Abstract 18672: Association Between Sleep Disordered Breathing and Electrocardiographic Markers of Atrial Abnormalities: The MESA Study

Circulation ◽  
2015 ◽  
Vol 132 (suppl_3) ◽  
Author(s):  
Younghoon Kwon ◽  
Jeffrey R Misialek ◽  
Daniel Duprez ◽  
Alvaro Alonso ◽  
David R Jacobs, Jr ◽  
...  
Keyword(s):  
Logistic Regression ◽  
Left Atrial ◽  
Sleep Disordered Breathing ◽  
P Wave ◽  
Apnea Hypopnea Index ◽  
Linear Regression Models ◽  
Cross Sectional ◽  
Increased Risk ◽  
Electrocardiographic Markers ◽  
Disordered Breathing

Introduction: Abnormal P wave terminal force in V1 (PTFV1), an electrocardiographic marker of left atrial abnormalities, has been linked to increased risk of atrial fibrillation (AF). Examining the association between sleep disordered breathing (SDB) and PTFV1 might shed light on the potential mechanisms by which SDB increases risk of AF. Methods: A total of 1546 participants (mean age 67.2 (± 8.8) years, 53.4 % women and 63.3 % non-Whites) from the Multi-Ethnic Study of Atherosclerosis (MESA) Exam 5 Sleep ancillary were included in this analysis. PTFV1 was measured from resting standard digital ECG tracings that were automatically processed centrally. Linear and logistic regression analyses were used to examine the cross-sectional associations between measures of SDB (apnea hypopnea index [AHI], obstructive AHI [OAHI] and % time spent with oxygen saturation <90% [% SpO2 90]) and PTFV1. Results: There was a trend of higher PFTV1 values across quartiles of AHI, OAHI and % SpO2 90 (p for trend <0.01 for each). In multivariable linear regression models, the upper quartile of AHI and OAHI measures were associated with higher values of PTFV1 compared with the lower quartile (Table). A 1-SD increase of AHI and OAHI were associated with increased levels of PTFV1 (Table). When PTFV1 was considered as a binary variable (using the cut point of 4000 μV.ms to define abnormality) in logistic regression analysis, AHI and OAHI were also associated with abnormal PTFV1. Conclusion: Severity of SDB, as measured by AHI is associated with subclinical left atrial disease, as measured by PTFV1. This could partially explain the reported association between SDB and AF.

scholarly journals Enhanced CaMKII-Dependent Late I Na Induces Atrial Proarrhythmic Activity in Patients With Sleep-Disordered Breathing

2020 ◽  
Vol 126 (5) ◽  
pp. 603-615 ◽  
Author(s):  
Simon Lebek ◽  
Konstantin Pichler ◽  
Kathrin Reuthner ◽  
Maximillian Trum ◽  
Maria Tafelmeier ◽  
...  
Keyword(s):  
Sleep Disordered Breathing ◽  
Artery Bypass ◽  
Right Atrial ◽  
Apnea Hypopnea Index ◽  
Na Channel ◽  
Linear Regression Models ◽  
Inhibitory Peptide ◽  
Clinical Trial Registration ◽  
Cross Sectional ◽  
Disordered Breathing

