.72), 1.73 (1.33-2.25), and 1.87 (1.45-2.42) (P < .001), respectively, for prevalent T2DM. Diabetic subjects with more severe OSA had worse glycemic control, with adjusted mean HbA1c levels 0.72% higher in patients with severe OSA than in those without sleep-disordered breathing (analysis of covariance, P < .001). CONCLUSIONS Increasing OSA severity is associated with increased likelihood of concomitant T2DM and worse diabetic control in patients with T2DM.

sleep-related Obstructive Disordered Breathing in Cleft Palate Patients after Palatoplasty

&NA; Sleep‐disordered breathing is frequently associated with children presenting congenital midface defects. Because of structural and functional anomalies in the upper airway, children with cleft palate, especially after surgery, may carry a higher risk of developing sleep‐disordered breathing. However, the presence of such sleep‐disordered breathing in older cleft palate children has not been emphasized. The aim of this comparative overnight cardiorespiratory sleep study was to evaluate cleft palate patients according to sleep‐disordered breathing. A group of 43 cleft palate children (17 girls and 26 boys; mean age, 12.1 ± 3.8 years) was compared with a control group of 20 randomly selected, noncleft children matched for age, sex, and body mass index. None of the patients suffered from manifest sleep‐disordered breathing. Cleft palate patients had a statistically significantly higher respiratory disturbance index and snoring index, but no increased apnea index. The data suggest that cleft palate patients having undergone primary closure of the palate demonstrate microsymptoms of nocturnal upper airway obstruction. (Plast. Reconstr. Surg. 110: 392, 2002.)

Occlusal Side Effects Caused by a Mandibular Advancement Appliance in Patients with Obstructive Sleep Apnea

Mandibular advancement appliances (MAA) have been established as an alternative treatment option for obstructive sleep apnea (OSA). Although the therapeutic effect of these devices has been proven both clinically and polysomnographically through various studies, there are very few follow-up examinations in existence concerning possible dental side effects caused by the MAA. However, if lifelong treatment of OSA is considered, these follow-up examinations are of utmost importance. This article presents 2 cases with unexpected dental side effects and occlusal alterations caused by MAA therapy.

Cephalometric analysis in patients with obstructive sleep apnea. Part II: Prognostic value in treatment with a mandibular advancement device.

AbstractBackground: The mandibular advancement device (MAD) is accepted as an additional treatment option for snoring and mild obstructive sleep disorders. Its therapeutic efficacy can only be verified through nocturnal polysomnography with the appliance in situ. The relevance of the craniofacial skeletal and soft-tissue structures as an etiological cofactor is controversial. While the lateral cephalogram of the facial skeleton is of no direct diagnostic relevance, it remains unclear to what extent cephalometric assessment can provide prognostic information to better ensure treatment success with an MAD. Methods and Results: This study is based on the evaluation of 57 patients diagnosed polysomnographically with obstructive sleep apnea (OSA). The patients were treated primarily with a modified activator; after 6–12 weeks, control polysomnography was carried out in the sleep laboratory. The cephalometric variables were analyzed using a multivariate regression procedure with the response variable of treatment outcome.In addition to a horizontal craniofacial morphology, the downward and forward posture of the hyoid is a prognostic variable for effective therapy with an MAD.ZusammenfassungHintergrund: Intraorale Protrusionsgeräte (IPG) gelten als eine Therapiemodalität bei Schnarchen und leichten obstruktiven Schlafstörungen. Der therapeutische Effekt dieser Therapieform kann zurzeit ausschließlich in einer nächtlichen Polysomnogrphie mit dem Gerät in situ beurteilt werden. Die Bedeutung der skelettalen und weichteiligen Strukturen des Gesichtsschädels als ätiologischer Kofaktor von nächtlichen obstruktiven Atemregulationsstörungen ist umstritten. Während die Fernröntgenseitenaufnahme des Gesichtsschädels der Forderung nach einer unmittelbaren diagnostischen Relevanz nicht gerecht wird, ist es gegenwärtig ungeklärt, inwiefern mit der Kephalometrie eine prognostische Aussage zum Therapieeffekt bei der Behandlung mit einem IPG getroffen werden kann. Methoden und Ergebnisse: Die Studie basiert auf der Untersuchung von 57 Patienten mit der polysomnographisch gestellten Diagnose einer obstruktiven Schlafapnoe (OSA). Die Patienten wurden mit einem modifizierten Aktivator primär therapiert. Nach 6–12 Wochen wurde eine Kontrollpolysomnographie im Schlaflabor durchgeführt. Die kephalometrischen Parameter wurden in einer multivarianten Regressionsanalyse zur Kriteriumsvariablen des erzielten therapeutischen Erfolges untersucht.Neben einem horizontalen Gesichtsschädelaufbau ist eine kaudoventraele Position des Hyoids ein prognostisch positiver Parameter für eine erfolgreiche Therapie mit einem IPG.

