Snoring could be an early warning sign for memory loss.

CBS NEWS     April 16, 2015, 12:43 PM

There's new evidence suggesting just how important sleep is for the brain.

A study, published Wednesday in the journal Neurology, finds that people who snore heavily and have breathing problems during sleep may develop memory loss and cognitive decline at a much younger age than average.

"This study might be keeping some people up at night," Dr. Carol Ash, director of sleep medicine at Meridian Health, told "CBS This Morning."

http://www.cbsnews.com/pictures/sleep-hacking-tips-7-ways-to-maximize-your-zzzzzs/

Snoring and sleep apnea -- a condition where breathing is repeatedly interrupted during sleep -- are common among older people, affecting about half of men and a quarter of women, according to the researchers from NYU Langone Medical Center.

They studied the medical histories of nearly 2,500 people ages 55 to 90. Participants were categorized as having either normal brain function, mild cognitive impairment (MCI), or early stages of Alzheimer's disease.

The study found that people with sleep apnea were diagnosed with mild cognitive impairment an average of nearly 10 years earlier than people without sleep apnea.

"That's significant," Ash said. Even though the study did not prove cause and effect, she said it adds to a growing body of evidence that links sleep to brain health.

• How to protect your aging brain
• New clue about what causes Alzheimer's disease

Fortunately, she said, there are things you can do to lower the risk. "When you have symptoms of snoring or symptoms that suggest you have sleep-disordered breathing, you really want to take it seriously. There's simple screening that can be done to identify somebody that has a problem. There's a home sleep test to make the diagnosis. Then there's treatment options."

For people with sleep apnea, a device called a CPAP mask, worn over the nose and mouth, can help keep the airways open at night. It may look uncomfortable, but Ash said, "When you have a patient who truly has this problem, it can change and save their life. You have to coax them through and get them comfortable, but once they're using it, they won't go back."

Losing a few pounds can also be effective, since excess weight often contributes to snoring and breathing problems. In other cases, dental work or surgery can make a difference.

The NYU researchers found that patients whose sleep issues were treated were able to ward off cognitive decline. "The age of onset of MCI for people whose breathing problems were treated was almost identical to that of people who did not have any breathing problems at all," study author Ricardo Osorio, MD, said in a press statement. "Given that so many older adults have sleep breathing problems, these results are exciting --we need to examine whether using CPAP could possibly help prevent or delay memory and thinking problems."

Ash stressed the importance of getting diagnosed and dealing with sleep problems, since in addition to memory decline, snoring and sleep apnea have also been linked to an increased risk of stroke, heart attack, and other life-threatening conditions.

"Sometimes you can't undo all of the damage, but I've seen significant improvements," she said. "It's worth looking into."

Could Chrona Be the Key to Deeper Sleep?

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Dental Clinicians’ Observations of Combination Therapy in PAP-Intolerant Patients

March 9, 2015

Based on the experiences of four highly experienced dental sleep practices, this pilot study sought to determine whether combination therapy, in which a PAP interface and mandibular advancement splint are physically connected, may provide a more acceptable therapeutic modality in obstructive sleep apnea patients who have abandoned conventional PAP therapy.

By Anne E. Sanders, MS, PhD, MS; Martin A. Denbar, DDS, DABDSM; John White, DDS, DABDSM; Ronald S. Prehn, ThM, DDS, DABDSM; Robert R. Rogers III, DMD, DABDSM; Thomas Pardue, BA; Max Schweizer, BS; and Greg K. Essick, DDS, PhD

TAP-PAPComboTherapy

In the PAP/MAS device, the PAP interface (nasal pillows) is connected to, and stabilized in position by, a rod extending from the oral appliance, a mandibular advancement splint. This obviates the need for headgear required when the PAP interface and oral appliance are not connected.

Patients with obstructive sleep apnea (OSA) attribute their poor tolerance of positive airway pressure (PAP) therapy to the presence and fit of headgear and chin straps, claustrophobia, unstable or inadequate fit of mask to facial contours, air leakage, mask-related skin ulceration and headache, aerophagia, and uncomfortably high pressure levels. As a result, only about 50% of patients continue to adhere with therapy after 1 year.

Anecdotally, sleep clinicians claim better tolerance when PAP therapy is used in conjunction with a mandibular advancement splint (MAS), but published evidence is scarce. The MAS stabilizes and advances the mandible, simulating jaw thrust and clearing the upper airway for unobstructed breathing. Improved tolerance of this combination therapy (CT) is attributed to fewer pressure-related complaints. El-Sohl et al showed in 10 patients that CT reduced both the effective continuous PAP and pressure-related complaints shortly after implementation. Consistent with lower effective pressures, Borel et al found that velopharyngeal resistance is lower with CT than with a nasal mask alone. 