Rationale: Sleep-disordered breathing (SDB) is frequently associated with atrial arrhythmias. Increased CaMKII (Ca/calmodulin-dependent protein kinase II) activity has been previously implicated in atrial arrhythmogenesis. Objective: We hypothesized that CaMKII-dependent dysregulation of Na current (I Na ) may contribute to atrial proarrhythmic activity in patients with SDB. Methods and Results: We prospectively enrolled 113 patients undergoing elective coronary artery bypass grafting for cross-sectional study and collected right atrial appendage biopsies. The presence of SDB (defined as apnea-hypopnea index ≥15/h) was assessed with a portable SDB monitor the night before surgery. Compared with 56 patients without SDB, patients with SDB (57) showed a significantly increased level of activated CaMKII. Patch clamp was used to measure I Na . There was a significantly enhanced late I Na , but reduced peak I Na due to enhanced steady-state inactivation in atrial myocytes of patients with SDB consistent with significantly increased CaMKII-dependent cardiac Na channel phosphorylation (Na V 1.5, at serine 571, Western blotting). These gating changes could be fully reversed by acute CaMKII inhibition (AIP [autocamtide-2 related inhibitory peptide]). As a consequence, we observed significantly more cellular afterdepolarizations and more severe premature atrial contractions in atrial trabeculae of patients with SDB, which could be blocked by either AIP or KN93 (N-[2-[[[(E)-3-(4-chlorophenyl)prop-2-enyl]-methylamino]methyl]phenyl]-N-(2-hydroxyethyl)-4-methoxybenzenesulfonamide). In multivariable linear regression models incorporating age, sex, body mass index, existing atrial fibrillation, existing heart failure, diabetes mellitus, and creatinine levels, apnea-hypopnea index was independently associated with increased CaMKII activity, enhanced late I Na and correlated with premature atrial contraction severity. Conclusions: In atrial myocardium of patients with SDB, increased CaMKII-dependent phosphorylation of Na V 1.5 results in dysregulation of I Na with proarrhythmic activity that was independent from preexisting comorbidities. Inhibition of CaMKII may be useful for prevention or treatment of arrhythmias in SDB. Clinical Trial Registration: URL: http://www.clinicaltrials.gov . Unique identifier: NCT02877745. Visual Overview: An online visual overview is available for this article.

417 Transgender Hormone Therapy and Sleep-Disordered Breathing

SLEEP ◽  
2021 ◽  
Vol 44 (Supplement_2) ◽  
pp. A165-A165
Author(s):  
Ronald Gavidia ◽  
Galit Levi Dunietz ◽  
Lisa Matlen ◽  
Shelley Hershner ◽  
Daphna Stroumsa ◽  
...  
Keyword(s):  
Linear Regression ◽  
Regression Models ◽  
Sleep Disordered Breathing ◽  
Hormone Replacement ◽  
Apnea Hypopnea Index ◽  
Linear Regression Models ◽  
Sleep Complaints ◽  
Human Respiration ◽  
Lower Oxygen ◽  
Disordered Breathing

Abstract Introduction Sex hormones may affect human respiration during wakefulness and sleep. Testosterone has been associated with increased obstructive respiratory events contributing to sleep-disordered breathing (SDB) in men, whereas a protective effect against SDB has been attributed to estrogen in women. These associations, primarily observed in cisgender populations, have been rarely examined in transgender individuals on hormone replacement therapy (HRT). The present study investigated associations between HRT and SDB in transgender adults. Methods A chart review of medical records from transgender patients was conducted in a large academic sleep medicine center. Individuals were included if they were at least 18 years old, had one or more sleep complaints, and SDB testing results available. Participants were then stratified by affirmed gender (transmasculine and transfeminine) and by HRT status. We used descriptive statistics procedures to examine differences between gender and HRT groups. Associations between HRT and the apnea-hypopnea index (AHI) were estimated with age-adjusted linear regression models. Results Of the 194 individuals identified, 89 satisfied the inclusion criteria. Nearly half of participants were transmasculine (52%). The mean age was 38±13 years, and mean body mass index was 34.7±9.0 Kg/m2. Approximately 60% of participants were on HRT at the time of SDB evaluation. Transmasculine people who were prescribed testosterone had a significantly increased AHI and lower oxygen nadir in comparison to transmasculine individuals not on testosterone (AHI 36.8±37.8/hour vs.15.3±16.6/hour, p=0.01; oxygen nadir 83.4±8.3% vs. 89.1±2.4%, p=0.001). In contrast, differences between transfeminine people with and without feminizing HRT (androgen blocker + estrogen) were not statistically significant (AHI 21.4±27.7/hour vs. 27.7±26.0/hour, p=0.45; oxygen nadir 86.5±6.7% vs. 84.1±7.7%, p=0.29). Linear regression models adjusted for age found an association between HRT and AHI for transmasculine (β=16.7, 95% CI 2.7, 30.8), but not for transfeminine participants (β=-2.5, 95% CI -17.9, 12.9). Conclusion These findings suggest differential associations between HRT and AHI among transgender individuals, with transmasculine on testosterone having a significant increase in AHI. Prospective studies with large sample sizes are warranted to evaluate these associations. Support (if any) Dr. Gavidia’s work was supported by an NIH/NINDS T32-NS007222 grant

scholarly journals Detection of Sleep-Disordered Breathing in Patients with Spinal Cord Injury Using a Smartphone

