Shane Landry

Therapeutic CPAP Level Predicts Upper Airway Collapsibility in Patients With Obstructive Sleep Apnea

Study Objectives Upper airway collapsibility is a key determinant of obstructive sleep apnea (OSA) which can influence the efficacy of certain non-continuous positive airway pressure (CPAP) treatments for OSA. However, there is no simple way to measure this variable clinically. The present study aimed to develop a clinically implementable tool to evaluate the collapsibility of a patients upper airway. Methods Collapsibility, as characterized by the passive pharyngeal critical closing pressure (Pcrit), was measured in 46 patients with OSA. Associations were investigated between Pcrit and data extracted from patient history and routine polysomnography, including CPAP titration. Results Therapeutic CPAP level, demonstrated the strongest relationship to Pcrit (r2=0.51, p < .001) of all the variables investigated including apnea-hypopnea index, body mass index, sex, and age. Patients with a mildly collapsible upper airway (Pcrit ≤ -2 cmH2O) had a lower therapeutic CPAP level (6.2 ± 0.6 vs. 10.3 ± 0.4 cmH2O, p < .001) compared to patients with more severe collapsibility (Pcrit > -2 cmH2O). A therapeutic CPAP level ≤8.0 cmH2O was sensitive (89%) and specific (84%) for detecting a mildly collapsible upper airway. When applied to the independent validation data set (n = 74), this threshold maintained high specificity (91%) but reduced sensitivity (75%). Conclusions Our data demonstrate that a patients therapeutic CPAP requirement shares a strong predictive relationship with their Pcrit and may be used to accurately differentiate OSA patients with mild airway collapsibility from those with moderate-to-severe collapsibility. Although this relationship needs to be confirmed prospectively, our findings may provide clinicians with better understanding of an individual patients OSA phenotype, which ultimately could assist in determining which patients are most likely to respond to non-CPAP therapies.

Oronasal masks require a higher pressure than nasal and nasal pillow masks for the treatment of obstructive sleep apnea

STUDY OBJECTIVES Oronasal masks are frequently used for continuous positive airway pressure (CPAP) treatment in patients with obstructive sleep apnea (OSA). The aim of this study was to (1) determine if CPAP requirements are higher for oronasal masks compared to nasal mask interfaces and (2) assess whether polysomnography and patient characteristics differed among mask preference groups. METHODS Retrospective analysis of all CPAP implementation polysomnograms between July 2013 and June 2014. Prescribed CPAP level, polysomnography results and patient data were compared according to mask type (n = 358). RESULTS Oronasal masks were used in 46%, nasal masks in 35% and nasal pillow masks in 19%. There was no difference according to mask type for baseline apnea-hypopnea index (AHI), body mass index (BMI), waist or neck circumference. CPAP level was higher for oronasal masks, 12 (10-15.5) cm H2O compared to nasal pillow masks, 11 (8-12.5) cm H2O and nasal masks, 10 (8-12) cm H2O, p < 0.0001 (Median [interquartile range]). Oronasal mask type, AHI, age, and BMI were independent predictors of a higher CPAP pressure (p < 0.0005, adjusted R(2) = 0.26.). For patients with CPAP ≥ 15 cm H2O, there was an odds ratio of 4.5 (95% CI 2.5-8.0) for having an oronasal compared to a nasal or nasal pillow mask. Residual median AHI was higher for oronasal masks (11.3 events/h) than for nasal masks (6.4 events/h) and nasal pillows (6.7 events/h), p < 0.001. CONCLUSIONS Compared to nasal mask types, oronasal masks are associated with higher CPAP pressures (particularly pressures ≥ 15 cm H2O) and a higher residual AHI. Further evaluation with a randomized control trial is required to definitively establish the effect of mask type on pressure requirements. COMMENTARY A commentary on this article appears in this issue on page 1209.

The impact of obstructive sleep apnea on motor skill acquisition and consolidation

STUDY OBJECTIVE Recent investigations suggest that motor skill learning is impaired in patients with obstructive sleep apnea (OSA) syndrome; however, it is not fully understood at what stages of learning this impairment occurs. The current study aimed to compare motor learning and memory across both daytime acquisition and overnight consolidation. METHODS Twelve OSA patients and twelve control participants, matched for age and education, were recruited and completed the Karolinska Sleepiness Scale and the sequential finger-tapping task (SFTT), a motor skill learning task, both before and after polysomnographic recorded sleep. RESULTS During the evening acquisition phase both groups showed significant and equitable improvement in the number of correctly typed sequences across trials. On retesting the following morning, the control patients showed significantly greater improvement overnight (15.35%) compared to OSA patients (1.78%). The post sleep improvement in controls, but lacking in OSA patients, was typical of a sleep dependent enhancement effect. The magnitude of improvement overnight for either group was not significantly correlated with any of the recorded sleep variables. CONCLUSIONS These results suggest daytime/practice related acquisition of motor skill is largely intact in OSA patients; however, marked impairment in the consolidation phase is evident following a sleep period. This particular pattern of dysfunction may remain unnoticed following single-day learning/memory assessments.

