Snoring Could Be Hurting Your Relationship

February 23, 2015 4:00 AM

(credit: American Academy of Dental Sleep Medicine)

FORT WORTH (CBSDFW.COM) - If you’re having trouble in the bedroom, you might not need to look any further than your nose for the solution. A recent survey from the American Academy of Dental Sleep Medicine found that more than a quarter of Americans are annoyed — even angered — by a snoring bed partner.

The study looked at more than 1,000 randomly selected adults.

One out of five people surveyed added that the noise drives them out of bed. But the problems do not end there. Nearly one out 10 people admitted that snoring has hurt at least one past romantic relationship. And, guys, some 40 percent of women cited snoring as a turn off.

“It can be embarrassing,” stated AADSM president Kathleen Bennett in a news release on the study’s findings. “Snoring can often be the elephant in the room when it comes to addressing relationship frustrations and health concerns.”

People in the Generation X age range (35-44) reported the highest number of snoring struggles, with 43 percent saying that their partner’s snoring forces them to lose sleep, and 24 percent adding that they do — or would like to — sleep in a different room.

But many snorers are not even aware that they are making the noise. “It’s important that your significant other is made aware of their snoring,” Bennett added, “and the effects it has on you, your relationship and their personal health — so they can begin taking steps to remedy it.”

Frequent snoring could be a sign of sleep apnea, which causes sufferers to stop breathing during their sleep, sometimes for more than a minute. This can increase the risk of other serious health problems — from heart disease to depression, just to name a few.

Click here to find a dentist that can help you — or your loved one — with regular snoring or possible sleep apnea.

The Annoying Thing You're Doing In Bed That Might Be A Total Turn-Off

The Huffington Post  |  By Sarah Klein

Posted: 02/14/2015 8:46 am EST Updated: 02/15/2015 9:59 pm EST

If there's one thing we think it's safe to say is almost always a bummer in the bedroom, it's snoring.

According to a new survey from the American Academy of Dental Sleep Medicine (AADSM), 39 percent of American adults agree: When the opposite sex snores, it's a turn-off.

Luckily for the snorers among us, it's not a total deal-breaker -- 83 percent of the 1,009 people surveyed by telephone said they had had a snoring bed partner, but only 26 percent said all that log sawing made them angry or annoyed and just 9 percent said snoring has had a negative impact on a romantic relationship.

"Because it can be embarrassing, snoring can often be the elephant in the room when it comes to addressing relationship frustrations and health concerns," Kathleen Bennett, DDS, president of the AADSM, said in a statement. "But it's important that your significant other is made aware of their snoring -- and the effects it has on you, your relationship and their personal health -- so they can begin taking steps to remedy it."

Long thought to be simply an annoyance to a bed partner and not much more, snoring is now understood to carry some pretty substantial health risks. "When you are snoring, you're spending too much energy to breathe," Dr. M. Safwan Badr, past president of the American Academy of Sleep Medicine, previously told HuffPost. "Snoring is like fever for a general internist -- it tells you somethig is going on, but it doesn't tell you what."

Snoring could be a sign of sleep apnea or other sleep-disordered breathing, which has been linked to increased risk of hearing loss, osteoporosis, depression and more. Understandably, 43 percent of the AADSM survey respondents said they worried about the health of their snoring bed partners.

Sleep apnea is typically treated with continuous positive airway pressure, or CPAP, which is delivered by a bedside machine that can be, let's just say, a little cumbersome. The AADSM advocates for another option called oral appliance therapy, or OAT, a mouthguard-like device that, while not exactly sexy, may at least be a little sexier.

For snorers who don't have sleep apnea, experts recommend sleeping on your side, avoiding alcohol too close to bedtime and shedding excess weight. Your bed partner will thank you for the Valentine's Day gift of a quieter night's rest.

http://www.huffingtonpost.com/2015/02/14/snoring-turn-off_n_6679120.html#slide=start

How Much Sleep Is "Enough"?

By Dr. Mercola

If you’re like most people, you’re probably not sleeping enough, and the consequences go far beyond just feeling tired and sluggish the next day.

According to a 2013 Gallup poll,1 40 percent of American adults get six hours or less per night. Even children are becoming sleep deprived. According to the 2014 Sleep in America Poll,2 58 percent of teens average only seven hours of sleep or less.