Sensors ◽  
2021 ◽  
Vol 21 (21) ◽  
pp. 7182
Author(s):  
Yolanda Castillo-Escario ◽  
Hatice Kumru ◽  
Ignasi Ferrer-Lluis ◽  
Joan Vidal ◽  
Raimon Jané
Keyword(s):  
Spinal Cord ◽  
Spinal Cord Injury ◽  
Supine Position ◽  
Sleep Disordered Breathing ◽  
Cost Effective ◽  
Apnea Hypopnea Index ◽  
Accelerometer Data ◽  
Increased Risk ◽  
Cord Injury ◽  
Disordered Breathing

Patients with spinal cord injury (SCI) have an increased risk of sleep-disordered breathing (SDB), which can lead to serious comorbidities and impact patients’ recovery and quality of life. However, sleep tests are rarely performed on SCI patients, given their multiple health needs and the cost and complexity of diagnostic equipment. The objective of this study was to use a novel smartphone system as a simple non-invasive tool to monitor SDB in SCI patients. We recorded pulse oximetry, acoustic, and accelerometer data using a smartphone during overnight tests in 19 SCI patients and 19 able-bodied controls. Then, we analyzed these signals with automatic algorithms to detect desaturation, apnea, and hypopnea events and monitor sleep position. The apnea–hypopnea index (AHI) was significantly higher in SCI patients than controls (25 ± 15 vs. 9 ± 7, p < 0.001). We found that 63% of SCI patients had moderate-to-severe SDB (AHI ≥ 15) in contrast to 21% of control subjects. Most SCI patients slept predominantly in supine position, but an increased occurrence of events in supine position was only observed for eight patients. This study highlights the problem of SDB in SCI and provides simple cost-effective sleep monitoring tools to facilitate the detection, understanding, and management of SDB in SCI patients.

P1767Prevalence and clinical significance of sleep-disordered breathing in patients with hypertrophic cardiomyopathy

2019 ◽  
Vol 40 (Supplement_1) ◽  
Author(s):  
M Potratz ◽  
H Fox ◽  
H Fox ◽  
L Faber ◽  
L Faber ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Hypertrophic Cardiomyopathy ◽  
Clinical Significance ◽  
Left Atrial ◽  
Sleep Disordered Breathing ◽  
Clinical Aspects ◽  
Apnea Hypopnea Index ◽  
Left Atrial Diameter ◽  
Large Patient ◽  
Disordered Breathing

Abstract Background Despite major advances in knowledge on hypertrophic cardiomyopathy (HCM) at the genetic and molecular levels, the understanding of essential clinical aspects remains limited. The aim of this study is to identify the prevalence and clinical significance of Sleep-disordered Breathing (SDB) in a large patient population. Methods 201 patients (78 women, age 64±15 years) with HCM were screened for obstructive (OSA) or central (CSA) sleep-disordered breathing using multichannel cardiorespiratory polygraphy. Additionally, patients received a spiroergometric examination and echocardiography. SDB was defined as apnea-hypopnea index (AHI) ≥5/h and OSA/CSA differentiated after the majority of events. Results SDB was documented in 60% of all patients. OSA was diagnosed in 71 patients (35.3%) and CSA in 44 (21.9%) patients. SDB requiring treatment was found in 106 (52.7%) patients. In patients with AHI ≥15/h NYHA class was increased (2.1 vs. 2.39, p=0.04) and maximal O2 uptake during exercise was lower (20.1 vs. 16.1 p<0.001). Also left atrial diameter was significantly larger (46.9 mm vs. 50.41 mm, p=0.01) and rate of atrial fibrillation was increased (0.5 vs. 0.72 p=0.03). CSA pts had a larger left atrial diameter compared to pts with OSA (52.13 mm vs. 47.82 mm, p=0.02). Conclusion There is a high prevalence of SDB in HCM patients. Patients with moderate to severe SDB showed increased atrial fibrillation incidence and reduced cardiopulmonary performance. Whether the SDB has an independent prognostic relevance in patients with HCM needs to be elucidated.

