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Rationale: Moderate-severe obstructive sleep apnea (OSA) (apnea–hypopnea index [AHI], >15 events/h) disturbs sleep through frequent bouts of apnea and is associated with daytime sleepiness. However, many individuals without moderate-severe OSA (i.e., AHI <15 events/h) also report sleepiness. Objectives: To test the hypothesis that sleepiness in the AHI <15 events/h group is a consequence of substantial flow limitation in the absence of overt reductions in airflow (i.e., apnea/hypopnea). Methods: A total of 1,886 participants from the MESA sleep cohort were analyzed for frequency of flow limitation from polysomnogram-recorded nasal airflow signal. Excessive daytime sleepiness (EDS) was defined by an Epworth Sleepiness Scale score ⩾11. Covariate-adjusted logistic regression assessed the association between EDS (binary dependent variable) and frequency of flow limitation (continuous) in individuals with an AHI <15 events/h. Results: A total of 772 individuals with an AHI <15 events/h were included in the primary analysis. Flow limitation was associated with EDS (odds ratio, 2.04; 95% confidence interval, 1.17–3.54; per 2–standard deviation increase in flow limitation frequency) after adjusting for age, sex, body mass index, race/ethnicity, and sleep duration. This effect size did not appreciably change after also adjusting for AHI. Conclusions: In individuals with an AHI <15 events/h, increasing flow limitation frequency by 2 standard deviations is associated with a twofold increase in the risk of EDS. Future studies should investigate addressing flow limitation in low-AHI individuals as a potential mechanism for ameliorating sleepiness. [ABSTRACT FROM AUTHOR]

Background: Continuous positive airway pressure is the standard treatment for obstructive sleep apnea. However, nonadherence to continuous positive airway pressure use remains a significant limitation that prevents satisfactory results from being achieved. Epworth Sleepiness Scale score and sleep efficiency values may predict adherence. This study aims to assess the relationship between the Epworth Sleepiness Scale score and sleep efficiency measured during continuous positive airway pressure titration polysomnography. Methods: A retrospective analysis of the medical records of patients with obstructive sleep apnea/hypopnea who had undergone polysomnography for continuous positive airway pressure titration in an ear, nose, and throat center between January 2014 and August 2017. Results: Assessment of 170 individuals based on the Epworth Sleepiness Scale score and sleep efficiency during polysomnography with continuous positive airway pressure showed that patients with excessive daytime sleepiness had higher sleep efficiency (mean = 82.0%) than patients with normal daytime sleepiness (mean = 78.1%) (P = .043). Conclusion: Patients with excessive daytime sleepiness as measured on the Epworth Sleepiness Scale have higher sleep efficiency during continuous positive airway pressure titration polysomnography. [ABSTRACT FROM AUTHOR]

Objective: To establish the prevalence of upper airway resistance syndrome (UARS) according to different diagnostic criteria and evaluate its epidemiological characteristics in a representative sample of a large urban center.Methods: This was a single-center evaluation involving volunteers from EPISONO, an epidemiological study focused on sleep disturbances and related factors in adults from São Paulo, Brazil in 2007.Results: Considering the diagnostic criteria for UARS to be an apnea-hypopnea index of <5 events/h, minimum SpO2 ≥ 92%, the presence of airflow limitation during sleep for ≥5% of total sleep time, and daytime symptoms (sleepiness and/or fatigue), we observed a prevalence of the condition of 3.1% (4.4% in women and 1.5% in men).Conclusions: Although the diagnostic criteria for UARS, or even its existence as a syndrome, are still a subject of debate in the literature, the findings from this epidemiological study highlights UARS as a non-hypoxic sleep-disordered breathing condition with a significant prevalence in the general population, being more frequent among female young adults. [ABSTRACT FROM AUTHOR]

Background: Pulse transit time (PTT) is a non-invasive measure of arousals and respiratory effort for which we aim to identify threshold values that detect sleep disordered breathing (SDB) in children. We also compare the sensitivity and specificity of oximetry with the findings of a multi-channel study.Methods: We performed a cross-sectional observational study of 521 children with SDB admitted for multi-channel sleep studies (pulse oximetry, ECG, video, sound, movement, PTT) in a secondary care centre. PTT data was available in 368 children. Studies were categorised as normal; primary snoring; upper airway resistance syndrome (UARS); obstructive sleep apnoea (OSA), and “abnormal other.” Receiver operator characteristic curves were constructed for different PTT (Respiratory swing; Arousal index) thresholds using a random sample of 50% of children studied (training set); calculated thresholds of interest were validated against the other 50% (test set). Study findings were compared with oximetry categories (normal, inconclusive, abnormal) using data (mean and minimum oxygen saturations; oxygen desaturations > 4%) obtained during the study.Results: Respiratory swing of 17.92 ms identified SDB (OSA/UARS) with sensitivity: 0.80 (C.I. 0.62–0.90) and specificity 0.79 (C.I. 0.49–0.87). PTT arousal index of 16.06/ hour identified SDB (OSA/UARS) with sensitivity: 0.85 (95% C.I. 0.67–0.92) and specificity 0.37 (95% C.I. 0.17–0.48). Oximetry identified SDB (OSA) with sensitivity: 0.38 (C.I. 0.31–0.46) and specificity 0.98 (C.I. 0.97–1.00).Conclusions: PTT is more sensitive but less specific than oximetry at detecting SDB in children. The additional use of video and sound enabled detection of SDB in twice as many children as oximetry alone.

