Beyond Usual Care: A Multidisciplinary Approach Towards the Treatment of Obstructive Sleep Apnoea

Obstructive Sleep Apnoea (OSA) is common and characterised by repeated apnoeas and hypopnoeas while asleep due to collapse of the upper airway. OSA can have a significant impact on physical and mental health and, when left untreated, is associated with increased risk of developing cardiovascular ill health. Besides cardiorespiratory implications excessive daytime sleepiness, morning headaches, limited memory function and lack of concentration are some further symptoms caused by OSA. Continuous Positive Airway Pressure (CPAP) therapy is the evidence-based treatment to maintain upper airway patency in patients with moderate to severe OSA. Proper adherence to CPAP therapy successfully abolishes nocturnal apnoeas and hypopnoeas, and diminishes consequences of uncontrolled OSA, such as treatment resistant hypertension. However, long term adherence to CPAP remains an unresolved limitation of this method. Although alternatives to CPAP therapy may be less efficacious, there is a variety of non-CPAP treatments that includes conventional lifestyle advice, postural advice, the use of mandibular advancement devices (MADs), surgical treatment options, such as uvulopalatopharyngoplasty, tonsillectomy, or maxillomandibular advancement, and the use of electrical stimulation of the upper airway dilator muscles. Hypoglossal Nerve Stimulation is available as an invasive (HNS) and a transcutaneous (TESLA) approach. For the management of “difficult-to-treat” patients with OSA, particularly in those in whom first line therapy proved to be unsuccessful, a multidisciplinary team approach may be helpful to incorporate the available options of non-CPAP therapy and provide appropriate choices. Symptom control, patient-related outcome measures and long-term cardiovascular health should be prioritised when choosing long-term therapies to treat OSA. The inclusion of patients in the choice of successful management options of their condition will facilitate better long-term adherence. Advancing clinical trials in the field will further help to resolve the relative lack of evidence for effective non-CPAP methods.

Comparison of Saans neonatal continuous positive airway pressure against standard of care for intra-hospital transport of neonates with respiratory distress syndrome

Background: CPAP (continuous positive airway pressure) therapy, effective in managing neonates with respiratory distress. While CPAP therapy is indicated right from birth, existing CPAP systems are designed for/installed in, NICUs. As a result, most neonates with RD (respiratory distress) are managed with only oxygen therapy during transportation in low resource settings. This study compares a novel, low-cost, portable neonatal CPAP system for use in transport from the labor room to the NICU, against conventional oxygen therapy in low resource settings.Methods: This was an open-label, 2 arm study with a treatment arm (low-cost indigenous CPAP device for therapy) and a control group (oxygen therapy). A total of 132 neonates were assigned with 66 in (matched-control study), in each group.Results: Both arms (CPAP and oxygen) had similar gestational age. gender distributions and initial SAS scores. The CPAP group had higher use of antenatal steriods (38 versus 26) compared to oxygen group and a lower need for surfactant (28 versus 40). Also, a larger number of neonates required ventilation in oxygen group (42) versus CPAP group (15), with the p=0.000561 the result is significant at p<0.05.Conclusions: CPAP therapy induced in labor room measurably improves neonates health and reduces respiratory distress. The indigenous low-cost CPAP device (Saans) used in this study effectively provides CPAP therapy to neonates during transport from the labor room to the NICU, reducing respiratory distress and the need for mechanical ventilation, making useful addition to labor rooms.

Quantitative Changes in Muscular and Capillary Oxygen Desaturation Measured by Optical Sensors during Continuous Positive Airway Pressure Titration for Obstructive Sleep Apnea

Obstructive sleep apnea (OSA) is a common sleep disorder, and continuous positive airway pressure (CPAP) is the most effective treatment. Poor adherence is one of the major challenges in CPAP therapy. The recent boom of wearable optical sensors measuring oxygen saturation makes at-home multiple-night CPAP titrations possible, which may essentially improve the adherence of CPAP therapy by optimizing its pressure in a real-life setting economically. We tested whether the oxygen desaturations (ODs) measured in the arm muscle (arm_OD) by gold-standard frequency-domain multi-distance near-infrared spectroscopy (FDMD-NIRS) change quantitatively with titrated CPAP pressures in OSA patients together with polysomnography. We found that the arm_OD (2.08 ± 1.23%, mean ± standard deviation) was significantly smaller (p-value < 0.0001) than the fingertip OD (finger_OD) (4.46 ± 2.37%) measured by a polysomnography pulse oximeter. Linear mixed-effects models suggested that CPAP pressure was a significant predictor for finger_OD but not for arm_OD. Since FDMD-NIRS measures a mixture of arterial and venous OD, whereas a fingertip pulse oximeter measures arterial OD, our results of no association between arm_OD and finger_OD indicate that the arm_OD mainly represented venous desaturation. Arm_OD measured by optical sensors used for wearables may not be a suitable indicator of the CPAP titration effectiveness.