Sleep-disordered breathing, pharyngeal size and soft tissue anatomy in children

2003 ◽  
Vol 95 (5) ◽  
pp. 2030-2038 ◽  
Author(s):  
R. F. Fregosi ◽  
S. F. Quan ◽  
K. L. Kaemingk ◽  
W. J. Morgan ◽  
J. L. Goodwin ◽  
...  
Keyword(s):  
Soft Tissue ◽  
Soft Palate ◽  
Sleep Disordered Breathing ◽  
Magnetic Resonance Images ◽  
Apnea Hypopnea Index ◽  
Cross Sectional ◽  
Obstructive Apnea ◽  
Pharyngeal Airway ◽  
Air Space ◽  
Disordered Breathing

We tested the hypothesis that pharyngeal geometry and soft tissue dimensions correlate with the severity of sleep-disordered breathing. Magnetic resonance images of the pharynx were obtained in 18 awake children, 7-12 yr of age, with obstructive apnea-hypopnea index (OAHI) values ranging from 1.81 to 24.2 events/h. Subjects were divided into low-OAHI ( n = 9) and high-OAHI ( n = 9) groups [2.8 ± 0.7 and 13.5 ± 4.9 (SD) P < 0.001]. The OAHI correlated positively with the size of the tonsils ( r2 = 0.42, P = 0.024) and soft palate ( r2 = 0.33, P = 0.049) and inversely with the volume of the oropharyx ( r2 = 0.42, P = 0.038). The narrowest point in the pharyngeal airway was smaller in the high-compared with the low-OAHI group (4.4 ± 1.2 vs. 6.0 ± 1.3 mm; P = 0.024), and this point was in the retropalatal airway in all but two subjects. The airway cross-sectional area (CSA)-airway length relation showed that the high-OAHI group had a narrower retropapatal airway than the low-OAHI group, particularly in the retropalatal region where the soft palate, adenoids, and tonsils overlap ( P = 0.001). The “retropalatal air space,” which we defined as the ratio of the retropalatal airway CSA to the CSA of the soft palate, correlated inversely with the OAHI ( r2 = 0.49, P = 0.001). We conclude that 7- to 12-yr-old children with a narrow retropalatal air space have significantly more apneas and hypopneas during sleep compared with children with relatively unobstructed retropalatal airways.

400 Utility of the STOP Questionnaire in Predicting Sleep Disordered Breathing in Older Women Veterans

SLEEP ◽  
2021 ◽  
Vol 44 (Supplement_2) ◽  
pp. A159-A159
Author(s):  
Monica Kelly ◽  
Isabel Moghtaderi ◽  
Sarah Kate McGowan ◽  
Gwendolyn Carlson ◽  
Karen Josephson ◽  
...  
Keyword(s):  
Diagnostic Accuracy ◽  
Older Women ◽  
Sleep Disordered Breathing ◽  
Women Veterans ◽  
Time Estimation ◽  
Apnea Hypopnea Index ◽  
Likelihood Ratios ◽  
Cross Sectional ◽  
Stop Questionnaire ◽  
Disordered Breathing

Abstract Introduction Sleep disordered breathing (SDB) is underdiagnosed in older women, despite a significant increase in SDB prevalence post-menopause. Few studies have assessed the diagnostic accuracy of SDB screening questionnaires in older women, particularly older Women Veterans (WV). WV have higher rates of SDB compared to non-Veteran women and are particularly vulnerable to sleep disorders in general. We examined the diagnostic accuracy of the STOP questionnaire compared to home sleep apnea testing (HSAT) that includes sleep time estimation (i.e., WatchPAT) in older WV. Methods Cross-sectional baseline data obtained from chart review were combined from two behavioral sleep intervention studies targeting WV with sleep difficulties (i.e., insomnia symptoms) or SDB risk factors (e.g., hypertension, obesity). A total of 136 older WV (50-91y; age=60.0±7.8y) completed the STOP questionnaire (yes/no: snoring, tiredness, observed breathing pauses, and high blood pressure [BP]) and had an apnea-hypopnea index (AHI) available from their baseline HSAT (WatchPAT). Sensitivity, specificity, and positive and negative likelihood ratios (+LR/-LR) were calculated to characterize the diagnostic accuracy of STOP≥2 for AHI≥5 (mild SDB) or AHI≥15 (moderate SDB). Results 70.6% (n=96) of participants endorsed a STOP≥2, 83.8% (n=114) demonstrated an AHI≥5 and 46.3% (n=63) demonstrated an AHI≥15. For AHI≥5, sensitivity was 73.7% (95% CI=64.6,81.5%), specificity was 45.5% (95% CI=24.4,67.8%), +LR was 1.35 (95% CI=0.91, 2.01), and -LR was 0.58 (95% CI=0.33,1.00). For AHI≥15, sensitivity was 76.2% (95% CI=63.8,86%), specificity was 34.2% (95% CI=23.5,46.3%), +LR was 1.16 (95% CI=0.93,1.44), and -LR was 0.70 (95% CI=0.30,1.20). Conclusion The likelihood ratios for STOP≥2 limited the utility of the STOP vs. an HSAT system with sleep scoring in determining AHI. While the STOP correctly identified 3/4 of older WV with SDB on WatchPAT, it correctly identified &lt;50% of older WV without SDB. Screening measures that better capture predictors of moderate SDB in women at risk for SDB are needed, especially in older women who may not present clinically with the common SDB symptoms (i.e. snoring, tiredness, observed breathing pauses, and high BP). STOP compared to polysomnography studies are also needed. Support (if any) VA HSR&D IIR-13–058, IIR 16–244 and RCS 20–191; NIH/NHLBI K24 HL143055, VAGLAHS GRECC, VA Office of Academic Affiliations, and AASM Foundation.