In both studies, the MAS and PAP mask were not physically connected.

The PAP interface, however, can be physically connected to and supported by a MAS, eliminating the need for headgear. One early case report6 described a patient whose responses to PAP and to MAS therapy were poor, but who achieved near normal sleep respiration and a lower minimally effective PAP upon stabilization of the mandible in an upward and forward position, as corroborated elsewhere.  By analyzing existing data from four dental sleep practices, we sought to determine whether PAP delivered through an interface connected to a MAS can offer a more accepted therapeutic alternative for OSA patients who have failed conventional PAP therapy. 

Methods

The study employed a retrospective cohort design in which four dental sleep medicine experts in separate US practices retrieved existing data from records for all consecutive patients aged ≥18 years meeting inclusion criteria. The inclusion criteria were: physician diagnosis of OSA and referral to a dentist; having failed conventional PAP therapy; having attempted MAS-PAP within a specified time interval; and being on active recall for therapy evaluation. Clinicians were diplomates of the American Board of Dental Sleep Medicine with collective experience treating more than 14,000 patients with oral appliances for sleep-disordered breathing over a total of 79 years. The Biomedical IRB at the University of North Carolina at Chapel Hill approved the study.

De-identified diagnostic and CPAP titration information from patients’ sleep study reports and clinical records of CT were extracted and recorded on a standardized pretested electronic form.

Investigation was restricted to a single commercially available CT device—the TAP-PAP Chairside (manufactured by Airway Management Inc). In this device, a horizontal rod is secured to the upper component of a MAS, and a nasal pillow/hose assembly is attached using an acrylic material.

Tolerance was defined by clinician report that the patient was continuing to use PAP/MAS, based on periodic recall and ongoing evaluation by the dental sleep expert in the dental office. Acceptability was evaluated by patient report of complaints. Evidence of efficacy was determined in a subset of patients by comparison of follow-up polysomnogram or home sleep study against the diagnostic polysomnogram.

Data were imported into StataCorp LP Stata 13.1 Statistical Software for statistical analysis. Pearson chi-square tested the significance of differences between categorical variables. A paired t-test tested the null hypothesis that apnea-hypopnea index (AHI) values at OSA diagnosis did not differ from those obtained following PAP/MAS.

Results

Among 92 OSA patients aged 25 to 85 years (mean 55 years), the mean polysomnogram-determined diagnostic AHI value was 37.6 (standard deviation (sd): 25.9). Half (n=46) met the diagnostic threshold for severe OSA (AHI ≥30), a quarter (n=23) had moderate OSA (AHI 15–29.9), and the remainder (n=23) had mild OSA (AHI 5–14.9).  

Because the proportion of PAP/MAS tolerant patients did not differ between the practices (P = 0.612), results report pooled data. Overall, 65 patients (70.7%) tolerated PAP/MAS therapy, having used it for 14.0 months on average (sd: 11.1). Although tolerance was higher in patients with severe OSA (76.1%) than mild OSA (69.8%), this difference was not statistically significant (P = 0.421).

Patients expressed substantially fewer complaints to their dentists about PAP/MAS than conventional PAP (Table 1). The most common complaints about conventional PAP related to mask discomfort and leakage, and the perceived ineffectiveness of PAP. Again, mask discomfort and leakage were the most common complaints about PAP/MAS, but these were reported by only a small minority of patients. 

A follow-up polysomnogram or home sleep test was available for 34 of the 65 PAP/MAS tolerant patients while using PAP/MAS. Patients with severe OSA were more likely to have had the follow-up polysomnogram than those with mild OSA (P = 0.023). In these patients, AHI values decreased from an untreated mean of 48.0 (sd: 28.3) events/hour to a treated mean of 3.1 events/hour (sd: 3.8) (P < 0.001), indicating that, on average, PAP/MAS eliminated OSA.

Discussion

In this study of patients who had abandoned conventional PAP, 70.7% were reported using PAP/MAS for 14.0 months, on average, after initiation of treatment. PAP/MAS tolerant patients expressed to their sleep dentists substantially fewer complaints about the CT than conventional PAP. CT reduced the AHI to less than 5, on average, achieving values not dissimilar from those achieved with conventional PAP.

Several explanations may account for better tolerance of CT. Borel et al⁵ found that joint use of PAP with MAS was at least equally effective as nasal PAP alone by increasing airway patency beyond that achieved solely with PAP. Using a phrenic nerve magnetic stimulation paradigm, the investigators showed greater decrease in velopharyngeal resistance with CT. Since resistance values determined this way are related to pressures at which the pharynx collapses, the joint therapies act synergistically to improve velopharyngeal area patency, the area primarily implicated in upper airway collapse.