Obstructive sleep apnea syndrome: association of serum melatonin, increased daytime sleepiness, and intermitting night hypoxemia

The relevance of studies related to the features of respiratory disorders during sleep is undeniable due to the steady growth of the worldwide prevalence of apnea syndrome, which leads to a decrease in quality of life, the risk of early cardiovascular diseases together with cerebrovascular, endocrine, and pulmonary disorders.The aim of this study was to determine the relationship between the morning serum melatonin, blood oxygen saturation (SрO2), and increased daytime sleepiness in patients with SOAS, as well as to assess changes in the production of endogenous melatonin after eliminating clinical manifestations of nocturnal hypoxemia, through a 3-month course of non-invasive continuous positive airway pressure (CPAP) therapy. The study enrolled 30 male patients who came to the Federal State Public Scientific Institution “Scientific Centre of Family Health and Human Reproduction Problems” because of snoring, sleep apnea, and increased daytime sleepiness.Methods. Polysomnography, questionnaire, HPLC-MS/MS analysis of serum melatonin levels, CPAP-therapy for the respiratory support at home for 3 months, monitoring of the sleep scores, serum melatonin, and daytime sleepiness after the treatment.Results. A comparative assessment of the sleep scores before and after the respiratory support for 3 months revealed a significant improvement in sleep structure, elimination of the apnea episodes, and restoration of blood SрO2 after the therapy. Analysis of the serum melatonin vales confirmed a statistically significant increase of melatonin level against baseline in patients with SOAS after the treatment. A correlation analysis showed a relationship between the melatonin level, daytime sleepiness, and blood SрO2.Conclusion. The results of this study and the data of other researchers demonstrate that the elimination of intermittent nocturnal hypoxia in patients with SOAS allows reducing the morning serum melatonin level, thereby reducing the daytime sleepiness and subsequently improving the quality of life.

Obstructive sleep apnea and cardiovascular comorbidity: modern discordance in assessing the effectiveness of CPAP-therapy against the pathogenetic mechanisms and cardiovascular diseases

Sleep-disordered breathing (and obstructive sleep apnea, OSA) is a common pathology in the general population in economically developed countries. In the last decades, CPAP therapy (continuous positive airway pressure) became the first-choice treatment option in clinically relevant OSA.Objective. The review summarized available evidence about the effects of CPAP-therapy on the main pathogenetic pathways of OSA (sleep-related sympathetic activity, vascular inflammation, endothelial dysfunction, oxidative stress, and blood coagulation) and cardiovascular diseases (CVDs - hypertension, cardiac arrhythmias, heart failure, pulmonary hypertension, coronary heart disease, and combined cardiovascular outcomes, including cardiovascular mortality).Methods. We analyzed the data of the randomized observational cohort clinical trials and metaanalyses, which assessed the effects of CPAP-therapy on the pathophysiological mechanisms of OSA and the associated CVDs. We also analyzed current guidelines on the management of patients with CVDs and OAS. We searched the following databases: Scopus, Pubmed, Google Scholar, Russian Scientific Citation Index.Results. Despite the rather recent implementation of this method, the accumulated evidence shows its favorable impact on OSA pathogenesis (on sympathetic activity and, to some extent, on vascular inflammation and endothelial dysfunction) and CVDs (hypertension, in particular, resistant hypertension, and paroxysmal atrial fibrillation). The observational studies also demonstrate favorable outcomes regarding other CVDs. However, the data of the randomized clinical trials are limited or controversial, the samples are rather small, which leads to inconsistent conclusions.Conclusion. Currently, most of the researchers emphasize that the required CPAP-adherence level (regular use for at least 4 h nightly) is the main barrier to getting the high-level evidence of CPAP efficiency with regard to the cardiovascular risk. This factor becomes the biggest limitation in patients who are characterized by the low compliance because they are not prone to daytime sleepiness.