Prevalence of Sleep Disordered Breathing in Children With Myelomeningocele

Neurosurgery ◽  
2020 ◽  
Author(s):  
Brandon G Rocque ◽  
Mary Halsey Maddox ◽  
Betsy D Hopson ◽  
Isaac C Shamblin ◽  
Inmaculada Aban ◽  
...  
Keyword(s):  
Sleep Disordered Breathing ◽  
Primary Outcome ◽  
Clinical Symptoms ◽  
Cross Sectional Study ◽  
Demographic Variables ◽  
Apnea Hypopnea Index ◽  
Multivariable Logistic Regression Analysis ◽  
Cross Sectional ◽  
Neurological Lesion ◽  
Disordered Breathing

Abstract BACKGROUND Retrospective studies have shown high rates of sleep disordered breathing in children with myelomeningocele. However, most patients included in those studies underwent polysomnography because of symptoms, so the prevalence of sleep disordered breathing in this population is unknown. OBJECTIVE To determine the prevalence of sleep disordered breathing in children with myelomeningocele using screening polysomnography. METHODS In this cross-sectional study, all children with myelomeningocele seen in a multi-disciplinary spina bifida clinic between 2016 and 2020 were referred for polysomnography regardless of clinical symptoms. Included children had not previously undergone polysomnography. The primary outcome for this study was presence of sleep disordered breathing, defined as Apnea-Hypopnea Index (AHI, number of apnea or hypopnea events per hour of sleep) greater than 2.5. Clinical and demographic variables relevant to myelomeningocele were also prospectively collected and tested for association with presence of sleep apnea. RESULTS A total of 117 participants underwent polysomnography (age 1 mo to 21 yr, 49% male). The majority were white, non-Hispanic. Median AHI was 1.9 (interquartile range 0.6-4.2). A total of 49 children had AHI 2.5 or greater, yielding a sleep disordered breathing prevalence of 42% (95% CI 33%-51%). In multivariable logistic regression analysis, children with more rostral neurological lesion levels had higher odds of sleep disordered breathing (OR for thoracic, mid-lumbar, and low-lumbar: 7.34, 3.70, 4.04, respectively, compared to sacral level, P = .043). CONCLUSION Over 40% of a sample of children with myelomeningocele, who underwent screening polysomnography, had significant sleep disordered breathing. Routine screening polysomnography may be indicated in this population.

Abstract 11254: Association of Sleep Disordered Breathing and Sleep Architecture With Atrial Fibrillation: The MESA Study

Circulation ◽  
2014 ◽  
Vol 130 (suppl_2) ◽  
Author(s):  
Younghoon Kwon ◽  
Sina A Gharib ◽  
Mary Lou Biggs ◽  
David R Jacobs ◽  
Alvaro Alonso ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Sleep Disordered Breathing ◽  
Slow Wave Sleep ◽  
Cross Sectional Study ◽  
Sleep Architecture ◽  
Apnea Hypopnea Index ◽  
Cvd Risk ◽  
Cross Sectional ◽  
Sleep Study ◽  
Disordered Breathing