The effects of sleep, wake activity and time-on-task on offline motor sequence learning

While intervening sleep promotes the consolidation of memory, it is well established that cognitive interference from competing stimuli can impede memory retention. The current study examined changes in motor skill learning across periods of wakefulness with and without competing stimuli, and periods of sleep with and without disruption from external stimuli. A napping study design was adopted where participants (N=44) either had (1) a 30min nap composed of Non-Rapid Eye Movement (NREM) sleep, (2) 30min NREM nap fragmented by audio tone induced arousals, (3) 45min of quiet wakefulness, or (4) 45min of active wakefulness. Measures of subjective sleepiness (KSS), alertness (PVT) and motor skill learning (Sequential Finger Tapping Task, SFTT) were completed in the morning and evening to assess performance pre- and post-nap or wakefulness. Following a practice session, change in motor skill performance was measured over a 10min post training rest interval, as well as following a 7h morning to evening interval comprising one of the four study conditions. A significant offline enhancement in motor task performance (13-23%) was observed following 10min of rest in all conditions. Following the long delay with the intervening nap/wake condition, there were no further offline gains or losses in performance in any sleep (uninterrupted/fragmented) or wake (quiet/active) condition. The current findings suggest that after controlling for offline gains in performance that occur after a brief rest and likely to due to the dissipation of fatigue, the subsequent effect of an intervening sleep or wake period on motor skill consolidation is not significant. Consistent with this null result, the impact of disrupting the sleep episode or manipulating activity during intervening wake also appears to be negligible.

Loop Gain Predicts the Response to Upper Airway Surgery in Patients With Obstructive Sleep Apnea

Study Objectives Upper airway surgery is often recommended to treat patients with obstructive sleep apnea (OSA) who cannot tolerate continuous positive airways pressure. However, the response to surgery is variable, potentially because it does not improve the nonanatomical factors (ie, loop gain [LG] and arousal threshold) causing OSA. Measuring these traits clinically might predict responses to surgery. Our primary objective was to test the value of LG and arousal threshold to predict surgical success defined as 50% reduction in apnea-hypopnea index (AHI) and AHI <10 events/hour post surgery. Methods We retrospectively analyzed data from patients who underwent upper airway surgery for OSA (n = 46). Clinical estimates of LG and arousal threshold were calculated from routine polysomnographic recordings presurgery and postsurgery (median of 124 [91-170] days follow-up). Results Surgery reduced both the AHI (39.1 ± 4.2 vs. 26.5 ± 3.6 events/hour; p < .005) and estimated arousal threshold (-14.8 [-22.9 to -10.2] vs. -9.4 [-14.5 to -6.0] cmH2O) but did not alter LG (0.45 ± 0.08 vs. 0.45 ± 0.12; p = .278). Responders to surgery had a lower baseline LG (0.38 ± 0.02 vs. 0.48 ± 0.01, p < .05) and were younger (31.0 [27.3-42.5] vs. 43.0 [33.0-55.3] years, p < .05) than nonresponders. Lower LG remained a significant predictor of surgical success after controlling for covariates (logistic regression p = .018; receiver operating characteristic area under curve = 0.80). Conclusions Our study provides proof-of-principle that upper airway surgery most effectively resolves OSA in patients with lower LG. Predicting the failure of surgical treatment, consequent to less stable ventilatory control (elevated LG), can be achieved in the clinic and may facilitate avoidance of surgical failures.

Personalized Medicine for Obstructive Sleep Apnea Therapies: Are We There Yet?

Currently there is no method to predict which treatments for obstructive sleep apnea will have the best outcomes in individual patients. Given that there is increasing interest in a personalized medicine approach to the treatment of a variety of disorders, this review describes the personalized approaches that are currently available for the treatment of obstructive sleep apnea as well as future directions for individualized obstructive sleep apnea treatment.