El-Sohl et al found that the CPAP intolerance was associated with high pressure-related complaints. In agreement with greater pharyngeal patency demonstrated by Borel et al, El-Sohl et al also demonstrated that CT lowered the optimal pressure 29% on average and was well tolerated.

PAP therapy adherence is influenced by the mask interface. Typically, when a nasal mask results in air leakage via the mouth, an oronasal mask is tried. However, the higher pressures required for oronasal masks are associated with greater air leakage, more arousals, more residual respiratory events, dry mouth, and worse adherence than nasal masks. In addition, their manner of attachment tends to push the mandible and tongue backward, increasing the airflow resistance.

A nasal interface used with MAD overcomes the aforementioned problems. The effective pressure is typically lower than with a nasal mask. Rather than pushing the mandible backward, it is stabilized in a neutral or forward position, lowering velopharyngeal resistance and improving upper airway patency. As the mouth is kept closed, air leakage and mouth breathing are minimized.

Because nasal pillows have less facial contact, problems of claustrophobia, air leaks around the eyes, and pressure sores are minimized.  In their randomized cross-over study, Massie and Hart compared nasal pillows to nasal masks using pressures ranging from 5 to 14 cm H₂0. They reported no differences in treatment efficacy, effective CPAP pressure, Epworth sleepiness score, or quality of life measures. The nasal pillows produced fewer adverse effects, less air leakage, less difficulty sleeping and maintaining sleep, and improved sleep quality.

The nasal pillows in our study were supported via a rod extending from the maxillary component of the MAS, obviating need for a chin strap and headgear to support the air interface. This confined facial contact to the external nares and lip vermilion over which the supporting rod extended. Moreover, the rigidity of the connection with the MAS secured the nasal pillows in a stable “locked” relationship with respect to the external nares to minimize air leaks and thus disruptive arousals from sleep. Air leakage is a major deterrent to the use of PAP, hence the substantial reduction in complaints of “air leakage” and “not being able to keep in place” with PAP/MAS may, in part, underlie its success.

PAP/MAS-tolerant patients had remarkably fewer complaints about the CT than conventional PAP. Our expectation that the addition of MAS would cause discomfort in masticatory muscles, TMJ, and teeth, was not met. CT may be successful with a lesser degree of jaw advancement than required for treatment with a MAS alone,¹ thereby minimizing dental side effects.

The use of CT as a first-line therapy, rather than a rescue, may decrease the number of patients who remain untreated from nonadherence to PAP therapy. Compared to conventional PAP, CT appears to offer improved comfort and interface stability, and a reduction in air leakage.

We recognize the many limitations of this pilot study. Data were limited to existing clinical records of community-based dental sleep practices. Because of this, the patients were not matched either within or across the four practices. There was no standardization of the PAP titrations, types of masks employed, or counseling that the patients received on use of conventional PAP or combination therapy. The amount of jaw advancement with PAP/MAS was not standardized within or between practices, which could have affected tolerance of the CT. There was no standardization of the follow-up PSG or home sleep study, and these data were not available for approximately half the CT-tolerant subjects. Data were not available for the nightly duration of PAP/MAS use. Nonetheless, the consistency of the experiences reported across the four unrelated, expert dental sleep practices supports the general conclusion that PAP/MAS can provide an effective treatment for OSA in many otherwise CPAP-intolerant patients and merits formal evaluation in a prospective controlled clinical trial.

Does your dog's snoring keep you awake?

Dogs that snore aren't getting a good night's sleep -- and, chances are, neither are you.

By Stacey Cohen

Stacey Cohen has been a news broadcaster and talk show host for more than 25 years. She has worked with Sally Jesse Raphael, G Gordon Liddy, Martha Stewart, Jane Fonda and many more. She even did play-by-play for the O.J. Simpson trial.

Photo © Tatiana Katsai - Fotolia

For some reason we tolerate our pets' snoring more than we do our spouse's, but it can be the cover-up for an array of issues. Like any problem, if it is something new, it might be worth a trip to the vet to check out. Snoring can have some underlying serious causes.

If your dog is snoring it is some kind of obstruction that is causing the problem. Digging in the dirt, rolling in the grass, even drinking water and eating can introduce foreign objects into your dog’s nasal passage, resulting in snoring. Extra mucus from a cold will also create snoring.