Background: Pulse transit time (PTT) is a non-invasive measure of arousals and respiratory effort for which we aim to identify threshold values that detect sleep disordered breathing (SDB) in children. We also compare the sensitivity and specificity of oximetry with the findings of a multi-channel study. Methods: We performed a cross-sectional observational study of 521 children with SDB admitted for multi-channel sleep studies (pulse oximetry, ECG, video, sound, movement, PTT) in a secondary care centre. PTT data was available in 368 children. Studies were categorised as normal; primary snoring; upper airway resistance syndrome (UARS); obstructive sleep apnoea (OSA), and "abnormal other." Receiver operator characteristic curves were constructed for different PTT (Respiratory swing; Arousal index) thresholds using a random sample of 50% of children studied (training set); calculated thresholds of interest were validated against the other 50% (test set). Study findings were compared with oximetry categories (normal, inconclusive, abnormal) using data (mean and minimum oxygen saturations; oxygen desaturations > 4%) obtained during the study. Results: Respiratory swing of 17.92 ms identified SDB (OSA/UARS) with sensitivity: 0.80 (C.I. 0.62–0.90) and specificity 0.79 (C.I. 0.49–0.87). PTT arousal index of 16.06/ hour identified SDB (OSA/UARS) with sensitivity: 0.85 (95% C.I. 0.67–0.92) and specificity 0.37 (95% C.I. 0.17–0.48). Oximetry identified SDB (OSA) with sensitivity: 0.38 (C.I. 0.31–0.46) and specificity 0.98 (C.I. 0.97–1.00). Conclusions: PTT is more sensitive but less specific than oximetry at detecting SDB in children. The additional use of video and sound enabled detection of SDB in twice as many children as oximetry alone. [ABSTRACT FROM AUTHOR]

Barry J Krakow,1–3 Jessica J Obando,2 Victor A Ulibarri,1,2 Natalia D McIver1,2 1Sleep & Human Health Institute, 2Maimonides Sleep Arts & Sciences, Albuquerque, 3Los Alamos Medical Center, Los Alamos, NM, USA Study objectives: Patients with comorbid posttraumatic stress disorder (PTSD) and obstructive sleep apnea (OSA) manifest low adherence to continuous positive airway pressure (CPAP) due to fixed, pressure-induced expiratory pressure intolerance (EPI), a subjective symptom and objective sign aggravated by anxiety sensitivity and somatosensory amplification. As advanced PAP therapy modes (ie, auto-bilevel PAP [ABPAP] or adaptive servo-ventilation [ASV]) may address these side effects, we hypothesized such treatment would be associated with decreased expiratory intolerance and increased adherence in posttraumatic stress patients with co-occurring OSA.Methods: We reviewed charts of 147 consecutive adult patients with moderately severe posttraumatic stress symptoms and objectively diagnosed OSA. All patients failed or rejected CPAP and were manually titrated on auto-adjusting, dual-pressure ABPAP or ASV modes in the sleep laboratory, a technique to eliminate flow limitation breathing events while resolving EPI. Patients were then prescribed either mode of therapy. Follow-up encounters assessed patient use, and objective data downloads (ODDs) measured adherence.Results: Of 147 charts reviewed, 130 patients were deemed current PAP users, and 102 provided ODDs: 64 used ASV and 38 used ABPAP. ODDs yielded three groups: 59 adherent per insurance conventions, 19 subthreshold compliant partial users, and 24 noncompliant. Compliance based on available downloads was 58%, notably higher than recently reported rates in PTSD patients with OSA. Among the 19 partial users, 17 patients were minutes of PAP use or small percentages of nights removed from meeting insurance compliance criteria for PAP devices.Conclusion: Research is warranted on advanced PAP modes in managing CPAP failure in PTSD patients with comorbid OSA. Subthreshold adherence constructs may inform clinical care in a patient-centric model distinct from insurance conventions. Speculatively, clinical application of this transitional zone (“subthreshold” number of hours) may increase PAP use and eventual adherence. Keywords: obstructive sleep apnea, upper airway resistance syndrome, CPAP, compliance, auto-bilevel, adaptive servo-ventilation

Barry Krakow,1–3 Natalia D McIver,1,2 Victor A Ulibarri,1,2 Michael R Nadorff4,5 1Sleep & Human Health Institute, 2Maimonides Sleep Arts & Sciences, Ltd, Albuquerque, 3Los Alamos Medical Center, Los Alamos, NM, 4Department of Psychology, Mississippi State University, Mississippi, MS, 5Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, Houston, TX, USA Purpose: Emerging evidence shows that positive airway pressure (PAP) treatment of obstructive sleep apnea (OSA) and upper airway resistance syndrome (UARS) in chronic insomnia patients (proposed “complex insomnia” disorder) leads to substantial decreases in insomnia severity. Although continuous PAP (CPAP) is the pressure mode most widely researched, intolerance to fixed pressurized air is rarely investigated or described in comorbidity patients. This retrospective study examined dual pressure, autoadjusting PAP modes in chronic, complex insomnia disorder patients.Patients and methods: Chronic insomnia disorder patients (mean [SD] insomnia severity index [ISI] =19.11 [3.34]) objectively diagnosed with OSA or UARS and using either autobilevel PAP device or adaptive servoventilation (ASV) device after failing CPAP therapy (frequently due to intolerance to pressurized air, poor outcomes, or emergence of CSA) were divided into PAP users (≥20 h/wk) and partial users (

Objective: To characterize sleep-disordered breathing patterns not related to hypoxia resulting in fragmented sleep in children.Methods: We reviewed the polysomnogram (PSG) data of children with sleep complaints who were being evaluated for sleep-disordered breathing and had an apnea-hypopnea-index ≤ 3. These data were compared to the recordings of the same children with nasal CPAP administered for one night and to 60 control subjects (children without any sleep complaints). A subgroup of children was monitored with esophageal manometry, but nasal cannula flow data was recorded in all cases.Results: Abnormal breathing patterns, particularly flow limitation, could be seen with more severity and frequency compared to apnea or hypopnea. The observed abnormal breathing patterns were associated with EEG disturbances.Conclusions: Patterns such as flow-limitation, mouth-breathing, changes in inspiratory and expiratory time, rib-cage and expiratory muscle activity, transcutaneous CO2 electrode changes and snoring noises are all variables that should be systematically reviewed when analyzing nocturnal PSG. Current scoring guidelines emphasizes apnea-hypopnea and hypoxic-sleep disordered breathing and therefore treatment is often much delayed in this population of children with evidence of abnormal breathing patterns. Analysis of the various patterns of abnormal breathing noted above allows recognition of "non-hypoxic" sleep-disordered-breathing (SDB). [ABSTRACT FROM AUTHOR]

Obstructive sleep apnea (OSA) is defined by quantifying apneas and hypopneas along with symptoms suggesting sleep disruption. Subtler forms of sleep-disordered breathing can be missed when this criteria is used. Newer technologies allow for non-invasive detection of flow limitation, however consensus classification is needed. Subjects with flow limitation demonstrate electroencephalogram changes and clinical symptoms indicating sleep fragmentation. Flow limitation may be increased in special populations and treatment with nasal continuous positive airway pressure (CPAP) has been shown to improve outcomes. Titrating CPAP to eliminate flow limitation may be associated with improved clinical outcomes compared to treating apneas and hypopneas.