Accepting an Assisted Sleep - Addressing Barriers that Influence Engagement with Continuous Positive Air Pressure Therapy through Design.

<p>This paper aims to answer the question ‘What are the initial experiences of people who use Continuous Positive Air Pressure (CPAP) therapy, and how can design address barriers that influence engagement within the first week of therapy?’ Obstructive Sleep Apnoea (OSA) is a respiratory sleep condition that is characterised by a repetitive collapse of the upper airway during sleep, causing a lack of oxygen and build up on carbon dioxide within the body. Left untreated, OSA can lead to serious medical conditions that may significantly reduce one’s quality of life and risk early death. The primary treatment for OSA is Continuous Positive Air Pressure (CPAP) therapy. This is a machine that pumps pressurised air through a facial mask to keep the airway open during sleep. Even though CPAP is the most effective treatment for OSA, it is known to be burdensome and adherence is problematic. This thesis identifies the barriers that influence CPAP engagement through literature reviews, online surveys, cultural probes, and interviews with manufacturers, clinicians and CPAP users. The barriers identified include first impressions, product-related and social stigma, the ability to troubleshoot issues and the level of support, education and feedback present in the initial stages of therapy. The outputs from this research focus on improving the user experience through design-based interventions. First, packaging solutions that focus on the interaction, the user’s first impressions, display of product information, and ease of assembly of the equipment. Second, a website that addresses education, support, customisation and the ability to troubleshoot issues. Third, customisable aspects that focus on personalisation of the CPAP equipment through 3D knitting processes that develop customised fabric hose covers. Lastly an application that addresses feedback, support and troubleshooting issues. Concepts are assessed against their relevance to the design criteria.</p>

Accepting an Assisted Sleep - Addressing Barriers that Influence Engagement with Continuous Positive Air Pressure Therapy through Design.

<p>This paper aims to answer the question ‘What are the initial experiences of people who use Continuous Positive Air Pressure (CPAP) therapy, and how can design address barriers that influence engagement within the first week of therapy?’ Obstructive Sleep Apnoea (OSA) is a respiratory sleep condition that is characterised by a repetitive collapse of the upper airway during sleep, causing a lack of oxygen and build up on carbon dioxide within the body. Left untreated, OSA can lead to serious medical conditions that may significantly reduce one’s quality of life and risk early death. The primary treatment for OSA is Continuous Positive Air Pressure (CPAP) therapy. This is a machine that pumps pressurised air through a facial mask to keep the airway open during sleep. Even though CPAP is the most effective treatment for OSA, it is known to be burdensome and adherence is problematic. This thesis identifies the barriers that influence CPAP engagement through literature reviews, online surveys, cultural probes, and interviews with manufacturers, clinicians and CPAP users. The barriers identified include first impressions, product-related and social stigma, the ability to troubleshoot issues and the level of support, education and feedback present in the initial stages of therapy. The outputs from this research focus on improving the user experience through design-based interventions. First, packaging solutions that focus on the interaction, the user’s first impressions, display of product information, and ease of assembly of the equipment. Second, a website that addresses education, support, customisation and the ability to troubleshoot issues. Third, customisable aspects that focus on personalisation of the CPAP equipment through 3D knitting processes that develop customised fabric hose covers. Lastly an application that addresses feedback, support and troubleshooting issues. Concepts are assessed against their relevance to the design criteria.</p>

A latent-class heteroskedastic hurdle trajectory model: patterns of adherence in obstructive sleep apnea patients on CPAP therapy

Background Sleep apnea patients on CPAP therapy exhibit differences in how they adhere to the therapy. Previous studies have demonstrated the benefit of describing adherence in terms of discernible longitudinal patterns. However, these analyses have been done on a limited number of patients, and did not properly represent the temporal characteristics and heterogeneity of adherence. Methods We illustrate the potential of identifying patterns of adherence with a latent-class heteroskedastic hurdle trajectory approach using generalized additive modeling. The model represents the adherence trajectories on three aspects over time: the daily hurdle of using the therapy, the daily time spent on therapy, and the day-to-day variability. The combination of these three characteristics has not been studied before. Results Applying the proposed model to a dataset of 10,000 patients in their first three months of therapy resulted in nine adherence groups, among which 49% of patients exhibited a change in adherence over time. The identified group trajectories revealed a non-linear association between the change in the daily hurdle of using the therapy, and the average time on therapy. The largest difference between groups was observed in the patient motivation score. The adherence patterns were also associated with different levels of high residual AHI, and day-to-day variability in leakage. Conclusion The inclusion of the hurdle model and the heteroskedastic model into the mixture model enabled the discovery of additional adherence patterns, and a more descriptive representation of patient behavior over time. Therapy adherence was mostly affected by a lack of attempts over time, suggesting that encouraging these patients to attempt therapy on a daily basis, irrespective of the number of hours used, could drive adherence. We believe the methodology is applicable to other domains of therapy or medication adherence.