For the most part, snoring caused by nasal obstructions is temporary and should stop when the passage is cleared. There are some other common reasons for snoring:

Dental problems can be a factor. If your dog has bad teeth. It can lead to an abscess. It will go right through the nasal passages. If you don't have your dog’s teeth looked at, dental problems can be a source of infection that goes through your dog’s whole body. Infections can be a host for another set of problems.

Extra pounds

Is your dog carrying a little extra weight? If so, that can be a factor that is causing the snoring. Excess tissue in the throat will cause the obstruction that blocks the airways. As your dog breathes in and out, obesity makes the trachea rings slam shut.

Or it could be a fungus that you may not even be aware of but your dog sure is, such as mold found in hay, grass clippings and similar environments. Left untreated, this fungal disease can cause discomfort, loss of appetite and serious health problems.Any type of upper respiratory problem can cause a blockage, including a temporary inflammation in the nose from a cold or seasonal allergies.

You may have just picked a breed that has this issue through genetics. Because of genetics some breeds may actually have to have a surgery to open up their nasal passages because they are almost completely shut, like a pug or Boston terrier. Brachycephalic breeds -- the breeds with very short noses, such as English/French bulldogs, Boston terriers and pugs -- have a natural tendency to snore.

Is your dog breathing secondhand smoke? Smoke can irritate the nasal passages and make it difficult to breathe. Smoke away from the dog or better yet quit. You both will be healthier.

How can you help your dog breathe more easily? Try giving your dog a pillow. It will elevate the head.

A round bed will encourage a different sleeping position. The round bed will encourage a curled position that allows air passages to expand.

A humidifier can help increase the moisture in the air and help, so the nasal passages won't be so dry.

If your dog is snoring it most likely isn't getting a restful sleep and if it isn't getting good sleep that means you probably aren't either. If the problem persists after trying to change up the sleep environment go back to the vet and see if it is an allergy or if possibly surgery is needed.

Israeli Researchers Develop Groundbreaking Approach To Evaluate Sleep Disorders.

Mon, Mar 16th, 2015

Ben-Gurion University of the Negev (BGU) researchers have developed a groundbreaking approach to determine sleep quality using their new breath sound analysis (BSA). This is less expensive and invasive than current polysomnography (PSG) technology, according to a new study published on PLOS Online.

“One of the main goals of sleep medicine today is to improve early diagnosis and treatment of the ’flood” of subjects presenting with sleep disorders,” says Prof. Yaniv Zigel Ph.D., head of the Biomedical Signal Processing Research Lab in BGU’s Department of Biomedical Engineering.

“We’ve developed a non-contact ‘breathing sound analysis’ algorithm that provides a reliable estimation of whole-night sleep evaluation for detection of sleep quality, snoring severity and Obstructive Sleep Apnea (OSA). It has the potential to reduce the cost and management of sleep disorders compared to PSG, the current standard of treatment, and could be used at home.”

PSG requires a full night sleep center stay and subjects are connected to numerous electrodes and sensors that are attached to the patient to acquire signals and data from electroencephalography (EEG), electrooculography (EOG), electromyography (EMG), and electrocardiography (ECG) tests. The data is processed and visually examined or mathematically transformed manually in order to reveal insights about sleep/wake states and many aspects of physiology. “This procedure is time-consuming, tedious and costly due to complexity and the need for technical expertise; the market is begging for a better solution,” says Eliran Dafna who conducted this study as part of his Ph.D. research.

In the study, the researchers measured whole-night breathing sounds from 150 patients using both ambient microphones and PSG simultaneously at a sleep laboratory. The system was trained on 80 subjects and a validation study was blindly performed on the additional 70 subjects. A set of acoustic features quantifying breathing patterns was developed to distinguish between sleep and wake segments. Sleep quality parameters were calculated based on the sleep/wake classifications and compared with PSG for validity.

When comparing sleep quality parameters, there were only minor average differences in the measurements between PSG and BSA. Measuring 150,000 individual time segments (epochs), the BSA epoch-by-epoch accuracy rate for the validation study was 83.3 percent with 92.2 percent sensitivity measuring sleep as sleep.

“The results showed that sleep/wake activity and sleep quality parameters can be reliably estimated solely using breathing sound analysis,” says Prof. Ariel Tarasiuk of BGU’s Department of Physiology and head of the Sleep-Wake Disorders Unit, at Soroka University Medical Center. “This study highlights the potential of this innovative approach to measure sleep in research and clinical circumstances. Clearly, the transition of this technology to at-home sleep evaluation depends on third party reimbursements for the use of home study equipment.”

The Biomedical Signal Processing Research Laboratory was established in 2007 by Prof. Yaniv Zigel. The lab’s team are experts in physiological signal processing and pattern recognition.