Background: Reduction of upper airway (UA) dimensions during sleep is contemplated to cause reduced sleep efficiency (SE) but a definitive association is not affirmed. Efficacy of nasopharyngeal appliance (NPA) in management of UA resistance syndrome (UARS) has not been compared with mandibular repositioning splint (MRS). This study intended to assess relation of UA dimensions to SE and effectiveness of NPA. Materials and Methods: Research had two phases: Case-control study to determine association between UA and SE; randomized control trial (with independent concurrent trial groups and double-blind design) to analyze treatment outcome with NPA. Subjects were categorized to three groups of 20 in each: A control group of healthy subjects (Group A); two "Randomly Assigned" sample groups of subjects with reduced SE (Groups B and C). Preliminary questionnaire for sleep analysis, Final data collection sheet (first and second case sheets) were recorded, cephalometric variables analyzed, and diagnostic overnight polysomnography was done to match and confirm selection criteria. Three-dimensional computed tomography was done to analyze airway dimensions before and after appliance placement. ANOVA and post-hoc tests were used for statistical analysis of results. Conclusions: Reduced UA dimension during sleep is associated with reduced SE; NPA gives better improvement for UARS than MRS.

Objective: To evaluate the available literature regarding Upper Airway Resistance Syndrome (UARS) treatment. Methods: Keywords “Upper Airway Resistance Syndrome,” “Sleep-related Breathing Disorder treatment,” “Obstructive Sleep Apnea treatment” and “flow limitation and sleep” were used in main databases. Results: We found 27 articles describing UARS treatment. Nasal continuous positive airway pressure (CPAP) has been the mainstay therapy prescribed but with limited effectiveness. Studies about surgical treatments had methodological limitations. Oral appliances seem to be effective but their efficacy is not yet established. Conclusion: Randomized controlled trials with larger numbers of patients and long-term follow-up are important to establish UARS treatment options.

Clinical and radiographic characteristics of a subset of South East Asian temporomandibular disorder (TMD) patients with comorbid upper airway resistance syndrome (UARS) were documented in a multi-center prospective series of 86 patients (26 men and 60 women / mean age 35.7 years). All had excessive daytime sleepiness, high arousal index and Apnoea-Hypopnoea Index ( AHI) <5. The mean body mass index was 20·1, mean arousal index 16·2, mean respiratory disturbance index 19·6, mean AHI 3·9 while the mean Epworth Sleepiness Scale was 14·8. Many had functional somatic complaints; 66·3% headaches, 41·9% neck aches, 53·5% masticatory muscle myalgia, 68·6% temporomandibular joint ( TMJ) arthralgia while 90·7% reported sleep bruxism ( SB). Unlike patients with obstructive sleep apnoea ( OSA), hypertension was uncommon (4·7%) while depression was prevalent at 68·6% with short REM latency of <90 min and an increased REM composition >25% documented in 79·6% and 57·6% of these depressed patients, respectively. 65·1% displayed a posteriorly displaced condyle at maximum intercuspation with or without TMJ clicking. Most exhibited a forward head posture ( FHP) characterised by loss of normal cervical lordosis (80·2%), C0-C1 narrowing (38·4%) or an elevated hyoid position (50%), and 91·9% had nasal congestion. We postulate the TMD- UARS phenotype may have originally developed as an adaptive response to 'awake' disordered breathing during growth. Patients with persistent TMD and/or reporting SB should be screened for UARS and chronic nasal obstruction, especially when they also present with FHP. The lateral cephalogram is a useful tool in the differentiation of UARS from other OSA phenotypes. [ABSTRACT FROM AUTHOR]

Introduction: Obstructive sleep apnea (OSA) is a secondary cause of intracranial hypertension (IH). Decreased jugular venous drainage has been seen in patients with idiopathic IH.Clinical Presentation: A complex case of a 48-year-old female whose idiopathic IH was put into remission after counterclockwise maxillomandibular advancement (CC-MMA), despite persistence of her OSA.Conclusion: This case highlights the relationship between OSA and IH and points to the significant morbidity that can result from mild OSA and from what are considered borderline intracranial pressures. This indicates the need for a high index of suspicion for actual underlying pathology that can be surgically corrected when patients manifest symptoms of a somatic syndrome. This is the first report in the medical literature of clinical elimination of IH by CC-MMA. The authors propose that this positive outcome was effected via mandibular advancement producing a decrease in jugular venous resistance, allowing improved absorption of cerebrospinal fluid. [ABSTRACT FROM AUTHOR]

This case presentation illustrates the importance of 24 hour ambulatory blood pressure monitoring in patients with white coat hypertension, as many progress into sustained hypertension over time. Also, it serves as a reminder not to overlook a possible underlying sleep breathing disorder in patients who are not obese or fatigued. Finally, the case provides an opportunity to review the value of non-pharmacological and lifestyle approaches to the treatment of both white coat hypertension and sustained hypertension. [ABSTRACT FROM AUTHOR]

Statement of Problem: Obstructive sleep apnea is the most frequent cause for insomnia in the populace. Snoring is mulled over as the potential factor that can lead the sequel to obstructive sleep apnea. Although the etiology and deterrence measures for snoring are yet to be undoubtedly clarified by our scientific sorority, various means of surgical corrections have been affirmed and put into practice, with a substantial degree of success. Despite this, it is implicit that a noninvasive method of managing obstructive sleep apnea is more relevant for overcoming this condition. Purpose: This manuscript intends to establish how snoring can be controlled prosthodontically by different modalities of scientifically defensible approaches. The most effective among the modalities was affirmed as the investigative analyses of the treatment outcomes with each modality. Novel Methods: Four new methods of managing obstructive sleep apnea - uvula lift appliance, uvula and velopharynx lift appliance, nasopharyngeal aperture guard, and soft palate lift appliance were demonstrated through this article. Clinical Reports: The four new modalities stated and one conventional modality of mandibular advancement appliance for managing obstructive sleep apnea, a total of five types of appliance therapies, were described with case reports for each. Investigation: Five individuals undergoing the appliance therapy were chosen for each modality. The treatment outcome with each modality was examined by analysis of clinical predictors and also by means of standard investigation, with nasal and oral endoscopic analyses. Result: Among the five types of appliance therapies, the nasopharyngeal aperture guard provided the best treatment outcome in terms of clinical predictors and endoscopic analyses. Conclusion: Nasopharyngeal aperture guard, the novel method stated in this article is the better modality for managing obstructive sleep apnea, among the five different appliance therapies.