Cephalometric Analysis in Patients with Obstructive Sleep Apnea¶Part I: Diagnostic Value

AbstractBackground: Morphological soft-tissue and skeletal anomalies of the upper extrathoracic airways are considered to be an etiological cofactor of nocturnal obstructive respiratory disorders. Patients and Method: In this study 106 patients with a mean age of 56.1±8.4 years and a polysomnographic diagnosis of obstructive sleep apnea (OSA) were evaluated roentgenocephalometrically for soft-tissue and skeletal anomalies. Using cluster analysis and multivariate regression analysis, 18 skeletal variables, six pharyngeal variables and five hyoid variables were evaluated as predictor variables under the criterion variable “severity of the disorder”. The body mass index (BMI), as a recognized risk factor of OSA, was taken separately into account. Results: No direct correlation was found between the skeletal cephalometric findings and severity of OSA. Only the position of the hyoid as an expression of a probably adaptive alteration to a changed head posture and tongue position was found to be a significant parameter correlating with the severity of OSA. Conclusion: Whether cephalometric radiography is of direct diagnostic relevance in the diagnosis of OSA seems questionable in the light of the results of the present study.ZusammenfassungHintergrund: Morphologische Weichteil- und Skelettauffälligkeiten der oberen extrathorakalen Luftwege werden als ein Kofaktor in der Ätiologie von nächtlichen obstruktiven Atemstörungen angesehen. Patienten und Methode: In dieser Studie wurden 106 Patienten im durchschnittlichen Alter von 56,1±8,4 Jahren mit der polysomnographisch gestellten Diagnose einer obstruktiven Schlafapnoe (OSA) röntgenkephalometrisch auf das Vorliegen von Weichteil- und Skelettanomalien untersucht. In einer Cluster-Analsyse und einer multivariaten Regressionsanalyse wurden unter der Kriteriumsvariable des Schweregrades der Erkrankung 18 skelettale Variable, sechs Variable aus der Analyse des Pharynx und fünf Variable aus der Analyse des Hyoids als Prädikatorvariable ausgewertet. Der Bodymass-Index (BMI) als ein anerkannter auslösender Faktor der OSA wurde gesondert berücksichtigt. Ergebnisse: Ein eindeutiger Rückschluss von skelettalen kephalometrischen Befunden auf den Ausprägungsgrad der OSA konnte nicht gefunden werden. Lediglich die Stellung des Hyoids, als Ausdruck einer wahrscheinlich adaptativen Position auf eine veränderte Kopfhaltung und Zungenlage, bildet einen signifikanten Parameter, der mit dem Schweregrad der Erkrankung in Beziehung steht. Schlussfolgerung: Eine Indikation für eine Fernröntgenseitenaufnahme des Schädels zur Diagnostik der OSA erscheint aufgrund des Ergebnisses der Untersuchung unter dem Akspekt der unmittelbaren diagnostischen Relevanz fragwürdig.

Intraorale Protrusionsgeräte bei schlafbezogenen obstruktiven AtmungsstörungenZahnärztliche Befunde und Behandlungsmöglichkeiten

ZusammenfassungHintergrund. Intraorale Protrusionsgeräte (IPG) werden als eine Therapiealternative bei primärem Schnarchen und leichten bis mittelschweren obstruktiven Schlafatemstörungen verordnet. Neben der meist polysomnographisch gestellten Indikation unter Berücksichtigung der respiratorischen und somnographischen Befunde sind gesunde stomatognathe Verhältnisse mit ausreichender dentaler Retention für die Apparaturen eine abzuklärende notwendige Voraussetzung für einen erfolgreichen Einsatz dieser Therapieform. Patienten und Methoden. 112 Patienten, die mit der Diagnose einer obstruktiven Schlafapnoe zur Therapie mit einem IPG vom Schlaflabor an die Poliklinik für Kieferorthopädie in Freiburg i. Br. überwiesen wurden, wurden unter dem Gesichtspunkt einer dauerhaften Behandlung mit einem IPG klinisch und radiologisch untersucht. Ergebnisse. Zur Maximierung des Therapieerfolgs und zur Minimierung von dentalen Nebenwirkungen bedarf die Therapieform der IPG einer engen Zusammenarbeit mit dem zahnärztlichen Kollegen. Schlussfolgerungen. Akute Infektionen, parodontale Läsionen, mangelnde dentale Abstützung und temporomandibuläre Symptome stellen in Hinblick auf den Erfolg der Therapie und etwaige dentale Nebenwirkungen limitierende Faktoren dar.AbstractBackground. Oral protrusive devices are regarded as an alternative treatment option for snoring and mild to moderate obstructive breathing disorders. In addition to the polysomnographic indication based on the respiratory and somnographic findings, healthy stomatognatic conditions with sufficient dental retention for the device are essential for a successful treatment. Patients and Methods. The sleep laboratory of the University Hospital of Freiburg i.Br. referred 112 patients with obstructive sleep apnea to the Department of Orthodontics for treatment with an oral protrusive device. All patients were examined clinically and with a panoramic radiograph with regard to continuous treatment. Results. To maximize treatment success and minimize dental side effects, close collaboration with dental colleagues is necessary in treatment with an oral protrusive device. Conclusions. Acute periodontitis, periodontal lesions, insufficient dental anchorage, and temporomandibular symptoms can result in unwanted dental side effects and therefore limit the indication of this therapeutic approach.