Even the Centers for Disease Control and Prevention (CDC) has stated thatlack of sleep is a public health epidemic, noting that insufficient sleep has been linked to a wide variety of health problems.

For example, getting less than five hours of sleep per night may your double risk of heart disease, heart attack, and/or stroke. Research has also found a persistent link between lack of sleep and weight gain, insulin resistance, and diabetes.3,4

But while the risks of insufficient sleep are well-documented, there have been lingering questions about how much sleep is “enough,” and recommendations have shifted upward and downward over the years. On February 2, the National Sleep Foundation released updated guidelines5,6,7 to help clarify this question.

Updated Sleep Guidelines

Led by Harvard professor Charles Czeisler, the panel of experts reviewed more than 300 studies published between 2004 and 2014 to ascertain how many hours of sleep most people need in order to maintain their health. The recommendations they came up with are as follows:

Age Group	Recommended # of hours of sleep needed
Newborns (0-3 months)	14-17 hours
Infants (4-11 months)	12-15 hours
Toddlers (1-2 years)	11-14 hours
Preschoolers (3-5)	10-13 hours
School-age children (6-13)	9-11 hours
Teenagers (14-17)	8-10 hours
Young adults (18-25)	7-9 hours
Adults (26-64)	7-9 hours
Seniors (65 and older)	7-8 hours

As you can see, the general consensus is that from the time you enter your teenage years, you probably need right around eight hours of sleep on the average. According to the panel:

“Sleep durations outside the recommended range may be appropriate, but deviating far from the normal range is rare. Individuals who habitually sleep outside the normal range may be exhibiting signs or symptoms of serious health problems or, if done volitionally, may be compromising their health and well-being.”

Modern Technology Can Affect Your Sleep in Several Ways

Modern technology is in large part to blame for many peoples’ sleep problems, for several reasons, including the following:

1. For starters, the exposure to excessive amounts of light from light bulbs and electronic gadgets at night hinders your brain from winding down for sleep by preventing the release of melatonin. (Melatonin levels naturally rise in response to darkness, which makes you feel sleepy.)
2. Electromagnetic radiation can also have an adverse effect on your sleep even if it doesn’t involve visible light.
According to the 2014 Sleep in America Poll,8 53 percent of respondents who keep personal electronics turned off while sleeping rate their sleep as excellent, compared to just 27 percent of those who leave their devices on.
3. Maintaining a natural rhythm of exposure to daylight during the day, and darkness at night, is an essential component of sleeping well. But not only are most people exposed to too much light after dark, they’re also getting insufficient amounts of natural daylight during the day.
Daytime exposure to bright sunlight is important because it serves as the major synchronizer of something called your master clock, which in turn influences other biological clocks throughout your body.

Even Daytime Use of Technology Can Significantly Prevent Sleep, Especially Among Teens

People now get one to two hours less sleep each night, on average, compared to 60 years ago.9 A primary reason for this is the proliferation of electronics, which also allows us to work (and play) later than ever before. 

According to recent research, teens in particular may have difficulty falling asleep if they spend too much time using electronic devices—even if their use of technology is restricted to daytime hours! As reported by the Huffington Post:10

“The cumulative amount of screen time a teen gets throughout the day -- not just before bedtime -- affects how long they sleep, according to the study11...

‘One of the surprising aspects was the very clear dose-response associations,’ said the study's lead researcher Mari Hysing... ‘The longer their screen time, the shorter their sleep duration.’"

Boys spent more time using game consoles, while girls favored smartphones and MP3 music players, but regardless of the type of device, the effect on sleep was the same. The researchers found that:

• Using an electronic device within one hour of bedtime resulted in spending more than an hour tossing and turning before falling asleep
• Using electronics for four hours during the day resulted in a 49 percent increased risk of needing more than one hour to fall asleep, compared to those who used electronics for less than four hours total
• Those who used any device for more than two hours per day were 20 percent more likely to need more than an hour to fall asleep, compared to those whose usage was less than two hours
• Those who spent  more than two hours online were more than three times as likely to sleep less than five hours compared to their peers who spent less time online

Good Sleep in Middle Age May Benefit You in Your Senior Years

Another study12,13--which looked at sleep habits and mental functioning in later years—reviewed 50 years’ worth of sleep research, concluding that sleeping well in your middle-age years is an “investment” that pays dividends later. According to Michael Scullin, director of the Sleep Neuroscience and Cognition Laboratory at Baylor University in Texas: "We came across studies that showed that sleeping well in middle age predicted better mental functioning 28 years later.”