BACKGROUND: Research on subthreshold compliance with positive airway pressure (PAP) therapy in sleep apnea patients may inform clinical sleep medicine practice. We retrospectively assessed compliant and subthreshold compliant sleep apnea subjects to test whether regular but fewer hours of PAP use would demonstrate clinically meaningful improvements and correlate with outcomes. METHODS: A chart review was conducted of 113 consecutive sleep apnea subjects, naive to treatment, who completed a titration study and filled a PAP therapy prescription. Objective data categorized subjects into 3 groups: compliant, subthreshold compliant, and minimal use. Outcome measures assessed changes in insomnia, sleepiness, and nocturia on average 7 months from PAP initiation. Correlation coefficients analyzed dose-response relationships between hours of use and changes in outcomes. RESULTS: Among 113 PAP attempters, 104 (92%) were current users. Among 93 users with objective data, regular (consistent) PAP users included 59 compliant and 21 subthreshold compliant, and 13 subjects were minimal users. Compliant users averaging 6.6 ± 1.3 h/night and 42.0 ± 12.1 h/week showed the largest outcome improvements (all P < .05) with moderate to large effects for insomnia (d = 0.94), sleepiness (d = 0.58), and nocturia (d = 0.56). Subthreshold users averaging 4.1 ± 0.7 h/night but only 18.0 ± 5.6 h/week showed a large effect for insomnia (d = 0.76, P = .03) and nonsignificant, small effects for sleepiness (d = 0.38) and nocturia (d = 0.22). Correlation coefficients showed a trend for decrease in insomnia (P = .08; r = .20) and a significant decrease in nocturia (P = .034; r = 0.25), each in association with hours of PAP use. CONCLUSIONS: In a clinical sample, 86% of sleep apnea subjects regularly used PAP, but adherence was 63%. Regular users showed clinical treatment effects and potential dose-response relationships, suggesting that the term use offers advantages over the term adherence. Currently, subthreshold compliance may not merit insurance coverage in many countries, an issue affecting many sleep apnea patients. [ABSTRACT FROM AUTHOR]

Posttraumatic stress disorder (PTSD) and sleep-disordered breathing (SDB) are common disorders, but limited data address their co-morbidity. Emerging research indicates PTSD and SDB may co-occur more frequently than expected and may impact clinical outcomes. This review describes historical developments that first raised suspicions for a co-morbid relationship between PTSD and SDB, including barriers to the recognition and diagnosis of this co-morbidity. Objective diagnostic data from polysomnography studies in PTSD patients reveal widely varying prevalence rates for co-morbidity (0-90%). Use of standard, recommended technology (nasal cannula pressure transducer) versus older, less reliable technology (thermistor/thermocouple) appears to have influenced objective data acquisition and therefore SDB rates in sleep studies on PTSD patients. Studies using higher quality respiratory sensors demonstrated the highest prevalence of SDB in PTSD patients. Clinical relevance, theoretical models and research recommendations are discussed. The lack of widely acknowledged, tested, or proven explanatory models and pathophysiological mechanisms to understand the relationship between these two disorders may prove formidable barriers to further investigations on prevalence and clinical relevance, albeit both conditions are associated with waking or sleeping hyperarousal activity, which may inform future studies. [ABSTRACT FROM AUTHOR]

Background: Reduction of upper airway (UA) dimensions during sleep is contemplated to cause reduced sleep efficiency (SE) but a definitive association is not affirmed. Efficacy of nasopharyngeal appliance (NPA) in management of UA resistance syndrome (UARS) has not been compared with mandibular repositioning splint (MRS). This study intended to assess relation of UA dimensions to SE and effectiveness of NPA.Materials and Methods: Research had two phases: Case-control study to determine association between UA and SE; randomized control trial (with independent concurrent trial groups and double-blind design) to analyze treatment outcome with NPA. Subjects were categorized to three groups of 20 in each: A control group of healthy subjects (Group A); two "Randomly Assigned" sample groups of subjects with reduced SE (Groups B and C). Preliminary questionnaire for sleep analysis, Final data collection sheet (first and second case sheets) were recorded, cephalometric variables analyzed, and diagnostic overnight polysomnography was done to match and confirm selection criteria. Three-dimensional computed tomography was done to analyze airway dimensions before and after appliance placement. ANOVA and post-hoc tests were used for statistical analysis of results.Conclusions: Reduced UA dimension during sleep is associated with reduced SE; NPA gives better improvement for UARS than MRS. [ABSTRACT FROM AUTHOR]

Highlights: [•] Upper airway resistance syndrome (UARS) patients have increased somatic arousal (SA) compared to healthy controls. [•] For all participants, increased SA correlated with increased sleepiness/fatigue. [•] For all participants, increased SA correlated with decreased sleep quality. [•] For all participants, increased SA correlated with decreased physical/mental health. [•] For all participants, increased SA correlated with decreased cognitive function. [ABSTRACT FROM AUTHOR]