Obstructive sleep apnoea and 12-month weight loss in adults with class 3 obesity attending a multidisciplinary weight management program

Background Although there is a strong association between obesity and obstructive sleep apnoea (OSA), the effects of OSA and CPAP therapy on weight loss are less well known. The aim of this study in adults with class 3 obesity attending a multidisciplinary weight management program was to assess the relationship between OSA and CPAP usage, and 12-month weight change. Methods A retrospective cohort study of all patients commencing an intensive multidisciplinary publicly funded weight management program in Sydney, Australia, between March 2018 and March 2019. OSA was diagnosed using laboratory overnight sleep studies. Demographic and clinical data, and use of CPAP therapy was collected at baseline and 12 months. CPAP use was confirmed if used ≥4 h on average per night on download. Results Of the 178 patients who joined the program, 111 (62.4 %) completed 12 months in the program. At baseline, 63.1 % (n=70) of patients had OSA, of whom 54.3 % (n=38) were using CPAP. The non-OSA group had more females compared to the OSA with CPAP group and OSA without CPAP group (90.2 % vs. 57.9 % and 62.5 %, respectively; p=0.003), but there were no significant baseline differences in BMI (50.4±9.3 vs. 52.1±8.7 and 50.3±9.5 kg/m2, respectively; p=0.636). There was significant weight loss across all three groups at 12 months. However, there were no statistically significant differences across groups in the percentage of body weight loss (OSA with CPAP: 6.3±5.6 %, OSA without CPAP: 6.8±6.9 %, non-OSA: 7.2±6.5 %; p=0.844), or the proportion of patients who achieved ≥5 % body weight loss (OSA with CPAP: 57.9 %, OSA without CPAP: 59.4 %, non-OSA: 65.9 %; p=0.743). In patients with T2DM, there was a significant reduction in HbA1c from baseline to 12 months (7.8±1.7 % to 7.3±1.4 %, p=0.03), with no difference between groups (p=0.997). Conclusions This multidisciplinary weight management program resulted in significant weight loss at 12 months, regardless of OSA diagnosis or CPAP use in adults with class 3 obesity. Larger studies are needed to further investigate the effects of severity of OSA status and CPAP use in weight management programs. Until completed, this study suggests that the focus should remain on implementing lifestyle changes and weight management regardless of OSA status.

The Oxygen Desaturation Measured by Optical Sensor at Fingertip but Not at the Arm Is Diminished by Continuous Positive Airway Pressure in Obstructive Sleep Apnea

Obstructive sleep apnea (OSA) is a common sleep disorder, and continuous positive airways pressure (CPAP) is the most effective treatment. Poor adherence is one of the major challenges in CPAP therapy. The recent boom of wearable optical sensors measuring oxygen saturation makes the at-home multiple-night CPAP titrations possible, which may essentially improve the adherence of CPAP therapy by optimizing its pressure in a real-life setting economically. We tested whether the oxygen desaturations (OD) measured in the arm muscle (arm_OD) by gold-standard frequency-domain multi-distance near-infrared spectroscopy (FDMD-NIRS) changes with titrated CPAP pressures in OSA patients together with polysomnography. We found that the arm_OD (2.08 &plusmn; 1.23%, mean &plusmn; standard deviation) was significantly smaller (P-value &amp;lt;0.0001) than the fingertip OD (finger_OD) (4.46 &plusmn; 2.37%) measured by polysomnography pulse oximeter. Linear mixed-effects models suggested that CPAP pressure was a significant predictor for finger_OD but not for arm_OD. Since FDMD-NIRS measures a mixture of arterial and venous OD, whereas fingertip pulse oximeter measures arterial OD, our results of no association between arm_OD and finger_OD indicate that the arm_OD mainly represented venous desaturation. Arm_OD measured by near-infrared optical sensors may be not a suitable indicator of the effectiveness of CPAP titration.