This seems like a reasonable conclusion when you consider the more immediate benefits of getting enough sleep. Accumulated over time, both hazards and benefits are likely to pay dividends or exact a toll... For example, recent research14,15,16 shows that lack of sleep can shrink your brain, which, of course, can have adverse long-term ramifications. Other research published in the journal Neurobiology of Aging17 suggests that people with chronic sleep problems may develop Alzheimer’s disease sooner than those who sleep well.

Researchers have also found18 that adding just one hour of sleep a night can boost your health rather drastically. Here, they set out to determine the health effects of sleeping 6.5 hours versus 7.5 hours a night. During the study, groups of volunteers slept either 6.5 hours or 7.5 hours a night for one week. They then swapped sleeping durations for another week, yielding quite significant results. For starters, the mental agility tasks became much more difficult for the participants when they got less sleep. Other studies have also linked sleep deprivation to decreased memory recall, difficulty processing information, and dampened decision-making skills.

Even a single night of poor sleep—meaning sleeping only four to six hours—can impact your ability to think clearly the next day. It's also known to decrease your problem solving ability. The researchers also noted that about 500 genes were impacted. When the participants cut their sleep from 7.5 to 6.5 hours, there were increases in activity in genes associated with inflammation, immune excitability, diabetes, cancer risk and stress. From the results of this study, it appears as though sleeping for an extra hour, if you’re regularly getting less than seven hours of sleep a night, may be a simple way to boost your health. It may even help protect and preserve brain function in the decades to come.

A Fitness Tracker Can Be a Helpful Tool to Get More Sleep

To optimize sleep, you need to make sure you’re going to bed early enough, because if you have to get up at 6:30am, you’re just not going to get enough sleep if you go to bed after midnight. Many fitness trackers can now track both daytime body movement and sleep, allowing you to get a better picture of how much sleep you’re actually getting. Chances are, you’re getting at least 30 minutes less shut-eye than you think, as most people do not fall asleep as soon as their head hits the pillow.

I recently detailed some of the benefits of fitness trackers in my article “The Year in Sleep.” Newer devices, like Jawbone’s UP3 that should be released sometime this year, can even tell you which activities led to your best sleep and what factors resulted in poor sleep. When I first started using a fitness tracker, I was striving to get eight hours of sleep, but my Jawbone UP typically recorded me at 7.5 to 7.75. I have since increased my sleep time, not just time in bed, but total sleep time to over eight hours per night. The fitness tracker helped me realize that unless I am asleep, not just in bed, but asleep by 10 pm, I simply won’t get my eight hours. Gradually I have been able to get myself to sleep by 9:30 pm.

How to Support Your Circadian Rhythm and Sleep Better for Optimal Health

Making small adjustments to your daily routine and sleeping area can go a long way to ensure uninterrupted, restful sleep and, thereby, better health. I suggest you read through my full set of 33 healthy sleep guidelines for all of the details, but to start, consider implementing the following key changes:

• Make sure you regularly get BRIGHT sun exposure during the day. Your pineal gland produces melatonin roughly in approximation to the contrast of bright sun exposure in the day and complete darkness at night. If you are in darkness all day long, it can't appreciate the difference and will not optimize your melatonin production. To help your circadian system to reset itself, make sure to get at least 10-15 minutes of morning sunlight. This will send a strong message to your internal clock that day has arrived, making it less likely to be confused by weaker light signals later on.
Also aim for 30-60 minutes of outdoor light exposure in the middle of the day, in order to “anchor” your master clock rhythm. The ideal time to go outdoors is right around solar noon but any time during daylight hours is useful. A gadget that can be helpful in instances when you, for some reason, cannot get outside during the day is a blue-light emitter. Philips makes one called goLITE BLU.19 It’s a small light therapy device you can keep on your desk. Use it twice a day for about 15 minutes to help you anchor your circadian rhythm if you cannot get outdoors.
• Avoid watching TV or using your computer in the evening, at least an hour or so before going to bed. Once sun has set, avoid light as much as possible, to promote natural melatonin secretion, which helps you feel sleepy. Devices such as smartphones, TVs, and computers emit blue light, which tricks your brain into thinking it's still daytime. Normally, your brain starts secreting melatonin between 9 and 10 pm, and these devices emit light that may stifle that process and keep you from falling asleep.
Even the American Medical Association now states:20 “…nighttime electric light can disrupt circadian rhythms in humans and documents the rapidly advancing understanding from basic science of how disruption of circadian rhythmicity affects aspects of physiology with direct links to human health, such as cell cycle regulation, DNA damage response, and metabolism.”
• Be mindful of electromagnetic fields (EMFs) in your bedroom. EMFs can disrupt your pineal gland and its melatonin production, and may have other negative biological effects as well. A gauss meter is required if you want to measure EMF levels in various areas of your home. At minimum, move all electrical devices at least three feet away from your bed. Ideally, turn all devices off while you’re sleeping. You may also want to consider turning off your wireless router at night. You don’t need the Internet on when you are asleep.
• Sleep in darkness. Even a small amount of light in your bedroom can disrupt your body’s internal clock and your pineal gland's melatonin production. Even the glow from your clock radio could be interfering with your sleep, so cover your radio up at night or get rid of it altogether. You may want to cover your windows with drapes or blackout shades. A less expensive alternative is to use a sleep mask.
• Install a low-wattage yellow, orange, or red light bulb if you need a source of light for navigation at night. Light in these bandwidths does not shut down melatonin production in the way that white and blue bandwidth light does. Salt lamps are handy for this purpose. You can also download a free application called f.lux21 that automatically dims your monitor or screens.
• Keep the temperature in your bedroom below 70° Fahrenheit. Many people keep their homes too warm (particularly their upstairs bedrooms). Studies show that the optimal room temperature for sleep is between 60 to 68° F.

Is the Apnea/Hypopnea Index the Best Measure of Obstructive Sleep Apnea?

December 9, 2014


Obstructive sleep apnea (OSA) continues to challenge otolaryngologists and patients alike, with estimates of the condition affecting between 2% and 4% of the adult population in the United States. Gold standard OSA diagnosis is made through a polysomnogram (PSG) test, which uses the apnea/hypopnea index (AHI) as its main defining measure.

The AHI, which quantifies the number of times each hour a patient has a total (apnea) or partial (hypopnea) blockage of breathing during sleep, has been the most-used measure, not only of how OSA is diagnosed, but also of how well treatment modalities, including continuous positive airway pressure (CPAP) and surgery, improve breathing patterns.

Recently, however, some otolaryngologists have been questioning whether the AHI should be the main—and sometimes only—determining factor of treatment effectiveness, or whether other measures such as sleepiness scales, quality of life (QOL) measurements, and physiological measurements such as blood pressure should play a more prominent role.

The Challenges of AHI

Much of the focus around this questioning has arisen not only because of AHI’s value as a measurement index, but also because of its changing definition.

“As an index, the AHI can vary a lot between sleep centers and even within the same sleep center. You’ll get a different number depending on which definition and sensors you use,” said

Ofer Jacobowitz, MD, PhD, assistant clinical professor of otolaryngology at Mount Sinai Hospital in New York City. “Hypopnea can be defined based on either a 30% or 50% decrease in inflow and associated with either a 3% or 4% oxygen desaturation.or even an arousal. The recommended definition of hypopnea has changed multiple times over the years.”

The effects of this shifting definition have been noted in research. In a 2012 study published in The Laryngoscope that examined the effects of different PSG scoring systems on outcome measurement following OSA surgery, the researchers noted that interpretation of OSA surgical treatment literature remains problematic, because the study authors continue to use different AHI criteria for investigation and different AHI thresholds for defining surgical success (Laryngoscope. 2012;122:1878-1881). They found that the success rate for OSA surgical treatment ranged from 38.9% to 91.7%, depending on the criteria and metric used to define a successful outcome.

Another issue is that, even with a stable definition, the AHI number may not represent an accurate picture of an individual patient’s experience with the disease. “The AHI tells you about the sum of apneas and hypopneas, but two patients with the same AHI number may have completely different scenarios—one with mostly apneas and longer or more severe desaturations and one with mostly hypopneas with minimal desaturations,” said Dr. Jacobowitz.

“It used to be thought that the more severe a patient’s sleep apnea, the more sleepy he or she would be, but that turns out not to be the case,” said Eric Kezirian, MD, MPH, professor of clinical medicine in the department of otolaryngology-head and neck surgery at the Keck School of Medicine of the University of Southern California in Los Angeles. “Sleep apnea can reduce the sleep quality for patients, resulting in sleepiness, fatigue, and decreased quality of life. It turns out the AHI doesn’t capture that.”