Purpose: The aim of this study is to describe a distinctive respiratory pattern seen in subjects with inferior turbinate hypertrophy, nasal obstruction, and a polysomnogram-proven diagnosis of primary snoring or mild obstructive sleep apnea. These subjects demonstrated increased snoring with purely nasal breathing and alleviation of snoring with oral breathing. The study design is case series with chart review. The setting was a university-based tertiary care hospital. Methods: A retrospective chart review was performed for patients with complaints of nasal obstruction with associated inferior turbinate hypertrophy and a polysomnogram-proven diagnosis of mild obstructive sleep apnea or primary snoring. Demographic and polysomnography information were collected and analyzed. Snoring and airflow patterns were reviewed. Results: Twenty-five subjects were identified as having met the inclusion and exclusion criteria on polysomnography for either primary snoring or mild obstructive sleep apnea with inferior turbinate hypertrophy and no other significant nasal deformity or abnormality. Seventeen (68 %) of these patients had polysomnograms which demonstrated snoring during nasal breathing and alleviation of snoring with oral breathing. Of the 17 who snored during nasal breathing, ten of the subjects were female and seven of the subjects were male. The mean age was 27 years (range 18 to 68 years). The mean apnea-hypopnea index was 2.3 events/h (range 0 to 9.7 events/h). The mean body mass index was 25 kg/m (range 20 to 43 kg/m). Conclusion: Our study describes a newly recognized pattern of snoring in patients with a polysomnogram-proven diagnosis of either primary snoring or mild obstructive sleep apnea. This pattern of breathing demonstrates patients who snore during nasal breathing even with known nasal obstruction present and subsequently have resolution or improvement of the snoring with oral breathing. [ABSTRACT FROM AUTHOR]

Objectives: A test of the hypothesis that upper airway resistance syndrome (UARS) patients have an increased prevalence of inspiratory airflow limitation (IFL) during sleep compared to healthy controls. Methods: We compared inspiratory airflow dynamics during sleep between 12 UARS patients (nine females and three males) and 12 healthy controls matched for age, gender and obesity with maximal age limited at 45 years. A standard clinical polysomnogram (airflow measured with a nasal/oral pressure catheter) was performed to assess the impact of SDB on the participants’ natural sleep. A second full-night polysomnogram with a pneumotachograph and a supraglottic pressure catheter to measure airflow and effort was performed to compare the maximal inspiratory airflow and effort and the percentage of flow-limited breaths during supine, continuous stage 2 sleep between groups. Results: During clinical polysomnography, UARS participants did not differ significantly from controls in sleep architecture or fragmentation. We observed a small difference in apnea hypopnea index between UARS participants and controls (1.6 ± 1.9 vs. 0.4 ± 0.3, respectively; p = 0.035). During supine, continuous stage 2 sleep, 64.2 % (35.8; mean (SD)) of UARS participants’ breaths were flow-limited compared with 34.0 % (39.3) of controls’ breaths ( p = 0.06). The groups did not differ in maximal inspiratory airflow or inspiratory effort. Conclusions: Our findings indicate a less-than-robust difference in respiratory parameters during sleep between UARS patients and healthy controls and no difference in standard sleep parameters or sleep fragmentation. We consider a pathophysiology of UARS that incorporates these findings. [ABSTRACT FROM AUTHOR]

Abstract: Objective: To compare clinical manifestations and polysomnographic data of sleep-disordered breathing (SDB) in younger (less than 30years old) versus older premenopausal women. Methods: A cohort of 420 premenopausal women diagnosed with SDB in a university sleep clinic during a 5-year period underwent systematic collection of clinical and polysomnographic variables. Results: One-hundred and fifteen (27.4%) women were younger than 30 (mean 24.5±3.5years), while 305 (72.6%) were older than 30 (mean 39.5±5.7years). The younger premenopausal women had less severe SDB with a trend towards upper-airway resistance syndrome. Despite similar daytime consequences, snoring was less common in the younger group. Both groups of premenopausal women frequently had insomnia and nasal abnormalities or craniofacial-deficiency. Conclusion: Recognizing the different clinical features and understanding the different polysomnographic presentation of SDB in young premenopausal women are crucial to detecting and treating this syndrome. [Copyright &y& Elsevier]

Purpose: We aimed to investigate the prevalence of primary snoring (PS) and its association with neurocognitive impairments. Methods: Data from a community-based study in 1,114 primary school children were used to identify children who never ( N = 410) or habitually snored ( N = 114). In order to separate children with PS from those with upper airway resistance syndrome (UARS) or obstructive sleep apnoea (OSA), home polysomnography was conducted in all habitually snoring children. Neurocognitive impairments and poor school performance were compared between children who never snored, PS, and UARS/OSA. Results: Polysomnography was successfully conducted in 92 habitual snorers. Of these, 69 and 23 had PS and UARS/OSA, respectively. Prevalence [95% confidence interval (95% CI)] of PS was 6.1% (4.5-7.7). Compared to children who had never snored, children with PS had more hyperactive (39% vs. 20%) and inattentive behaviour (33% vs. 11%), as well as poor school performance in mathematics (29% vs. 16%), science (23% vs. 12%), and spelling (33% vs. 20%; all P values <0.05). PS was a significant risk factor (odds ratio; 95% CI) for hyperactive behaviour (2.8; 1.6-4.8), inattentive behaviour (4.4; 2.4-8.1), as well as daytime sleepiness (10.7; 4.0-28.4). PS was also an independent risk factor for poor school performance in mathematics (2.6; 1.2-5.8), science (3.3; 1.2-8.8), and spelling (2.5; 1.1-5.5). Odds ratios throughout were similar to the UARS/OSA group. Conclusions: Children with non-hypoxic, non-apnoeic PS may exhibit significant neurocognitive impairments. Consequences may be similar to those associated with UARS or OSA. If confirmed, PS is not 'benign' and may require treatment. [ABSTRACT FROM AUTHOR]

Upper airway resistance syndrome (UARS) is a condition where the apnea-hypopnea index is less than 5 and respiratory-effort related arousal index is more than 10. The clinical presentation of UARS may be the same as obstructive sleep apnea-hypopnea syndrome (OSAS); it sometimes shows up with symptoms hardly suggestive of a sleep-disordered breathing. A 17 year-old male patient had applied to a local psychiatry clinic and complained of chronic fatigue, insomnia, behavioral and academic problems and was treated for anxiety and depression. After a period of unresponsive treatment, he was sent to a sleep center for evaluation of insomnia, which turned out to be a fragmented, unrefreshing sleep episode. Polysomnographical evaluation revealed that he had UARS without OSAS. His complaints decreased dramatically after he received CPAP treatment. This case shows that UARS should be considered in young patients with functional somatic syndromes even if the clinical presentation does not apparently imply the condition. [ABSTRACT FROM AUTHOR]