Fixed But Not Autoadjusting Positive Airway Pressure Attenuates the Time-dependent Decline in Glomerular Filtration Rate in Patients With OSA

Background The impact of treating OSA on renal function decline is controversial. Previous studies usually included small samples and did not consider specific effects of different CPAP modalities. The aim of this study was to evaluate the respective influence of fixed and autoadjusting CPAP modes on estimated glomerular filtration rate (eGFR) in a large sample of patients derived from the prospective European Sleep Apnea Database cohort. Methods In patients of the European Sleep Apnea Database, eGFR prior to and after follow‐up was calculated by using the Chronic Kidney Disease‐Epidemiology Collaboration equation. Three study groups were investigated: untreated patients (n = 144), patients receiving fixed CPAP (fCPAP) (n = 1,178), and patients on autoadjusting CPAP (APAP) (n = 485). Results In the whole sample, eGFR decreased over time. The rate of eGFR decline was significantly higher in the subgroup with eGFR above median (91.42 mL/min/1.73 m2) at baseline (P < .0001 for effect of baseline eGFR). This decline was attenuated or absent (P < .0001 for effect of treatment) in the subgroup of patients with OSA treated by using fCPAP. A follow‐up duration exceeding the median (541 days) was associated with eGFR decline in the untreated and APAP groups but not in the fCPAP group (P < .0001 by two‐way ANOVA for interaction between treatment and follow‐up length). In multiple regression analysis, eGFR decline was accentuated by advanced age, female sex, cardiac failure, higher baseline eGFR, and longer follow‐up duration, whereas there was a protective effect of fCPAP. Conclusions fCPAP but not APAP may prevent eGFR decline in OSA.

Obstructive sleep apnoea independently predicts lipid levels: Data from the European Sleep Apnea Database: Obstructive sleep apnoea and dyslipidaemia

Obstructive sleep apnoea (OSA) and dyslipidaemia are independent risk factors for cardiovascular disease. This study investigates the association between OSA and plasma lipid concentrations in patients enrolled in the European Sleep Apnea Database (ESADA) cohort.

Decrease of perforin positive CD3+γδ-T cells in patients with obstructive sleep disordered breathing

IntroductionSleep related breathing disorders (SRBD) cause sleep fragmentation, intermittent hypoxia or a combination of both leading to homeostasis perturbations, including in the immune system. We investigated whether SRBD patients with or without intermittent hypoxia show substantial differences in perforin and granzyme-B positive peripheral blood lymphocytes.MethodsA total of 87 subjects were included and distributed as follows: 24 controls (C), 19 patients with respiratory effort related arousals due to increased upper airway resistance (UAR) without hypoxic events, 24 obese patients with obstructive sleep apnea (OSA) (oOSA), and 20 without obesity (noOSA). After polysomnographic recording, we analyzed in fasting blood samples routine hematologic and biochemical parameters and the percentage of lymphocytes containing the proteins perforin and granzyme-B (GrB). Kruskal-Wallis tests and a posteriori multiple comparisons were applied for statistical analysis of results.ResultsPerforin-positive γδ-cells revealed significant differences between groups (p = 0.017), especially between the Control group and the oOSA (p-value = 0.04); the remaining SRBD groups also showed differences from the control (C vs UAR: p = 0.08; C vs noOSA = 0.09), but they did not raise to statistical significance. There were no differences among the SRBD groups. Granzyme-B cells were decreased in SRBD patients, but the differences were not statistically significant. No additional statistical significant result was found in the other investigated lymphocyte subsets.ConclusionsObstructive sleep-disordered breathing is associated with a decrease in perforin-positive CD3+γδ-T cells. Although this finding was detected in lean patients without intermittent hypoxia, the reduction was only statistically significant in obese patients with severe OSA. Because CD3+γδ-T cells play an important role in the control of tumor cells, our findings are directly relevant for the study of the association of OSA and cancer.

Detection and Classification of Sleep-Disordered Breathing Using Acoustic Respiratory Input Impedance and Nasal Pressure

We are developing an algorithm for off-line detection and classification of sleep-disordered breathing based on time series analysis of nasal mask pressure and acoustic respiratory input impedance measured by forced oscillation technique at a frequency of 20 Hz throughout the night. A first version of the algorithm was applied to a data set consisting of full-night measurements on 5 subjects. The data set had a total duration of 34 hours and contained 577 respiratory events (hypopneas, obstructive and central apneas) recognized by the staff physicians of an accredited sleep laboratory. The algorithm detected 455 (79 %) of these events and 138 events that had not been marked by the physicians. 75 % of the congruently detected events were also concordantly classified. After further optimization and evaluation, this approach might be useful when implemented into a device designed to screening or treatment control of sleep-related breathing disorders at home.