Part of the issue is that people can be fatigued for a number of reasons, Dr. Kezirian added. They may not be sleeping enough, they may have insomnia, or there may be other sleep issues. “You want to have some objective way to measure how well you’re treating OSA,” he said. “The AHI is certainly part of that; it’s a single number that allows you to get a sense of what a patient’s breathing patterns are like. But we don’t treat numbers, we treat patients, and so we care about the broader implications of the treatment.”

These researchers looked at 21 studies on outcome measures in addition to the AHI that were published between 1997 and 2012. The authors found that patients with OSA scored differently in measurement tools in all categories when compared with control populations or after treatment and that, in general, there was a poor correlation with AHI.

“The issue with AHI is that it’s only part of the definition of OSA—it is a marker of sleep apnea, a surrogate variable of the disease,” said Dr. Jacobowitz. “AHI will remain important because there is reasonable evidence that when a patient’s AHI is over 30, it is associated with increased mortality. But it’s an indirect measure of only the respiratory component of sleep apnea and does not measure sleepiness. For example, if the AHI is less than 15, you can’t make an OSA diagnosis unless the patient has associated symptoms, and that’s exactly what we’re talking about: sleepiness, quality of life, and more.”

Other Measures of OSA

While researchers commonly use AHI, other metrics have been used alongside it to give a broader sense of treatment, according to Dr. Kezirian, including the Epworth Sleepiness Scale and QOL measurement questionnaires. Additional measures also include blood pressure, oxygen desaturation index, psychomotor vigilance tasks, and, over the long term, serious cardiovascular events and mortality.

In clinical application, these other measurements can give a clearer picture of the patient’s reason for seeking treatment, particularly where OSA surgery is concerned. “A sleep study comes from a single night, either in a sleep laboratory where patients are hooked up to many different monitors, or at home where, although there are fewer monitors, it can still be disruptive,” said Dr. Kezirian. “The study may not capture the general pattern of a patient’s sleep over longer periods of time. This single snapshot of one night may not represent what’s typically happening for a particular patient for a number of reasons: Many patients tend to sleep more on their backs during studies and may give an artificially worse picture of their sleep apnea, and there is some disruption of sleep by the monitors, to name just a couple of those reasons. For patients and sleep surgeons considering surgery, there are many gradations of sleep apnea and a number of reasons why the AHI might not capture the effects of treatment, good and bad. That’s why other measures are helpful.”

They are not, however, without their problems, including the fact that the questionnaire measurements are highly subjective and can have a placebo effect. “If a patient undergoes surgery and wants to feel better, they sometimes will,” said Dr. Kezirian. “A better assessment would include a combination of metrics. An otolaryngologist could look at the sleep study result, but also at how that patient is doing overall.”

Looking Forward

“The goals of surgical OSA treatment are the reduction of cardiovascular risk, increased survival, reduced sleepiness, improved quality of life, and, of course, reduced snoring,” said Dr. Jacobowitz. “These can only be captured by using the AHI in conjunction with other quality of life, physiological, and clinical measurements.

So why haven’t alternate metrics been used more often in the clinical assessment of OSA treatment? Dr. Jacobowitz believes it’s a matter of familiarity and ease with using a single quantifiable parameter—the AHI. “The traditional gold-standard treatment of OSA is CPAP [continuous positive airway pressure], and CPAP was designed to improve AHI,” he added.

There is some evidence validating the use of a variety of metrics in outcome measurements. In the 2012 Laryngoscope study, outcomes not only showed a reduction in AHI (in all indices) but also a reduction in patient-reported symptoms. “OSA is not defined solely by a metric; the diagnosis and management of this condition takes into account patient symptomatology as well as disease severity…. Polysomnographic parameters as outcome measures are important surrogates of some clinical outcomes, such as cardiovascular risk, but they should not be mistaken for clinical outcomes themselves,” said the authors. “Similarly, the definition of surgical success should be by more than just the AHI reduction alone, and other outcomes should be included in assessment of postoperative consideration.”

“For CPAP, although you can normalize the AHI in the sleep lab, often there is residual elevated AHI at home and many patients do not use CPAP for the entire night at home,” added Dr. Jacobowitz. “When you look at this AHI variable with regard to sleep surgery outcome, typically the AHI is reduced significantly but doesn’t normalize completely. At the same time, with respect to meaningful primary clinical outcomes, CPAP and surgery can reduce cardiovascular morbidity and decrease the rate of car accidents despite that imperfect AHI reduction.”