We report a young female with snoring and daytime sleepiness who exhibited frequent premature ventricular complexes (PVCs) primarily during non-rapid eye movement sleep. She was underweight and suspected to have respiratory effort-related arousal (RERA) based on polysomnographic data. The presence of autonomic instability and alternating conducting system provoked by repetitive markedly negative intrathoracic pressure was assumed to be precipitating PVCs. Follow-up polysomnography after oral appliance therapy showed reduced PVCs. The results suggest that a careful evaluation of polysomonographic data is warranted when RERA is suspected as an underlying mechanism for nocturnal PVCs even in non-obese patients. [ABSTRACT FROM AUTHOR]

Abstract: Background: Patients with obstructive sleep apnea syndrome (OSAS) are known to have an increased risk for motor vehicle crashes. They suffer from sleep-related respiratory abnormality causing repetitive arousal leading to daytime sleepiness. In turn, it has been demonstrated that sleepiness can impair human psychomotor performance causing slowing of reaction times (RTs). Patients with OSAS present with RTs comparable to young adults under the influence of blood alcohol concentrations above the legally permitted level to drive a motor vehicle. Vigilance related risk levels in patients with upper airway resistance syndrome (UARS) and potential deficits in psychomotor performance are unknown. Methods: We designed a study to compare psychomotor performance in UARS and compared it to patients with OSAS. Forty-seven UARS patients were matched by gender and age with 47 OSAS patients. All subjects completed a standardized vigilant attention task utilizing reaction time before undergoing polygraphic sleep studies. Results: Patients with UARS presented worse psychomotor performance on most test metrics than patients with OSAS. Conclusions: Our study results may suggest that patients with UARS may also present an increased risk for motor vehicle crashes as previously demonstrated in OSAS patients. [Copyright &y& Elsevier]

The question of whether upper airway resistance syndrome (UARS) is a distinct disease or an initial feature of obstructive sleep apnoea syndrome is still a matter of debate. We evaluated a retrospective group of UARS patients to determine the evolution of UARS over time and the relationship between clinical evolution and subjects’ phenotype. Investigations were performed in 30 patients, in whom UARS was diagnosed between 1995 and 2000 by the use of full polysomnography (PSG) without oesophageal pressure (Pes) measurement. The time between initial and follow-up investigations was 6.6 ± 2.6 years. All subjects had full PSG with Pes measurement and completed a sleep questionnaire, including the Epworth Sleepiness Scale. In 19 subjects, PSG results were compatible with UARS. In nine subjects, obstructive sleep apnoea–hypopnoea syndrome (OSAHS) was diagnosed. In two subjects, PSG did not demonstrate breathing abnormalities. The mean ± SD apnoea–hypopnoea index in the UARS group was 1.5 ± 1.7 h−1 and 25.2 ± 19 h−1 in the OSAHS group ( P < 0.01). The increase in body mass index (BMI) between initial and follow-up investigations in the UARS group was from 29.4 ± 4 to 31 ± 5.7 kg m−2 ( P = 0.014) and in the OSAHS group from 30 ± 4.1 to 32.4 ± 4.7 kg m−2( P = 0.004). Amplitude of Pes swings during respiratory events was significantly higher in OSAHS than that in UARS ( P = 0.014). Our results suggest that UARS is part of a clinical continuum from habitual snoring to OSAHS. Progression from UARS to OSAHS seems to be related to an increase in the BMI. [ABSTRACT FROM AUTHOR]

Obstructive sleep disorders develop when the normal reduction in pharyngeal dilator activity at sleep onset occurs in an individual whose pharynx requires a relatively high level of dilator activity to remain sufficiently open. They range from steady snoring, to slowly evolving hypopneas, to fast-recurring obstructive hypopneas and apneas. A fundamental observation is that the polysomnographic picture differs substantially among subjects with the same pharyngeal collapsibility, and even in the same subject at different times, indicating that the type and severity of the disorder is determined to a large extent by the individual's response to the obstruction. The present report reviews the various mechanisms involved in the response to sleep-induced obstructive events. When the obstructive event takes the form of mild-moderate flow limitation, compensation can take place through an increase in the fraction of time spent in inspiration (Ti/Ttot) without any increase in maximum flow (V[subMAX]). With more severe obstructions, V[subMAX] must increase. Recent data indicate that the obstructed upper airway can reopen reflexly, without arousal, if chemical drive is allowed to reach a threshold (T[subER]) but that this is often preempted by a low arousal threshold. The relation between T[subER] and arousal threshold, as well as the lung-to-carotid circulation time and the rate of rise of chemical drive during the obstructive event, determine the magnitude of ventilatory overshoot at the end of an event and, by extension, whether initial obstructive events will be followed by stable breathing, slow evolving hypopneas with occasional arousals, or repetitive events. [ABSTRACT FROM AUTHOR]

Abstract: Objective: In order to test the hypothesis that upper airway resistance syndrome (UARS) is merely an extension of the pathophysiology of obstructive sleep apnea/hypopnea (OSA/H) to less severe pharyngeal collapse during sleep, we compared the severity of hypersomnolence and the prevalence of insomnia in UARS patients to the patterns observed for OSA/H patients. Our goal was to determine whether the severity of hypersomnolence and the prevalence of insomnia observed in UARS patients could have been predicted from the patterns observed among OSA/H patients. Methods: We performed a retrospective study of a large consecutive patient series evaluated at an academic sleep disorders center, including 220 OSA/H patients and 137 UARS patients. Patients had no other sleep-related diagnosis and underwent an initial evaluation that included a measure of hypersomnolence [a multiple sleep latency test (MSLT); 95%] or insomnia questionnaire (87%). Patients were characterized by anthropometric data, polysomnographic descriptive measures of sleep, MSLT data and insomnia questionnaire data. Results: Severity of hypersomnolence decreased over the continuum from severe to mild OSA/H. A model fit to the OSA/H patients to predict severity of hypersomnolence significantly underestimated hypersomnolence in UARS patients, which was comparable in severity to that of patients with mild OSA/H. The frequency of sleep-onset insomnia increased over the continuum from severe to mild OSA/H and increased further in UARS. Conclusions: UARS is, in some respects, an extension of OSA/H to less severe pharyngeal collapse, but this does not adequately account for the symptom profile of patients with UARS. A physical model is proposed to account for the excess somnolence in UARS relative to expectations and the increasing frequency of sleep-onset insomnia along the continuum from severe OSA/H to UARS. [Copyright &y& Elsevier]