The for the Study and Diagnosis of Sleep Disorders was established in 1994 by Prof. Ariel Tarasiuk. The unit’s team of experts evaluate sleep disorders in children and adults and operates in conjunction with specialists in respiratory diseases, neurology, ENT, and gastrointestinal diseases.

WHAT SYDNEY LEROUX DOES TO HER NEW HUSBAND IF HE'S SNORING.

By D'Arcy Maine | Mar 16, 2015



Unless you've been living in an underground tunnel somewhere with no WiFi signal or cell service, you're aware that soccer stars Sydney Leroux and Dom Dwyer were recently married. In fact, if you follow either of them on social media, you probably already know more about their relationship than that of people you -- GASP -- actually know IRL.

And just when you thought you knew everything about their lives, Leroux documented her new husband's annoying sleep habit and maybe her attempt at killing him. So that's a new development.

After having her sleep disturbed by Dwyer's snoring, Leroux did what anyone would do and pinched his nose. It worked ... temporarily. She posted the video of her efforts on Instagram with the caption: "When you try to kill bae."

For those concerned: Dwyer is still very much alive and well. Although he might want to find a way to get his snoring in check ... before it's too late.

Snoring can lead to glaucoma: Experts

T Ramavarman,TNN | Mar 8, 2015, 06.15 AM IST

Snoring cuts off oxygen supply to your lungs and vital organs including the eyes. In glaucoma, already the opticval nerve cells are dying due to the increased pressure. Lack of oxygen accelerates the decay.

THRISSUR: Besides creating nuisance to those around you, snoring can aggravate glaucoma-optic nerve damage associated with the buildup of pressure in the eye-leading to loss of vision, experts said.

Studies reinforced the belief that those who snore were at the risk of developing glaucoma, ophthalmic surgeon Dr Rani Menon said.

"Snoring cuts off oxygen supply to your lungs and vital organs including the eyes. In glaucoma, already the opticval nerve cells are dying due to the increased pressure. Lack of oxygen accelerates the decay. So snoring is a very serious risk as far as glaucoma is concerned,'' she said.

When pressure builds up, the nerve cells inside the eye get strangulated and they start dying. There are about five million nerve cells in the human eye, and vision would be affected when about 30% cent of them are lost.

According to statistics, one in 200 of those aged above 40 stand the risk of getting glaucoma affected, while one in 100 aged above 65 were at risk. In India, about 11.9 million people are glaucoma-affected.

Though early detection is critical in treating glaucoma, patients seldom perceive any clear symptom, said Dr Babu Krishnakumar, secretary of the Kerala society of ophthalmic surgeons.

'Glaucoma Week' is being organized across the world from March 8.

Alternative Snoring Treatment Getting Rave Reviews

Posted: Mar 03, 2015 2:12 PM CSTUpdated: Mar 04, 2015 3:28 PM CST


http://www.waff.com/clip/11199609/newer-remedy-helps-snoring-sufferers

Norman Roby's dentist helped him find a new snoring treatment. (Source: WAFF)

DECATUR, AL (WAFF) -

Norman Roby says his snoring was pretty bad. He says he never felt rested and had a tendency to nap during the day. Finally he sought help.

"I did a sleep study over at Decatur General, at the time, and they determined that I was suffering from Sleep apnea, so I used a C-pap for a long time."

C-pap, or continuous positive airway pressure machines, have long been the standard treatment for slumberers who snore. But those machines come with some caveats.

Roby says he was miserable. "I didn't like being put in a bridle. I couldn't roll and turn and (it) had a noise going, and if I had any kind of a head cold I couldn't use the Cpap. I had to take it off. I slept worse with it than I did without it."

His friend Dr. Randall Sandlin, a Decatur dentist, helped him. "But, unfortunately it's not all that comfortable and there is a pretty high percentage, maybe half or more, of patients who just can't tolerate c-pap, because you're tethered to a machine and you're limited in your sleep position," Sandlin explained.

Sandlin says the oral appliance he recommended works differently. "It all fits within the mouth. It fits like a kid's retainer after braces." 

SomnoDent is a two-piece oral appliance that works to hold the lower jaw slightly forward. 

"The tongue is actually attached to the lower jaw, and when you bring the lower jaw slightly forward, you are bringing the tongue just a few millimeters slightly forward - which helps it open up the airway and keep it from collapsing," the dentist said.

Sandlin says you can speak, yawn, drink water with the device, so small, it can fit in your pocket. He says this device is a medical-grade acrylic appliance which will not "hold odor".

Roby says he can finally catch some "Z's.

"I was sleeping better than I had in years... sleeping like a fat baby," he laughed

And he says he's not the only one. "My wife is sleeping a lot better too ."

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.

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).