Response to a combination of oxygen and a hypnotic as treatment for obstructive sleep apnoea is predicted by a patient's therapeutic CPAP requirement

Upper airway collapsibility predicts the response to several non‐continuous positive airway pressure (CPAP) interventions for obstructive sleep apnoea (OSA). Measures of upper airway collapsibility cannot be easily performed in a clinical context; however, a patients therapeutic CPAP requirement may serve as a surrogate measure of collapsibility. The present work aimed to compare the predictive use of CPAP level with detailed physiological measures of collapsibility.

Improvement in obstructive sleep apnea with weight loss is dependent on body position during sleep

Study Objectives Weight loss fails to resolve obstructive sleep apnea (OSA) in most patients; however, it is unknown as to whether weight loss differentially affects OSA in the supine compared with nonsupine sleeping positions. We aimed to determine if weight loss in obese patients with OSA results in a greater reduction in the nonsupine apnea/hypopnea index (AHI) compared with the supine AHI, thus converting participants into supine-predominant OSA. Methods Post hoc analysis of data from a randomized controlled trial assessing the effect of weight loss (bariatric surgery vs. medical weight loss) on OSA in 60 participants with obesity (body mass index: >35 and <55) with recently diagnosed (<6 months) OSA and AHI of ≥ 20 events/hour. Patients were randomized to very low calorie diet with regular review (n = 30) or to laproscopic adjustable gastric banding (n = 30) with follow-up sleep study at 2 years. Results Eight of 37 (22%) patients demonstrated a normal nonsupine AHI (<5 events/hour) on follow-up compared to 0/37 (0%) patients at baseline (p = .003). These patients were younger (40.0 ± 9.6 years vs. 48.4 ± 6.5 years, p = .007) and lost significantly more weight (percentage weight change -23.0 [-21.0 to -31.6]% vs. -6.9 [1.9 to -17.4], p = .001). The percentage change in nonsupine AHI was greater than the percentage change in supine AHI (-54.0 [-15.4 to -87.9]% vs -33.1 [-1.8 to -69.1]%, p = .05). However, the change in absolute nonsupine AHI was not related to change in absolute supine AHI (p = .23). Conclusions Following weight loss, a significant proportion (22%) of patients with obesity have normalization of the nonsupine AHI. For these patients, supine sleep avoidance may cure their OSA.

Dynamic loop gain increases upon adopting the supine body position during sleep in patients with obstructive sleep apnoea

Obstructive sleep apnoea (OSA) is typically worse in the supine versus lateral sleeping position. One potential factor driving this observation is a decrease in lung volume in the supine position which is expected by theory to increase a key OSA pathogenic factor: dynamic ventilatory control instability (i.e. loop gain). We aimed to quantify dynamic loop gain in OSA patients in the lateral and supine positions, and to explore the relationship between change in dynamic loop gain and change in lung volume with position.

Overnight motor skill learning outcomes in obstructive sleep apnea: Effect of continuous positive airway pressure

STUDY OBJECTIVE To determine the effectiveness of continuous positive airway pressure (CPAP) therapy in alleviating known impairments in the overnight consolidation of motor skill learning in patients with obstructive sleep apnea (OSA). METHODS Twenty-five patients with untreated moderate-severe OSA, 13 first-night CPAP users, 17 compliant CPAP users, and 14 healthy control patients were trained on a motor sequence learning task (Sequential Finger Tapping Task, SFTT) and were subsequently tested prior to and after polysomnographic recorded sleep. Measures of subjective sleepiness (Karolinska Sleepiness Scale) and sustained attention (Psychomotor Vigilance Task) were also completed before and after sleep. RESULTS Typical analyses of overnight improvement on the SFTT show significantly greater overnight gains in motor task speed in controls (+11.6 ± 4.7%, p = 0.007) and compliant CPAP users (+8.9 ± 4.3%, p = 0.008) compared to patients with OSA (-4.86 ± 4.5%). Additional analyses suggest that these improvements in motor performance occurred prior to the sleep episode, as all groups significantly improved (15% to 22%) over a 10-min presleep rest period. Thereafter, performance in all groups significantly deteriorated over sleep (6% to 16%) with trends toward patients with OSA showing greater losses in performance compared to control patients and compliant CPAP users. No between-group differences in subjective sleepiness and sustained attention were found presleep and postsleep. CONCLUSIONS The current data suggest impairments in overnight motor learning in patients with OSA may be a combination of deficient stabilization of memory over a sleep episode as well as increased vulnerability to time on task fatigue effects. Compliant CPAP usage possibly offsets both of these impediments to learning outcomes by improving both sleep quality and subsequent daytime function.