Abstract: Background: The clinical features of patients with upper airway resistance syndrome (UARS) have previously been compared to patients with obstructive sleep apnea/hypopnea syndrome (OSAHS). No data regarding differences between patients with primarysnoring (PS) or patients with obstructive sleep apnea/hypopnea without daytime sleepiness (OSAH) are available. We conducted a study to investigate clinical features of UARS, comparing them to those in patients with PS, OSAH, and OSAHS. Methods: Retrospective chart analysis of 157 patients with PS, 424 patients with UARS, 562 patients with OSAH, and 1610 patients with OSAHS seen in two sleep disorders clinics between 1996 and 2006. All patients had a diagnostic polysomnography (PSG) and a comprehensive clinical history taken by board-certified sleep specialists. Results: PS and UARS patients were significantly younger, less overweight and had lower weight gain during the past 5years. The female-to-male ratio was highest in the UARS group. UARS patients had significantly less stage non-rapid eye movement sleep (NREM) 1 and NREM 2 and significantly more NREM 3 and NREM 4 sleep than OSAH and OSAHS patients. Arousal indices between PS/UARS and OSAH/OSAHS patients were significantly lower, with no significant difference within these diagnostic categories. Patients with UARS presented the highest degree of subjective impairment. Conclusions: UARS patients share some clinical features of patients with OSAHS and PS, although these two groups differ in their presentation of clinical sleepiness. Patients with UARS were most impaired in terms of their daily functioning and perception of sleep quality. This finding could not be corroborated by objective measures. [Copyright &y& Elsevier]

Abstract: This prospective study aimed to assess symptomatic evolution of patients diagnosed with Upper Airway Resistance Syndrome (UARS) four and half years after the initial UARS diagnosis. For this purpose, 138 UARS patients were contacted by mail between 43 and 69 months after the initial evaluation; 105 responded to the letter and 94 patients accepted to undergo new clinical and polysomnographic evaluations. Initial and follow-up polysomnographic recordings were scored using the same criteria. Results: Of the 94 patients who completed the follow-up examination, none of them were using nasal CPAP. It was related to refusal by insurance providers to provide equipment based on initial apnea–hypopnea index (AHI) in 90/94 subjects. Percentage of patients with sleep related-complaints significantly increased over the four and half year period: daytime fatigue, insomnia and depressive mood increased by 12 to 20 times. Reports of sleep maintenance sleep onset insomnia and depressive mood was significantly increased. Hypnotic, antidepressant and stimulant prescription increased from initial to follow-up visit (from 11.7% to 61.7%; from 3.2% to 25.5% and from 0% to 9.6%, respectively) with antidepressant given as much for sleep disturbance as mood disorder. The polysomnography results at follow-up showed that 5 subjects had AHI compatible with Obstructive Sleep Apnea Syndrome (OSAS) but overall, respiratory disturbance index had no significant change. Total sleep time was significantly reduced compared to initial visit. Conclusions: Many UARS patients remained untreated following initial evaluation. Worsening of symptoms of insomnia, fatigue and depressive mood were seen with absence of treatment of UARS. [Copyright &y& Elsevier]

Abstract: Background and purpose: Thirty-two chronic sleepwalkers who were part of a larger, previously reported sleepwalking group all achieved control of sleepwalking after undergoing treatment for an associated sleep disorder. In the current study, all records were blindly scored to perform a cyclic alternating pattern (CAP) analysis. Patients and methods: Thirty-two young adult chronic sleepwalkers had polysomnography (PSG) on initial nights without sleepwalking events, as did age-matched normal controls and patients with mild sleep-disordered breathing (SDB). More than 90% of these patients with mild SDB had upper airway resistance syndrome (UARS). Ten randomly selected PSGs for sleepwalkers and matched controls also had quantitative electroencephalographic (EEG) analysis using Fast Fourier Transformation (FFT) with determination of delta power for each non-rapid eye movement (NREM)–REM sleep cycle. Results: Compared to normal controls, an investigation of CAP in sleepwalkers demonstrated the presence of an abnormal CAP rate with a decrease in phase A1 and an increase in phases A2 and A3 on non-sleepwalking nights. The results of CAP analysis in sleepwalkers were similar to those obtained in age-matched UARS patients. Furthermore, the analysis of the first four NREM–REM sleep cycles reconfirmed the presence of an important decrease in delta power in sleep cycles 1 and 2 during a non-sleepwalking night in sleepwalkers compared to normal controls. Conclusions: The presence of both ‘hypersynchronous slow delta’ and ‘burst of delta waves’ have been reported in sleepwalkers, but their significance is controversial. These EEG patterns are similar to phase A1 (and possibly A2) of the CAP. Proper analysis of the sleep EEG of sleepwalkers should integrate CAP analysis. Sleepwalkers on a non-sleepwalking night present instability of NREM sleep, as demonstrated by this analysis. This instability is similar to the one noted in UARS patients. Subtle sleep disorders associated with chronic sleepwalking constitute the unstable NREM sleep background on which sleepwalking events occur. A subtle associated sleep disorder should be systematically searched for and treated in the presence of sleepwalking with abnormal CAP. [Copyright &y& Elsevier]