Background: Sleep disordered breathing (SDB) has been associated with nocturnal atrial fibrillation (AF). However, the association of SDB and other important sleep characteristics with prevalent AF (beyond nocturnal AF) is unclear. We explored the cross-sectional association of SDB and other objectively measured sleep characteristics with AF. Methods: Prevalence of AF was examined among MESA (Multi-Ethnic Study of Atherosclerosis) study participants who underwent polysomnography (PSG) (n=2048) (MESA Sleep Study). Presence or a history of AF was determined if AF or atrial flutter was identified by at least one of the following measures: (i) 12-lead ECG during study examination; (ii) PSG; (iii) ICD-9 codes from hospital discharge diagnosis; (IV) inpatient and outpatient Medicare claims data. Results: Overall prevalence of AF was 4.9 % (n=100). Prevalence of AF was significantly higher at 6.7% in subjects with moderate to severe SDB (n = 691, apnea hypopnea index (AHI) ≥15/h) compared with a prevalence of 4.0% in participants without SDB (n = 707, AHI < 5/h) (p=0.02). After accounting for demographics, body habitus, cardiovascular disease (CVD) risk factors and prevalent CVD, participants with higher values of AHI were more likely to have AF, although the result was not statistically significant (OR: 1.22 [0.99-1.49] per SD [17/hr], p = 0.06). Exploratory analyses of the association of sleep architecture with AF using the same model found significantly lower odds of AF associated with longer duration of slow wave sleep (SWS) (OR: 0.66 [0.5-0.89] per SD [34 min], p = 0.01). Results from a multivariable model that included 3 key sleep characteristics (AHI, SWS time and arousal index (AI)) suggested that all were independently associated with AF (AHI: OR 1.45 [1.13-1.87] per SD, p = 0.004; SWS time: OR 0.65 [0.49-0.87] per SD, p = 0.004; AI: OR 0.65 [0.50-0.86] per SD (12/hr), p = 0.002). Conclusion: In a cross-sectional study of a large multi-ethnic population, the prevalence of AF was associated with more severe SDB, shorter SWS time, and lower AI. This finding highlights sleep architecture’s implication, potentially via autonomic balance, in the association between sleep and AF.

Rural Barriers to Surgical Care for Children With Sleep-Disordered Breathing

2021 ◽  
pp. 019459982199338
Author(s):  
Flora Yan ◽  
Dylan A. Levy ◽  
Chun-Che Wen ◽  
Cathy L. Melvin ◽  
Marvella E. Ford ◽  
...  
Keyword(s):  
Logistic Regression ◽  
Regression Analysis ◽  
Sleep Disordered Breathing ◽  
Healthy Children ◽  
Loss To Follow Up ◽  
Cox Regression Analysis ◽  
Obstructive Sleep ◽  
The Impact ◽  
Disordered Breathing

Objective To assess the impact of rural-urban residence on children with obstructive sleep-disordered breathing (SDB) who were candidates for tonsillectomy with or without adenoidectomy (TA). Study Design Retrospective cohort study. Setting Tertiary children’s hospital. Methods A cohort of otherwise healthy children aged 2 to 18 years with a diagnosis of obstructive SDB between April 2016 and December 2018 who were recommended TA were included. Rural-urban designation was defined by ZIP code approximation of rural-urban commuting area codes. The main outcome was association of rurality with time to TA and loss to follow-up using Cox and logistic regression analyses. Results In total, 213 patients were included (mean age 6 ± 2.9 years, 117 [55%] male, 69 [32%] rural dwelling). Rural-dwelling children were more often insured by Medicaid than private insurance ( P < .001) and had a median driving distance of 74.8 vs 16.8 miles ( P < .001) compared to urban-dwelling patients. The majority (94.9%) eventually underwent recommended TA once evaluated by an otolaryngologist. Multivariable logistic regression analysis did not reveal any significant predictors for loss to follow-up in receiving TA. Cox regression analysis that adjusted for age, sex, insurance, and race showed that rural-dwelling patients had a 30% reduction in receipt of TA over time as compared to urban-dwelling patients (hazard ratio, 0.7; 95% CI, 0.50-0.99). Conclusion Rural-dwelling patients experienced longer wait times and driving distance to TA. This study suggests that rurality should be considered a potential barrier to surgical intervention and highlights the need to further investigate geographic access as an important determinant of care in pediatric SDB.

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