For the future, Dr. Kezirian sees more otolaryngologists adopting broader assessments of patients. “These questionnaires have been around for a while, but they are now being used more often in routine clinical practice. They go beyond just asking, ‘How are you doing?’” he said. “Using the questionnaires helps us determine the benefits of treatment if outcomes are not perfect, so we can tell if someone is making progress. The AHI alone is too simplistic. Patients may have no or little change in their AHI but still feel better, but they can also show major improvement in the AHI but still feel awful, which isn’t good enough either.”

Dr. Jacobowitz believes that widespread adoption will come with greater emphasis on alternative measurements in any clinical trial for OSA. “This isn’t difficult for quality-of-life measures, but it will present a challenge for some other variables such as cardiovascular incidents because they must be measured over a very long time,” he said. “But we have to remember what’s important to the patient and for our health system: how the patient is functioning, and the overall status of their health.”

Amy Hamaker is a freelance medical writer based in California.

The Three Different Definitions of AHI

AHIChicago More than 50% decrease in a valid measure of air flow, or a lesser airflow reduction in association with an oxygen desaturation of more than 3%, or an arousal.

AHIRec Abnormal respiratory event lasting 10 seconds or more, with 30% or higher reduction in thoracoabdominal movement or airflow, and with 4% or higher oxygen desaturation.

AHIAlt 50% or higher reduction in nasal pressure signal excursions and 3% or higher desaturation or arousal.

Non-AHI Measurements of OSA

• Biological Measurements (including assessment of hypertension, C-reactive protein, myeloperoxidase, oxygen desaturation, cardiovascular events)
• Measurements of Sleepiness (including the Epworth Sleepiness Scale)
• Performance Measurements (including assessment of motor vehicle collisions and psychomotor vigilance tasks)
• QOL Measurements (including Short Form-36, Nottingham Health Profile, Sickness Impact Profile)

Abstracts from The Laryngoscope

What Is ‘‘Success’’ Following Surgery for Obstructive Sleep Apnea? The Effect of Different Polysomnographic Scoring Systems

ABSTRACT

Objectives/hypothesis: To illustrate that the diagnosis of obstructive sleep apnea (OSA) is dependent on the polysomnographic scoring criteria used, and the success rates of treatments for OSA are dependent on the defined outcome measures.

Study design: Retrospective case series with prospective reanalysis of polysomnographic data.

Methods: Consecutively treated adult patients (N 1/4 40) with moderate to severe OSA having multilevel pharyngeal surgery in 2007 were studied. All patients underwent submucosal lingualplasty and concurrent or previous uvulopalatopharyngoplasty six palatal advancement. Full polysomnography (PSG) was performed preoperatively and at a mean of 145 days postoperatively. Pre- and postoperative PSG data were analyzed by two different but widely used scoring systems for the apnea-hypopnea index (AHI): The American Academy of Sleep Medicine (AASM) 1999 Chicago criteria and the AASM 2007 recommended criteria.

Results: Follow-up PSG data were available in 31 of 40 patients. Successful surgery was defined as a reduction in AHIRec <20 with a 50% reduction from the patient’s baseline, and in this group the surgical intervention was associated with a 72.2% success rate. If, however, differing AHI metrics are used or the absolute or percent reduction used to define a successful outcome is changed, then the rate of surgical success is shown to range from 39% to 92%.

Conclusions: Different criteria for measuring AHI and defining success following OSA surgery can produce widely conflicting outcome data. Reported results following OSA surgery should be interpreted with this in mind. Using acceptable criteria, multilevel sleep surgery can be demonstrated to be of benefit to the majority of carefully selected patients. (Laryngoscope. 2012;122:1878-1881).

Outcome Measurements in Obstructive Sleep Apnea: Beyond the Apnea-Hypopnea Index

ABSTRACT

Objectives/hypothesis: The apnea-hypopnea index (AHI) is overwhelmingly used as the main therapeutic metric in the assessment of obstructive sleep apnea (OSA) in surgical studies. However, using AHI as the sole measure is problematic. This study investigates the utility of other outcome measures for patients with OSA undergoing surgery.

Study design: Systematic review of cohort and review studies.

Methods: A review was performed using the PubMed database. English articles focusing on outcome measures in adults with OSA were included. Studies in pediatric populations, those combining obstructing and central sleep apnea, and those without the use of outcome measures were excluded. Articles were categorized according to level of evidence. The Downs and Black scale and AMSTAR scale were used to assess quality.

Results: Of a total of 10,454 retrieved articles, 21 studies met inclusion and exclusion criteria. Most articles related to continuous positive airway pressure outcomes. Many categories of outcome measures were found: general quality of life, OSA-specific quality of life, measurements of sleepiness, performance, and physiological. Subjects with OSA scored differently in measurement tools in all categories compared to control populations or after treatment, and generally a poor correlation with AHI was seen.

Conclusions: The literature shows a range of tools based on symptoms and physiology of OSA that can assess effects of treatment. Assessment of surgical treatment for OSA should neither be limited to AHI as an outcome, nor should this be the only outcome stressed (Laryngoscope. 2014;124:337-343).

Changes in Obstructive Sleep Apnea Severity, Biomarkers, and Quality of Life After Multilevel Surgery

ABSTRACT

Objectives/hypothesis: To evaluate the impact of multilevel obstructive sleep apnea surgical treatment on sleep-disordered breathing severity, health-related measures, and quality of life, and to examine the association between changes in sleep-disordered breathing severity and these other outcomes.

Study design: Prospective cohort study.

Methods: Subjects with obstructive sleep apnea unable to tolerate positive airway pressure therapy and with evidence of multilevel (palate and hypopharynx) obstruction underwent uvulopalatopharyngoplasty, tonsillectomy, and genioglossus advancement, with or without hyoid suspension. All subjects had preoperative and postoperative study assessments, including blood draw for C-reactive protein, interleukin-6, homocysteine, homeostasis model of insulin resistance, and leptin, and evaluation with the Functional Outcomes of Sleep Questionnaire.

Is the Apnea/Hypopnea Index the Best Measure of Obstructive Sleep Apnea?

Results: Thirty subjects underwent multilevel surgical treatment. The mean apnea-hypopnea index decreased from 44.9 ± 28.1 to 27.8 ± 26.4 events/hour (P = .008). Thirteen (43%) subjects in this heterogeneous sample achieved a response to surgery (defined as an apnea-hypopnea index reduction of ≥50% to an absolute level less than 15 events / hour and body mass index ≤32 kg/m2 was associated with a higher likelihood (55%, 12/22) of response (P = .04). There was no overall change in C-reactive protein levels, but responders demonstrated a decrease (−1.02 ± 0.98 mg/L, P = .003) that was independent of changes in body weight. There were no significant changes in other health-related measures. Responders and nonresponders both demonstrated improvements in sleep-related quality of life.

Depression, Sleepiness, and Disease Severity in Patients with Obstructive Sleep Apnea

ABSTRACT

Objectives/hypothesis: To determine if a relationship exists between depression, disease severity, and sleepiness in patients with obstructive sleep apnea (OSA).

Study design: Case control study.

Methods: Fifty-three consecutive patients with suspected OSA were evaluated before treatment and compared with controls by using the Beck Depression Inventory (BDI), Epworth Sleepiness Scale (ESS), and polysomnography.

Results: OSA was associated with an increased risk of depression in the study group compared to the control group (odds ratio = 6.3, 95% confidence interval: 1.9-20.6, P = .002); depression was seen in 35% of OSA patients and 8% of controls (P < .001). There was a significant correlation between BDI and ESS scores (r = 0.342, P = .012). In addition, ESS was significantly associated (P = .039) with depression in a linear regression model that controlled for race, sex, age, and respiratory disturbance index (RDI). RDI and depression were weakly associated (P = .056) in this model, and there was no correlation found between BDI scores and OSA disease severity (RDI)(r = 0.446).

Conclusions: Patients with OSA and daytime sleepiness are more likely to have depressive symptoms as compared with controls. OSA disease severity, as measured with the RDI score, is a weak predictor of BDI score, and no correlation was seen between the severity of OSA and BDI scores after controlling for other factors. However, there was a strong correlation between sleepiness (ESS) and disease severity (BDI). These data suggest that OSA patients with symptoms of excessive sleepiness have the highest risk of associated depressive symptoms and may benefit most from depression screening (Laryngoscope. 2010:120:2331-2335).