Abstract: Background and purpose: We questioned the role of respiratory events in obstructive sleep apnea syndrome (OSAS) and of upper airway resistance syndrome (UARS) on heart rate (HR) during sleep, paying specific attention to the termination of the abnormal breathing events and examining the presence of arousals or termination with only central nervous system (CNS) activation. Patients and methods: Twenty patients, 10 with UARS and 10 with mild OSAS, were studied. A nocturnal polysomnogram was performed including measurement of respiratory variables and pulse transit time (PTT). According to the presence or absence of a PTT event indicative of autonomic nervous system (ANS) activation, 148 events were extracted after having been randomly chosen in each represented sleep stage, with or without an electroencephalogram (EEG) arousal >1.5s. RR interval (RRI) in electrocardiogram (ECG) recordings, as well as heart rate variability, was calculated during 60 and 120s, respectively. Period amplitude analysis (PAA) was applied for RR-interval analysis, and fast Fourier transformation (FFT) was applied to perform HR variability analysis. Results: Visually scored EEG arousal was significantly associated with an increase in sympathetic index of heart rate, while PTT was associated with a drop in parasympathetic index, after the respiratory events. Patients with mild OSAS presented persistently shorter RRI when compared to patients with UARS. The latter also exhibited a significant decrease in parasympathetic index (High Frequency (HF)) at the termination of a respiratory event. Conclusion: The HF component was only significantly decreased in patients with UARS, which indicates a predominant involvement of the parasympathetic tone in patients with UARS in comparison to those with OSAS. [Copyright &y& Elsevier]

Study objectives: The upper airway resistance syndrome (UARS) is a recently described form of sleep-disordered breathing in which transient increases in upper airway resistance result in repetitive EEG arousals. UARS is not associated with apnea or diminished airflow, although snoring and excessive daytime somnolence (EDS) are common. This report describes a subset of patients with UARS diagnosed by polysomnography who do not manifest snoring, which we define as silent upper airway resistance syndrome (SUARS). Design: A retrospective review of all polysomnographies performed at our sleep disorders center during 2000. Setting: Sleep disorders center of a large, academic, military hospital. Patients: Our center serves military personnel, military retirees, and their dependent families. Interventions: Esophageal manometry during polysomnography was routinely performed on patients with hypersomnolence (Epworth sleepiness scale> 10) who demonstrated a total arousal index ≥ 10/h and a respiratory disturbance index of < 5/h on prior polysomnography. UARS was definitely diagnosed in patients who demonstrated repetitive increased upper airway resistance (IUAR) associated with brief EEG arousals followed by normalization of esophageal pressure (Pes). IUAR was defined by a pattern of crescendo negative inspiratory Pes of ≤ - 12 cm 1120. Results: During calendar year 2000, we performed 724 polysomnographies in 527 patients. Obstructive sleep apnea was diagnosed in 383 patients (72.6%), and 44 patients (8.4%) were found to have UARS. In four patients with UARS (0.8% of total and 9.1% of UARS), snoring was not reported by history or observed during polysomnography, and SUARS was ultimately diagnosed. Conclusions: UARS may occur in the absence of clinically significant snoring and may be an occult cause of EDS. We report a prevalence of SUARS of 9% among UARS patients and nearly 1% of all patients studied for hypersomnolence by polysomnography.

Objective: A high degree of sleep fragmentation by arousals related to respiratory events would result in an abnormal distribution of slow wave activity (SWA) and a decrease in sleep spindle density in sleep disordered breathing (SDB) patients when compared to controls.Methods: Eighteen mild SDB subjects (6 females and 12 males), aged 18–56 years with (5

Objectives: Upper airway resistance syndrome (UARS) and obstructive sleep apnea syndrome (OSAS) are associated with arousals and autonomic activation. Pulse transit time (PTT) has been used to recognize transient arousals. We examined the accuracy of PTT to recognize arousals, and the relationship between PTT deflection and visual and non-visual arousals.Methods: Ten UARS and 10 mild OSAS subjects were studied via polysomnography including measurement of esophageal pressure. Electroencephalogram (EEG) spectral power was obtained from central leads. Seven types of events were identified, depending upon the presence or absence of: a sleep-related respiratory event (SRRE), i.e. apnea, hypopnea, and abnormal breathing effort; a PTT signal; or a visually scored arousal (>1.5 s).Results: One thousand four hundred forty-six events were identified in 20 subjects. Fifty-nine percent of all SRREs were associated with a PTT signal and a visual EEG arousal. Nineteen percent of SRREs had no EEG arousals at their termination, and 7.4% had no associated PTT signal. Delta power was significantly increased when non-visual EEG arousals were scored. The time delay for PTT was determined by the presence or absence of EEG arousal. The sensitivity of PTT to recognize EEG arousal was 90.4% and the specificity was 16.8%. The sensitivity and specificity of PTT to recognize SRRE was 90.7 and 21.9%, respectively.Conclusions: These results preclude the use of PTT by itself. SRREs induce an activation with positive PTT response but without arousal in 14% of cases. This PTT response, however, is much slower than that occurring with arousal. UARS and mild OSAS do not respond in the same way to SRREs, particularly during rapid eye movement sleep. [ABSTRACT FROM AUTHOR]

Standard psychiatric classification (DSM-IV-TR) traditionally attributes post-traumatic sleep disturbance to a secondary or symptomatic feature of a primary psychiatric disorder. The DSM-IV-TR paradigm, however, has not been validated with objective sleep assessment technology, incorporated nosological constructs from the field of sleep disorders medicine, or adequately addressed the potential for post-traumatic stress disorder (PTSD) sleep problems to manifest as primary, physical disorders, requiring independent medical assessments and therapies. This paradigm may limit understanding of sleep problems in PTSD by promulgating such terms as “insomnia related to another mental disorder,” a.k.a. “psychiatric insomnia.” Emerging evidence invites a broader comorbidity perspective, based on recent findings that post-traumatic sleep disturbance frequently manifests with the combination of insomnia and a higher-than-expected prevalence of sleep-disordered breathing (SDB). In this model of complex sleep disturbance, the underlying sleep pathophysiology interacts with PTSD and related psychiatric distress; and this relationship appears very important as demonstrated by improvement in insomnia, nightmares, and post-traumatic stress with successful SDB treatment, independent of psychiatric interventions. Continuous positive airway pressure treatment in PTSD patients with SDB reduced electroencephalographic arousals and sleep fragmentation, which are usually attributed to central nervous system or psychophysiological processes. Related findings and clinical experience suggest that other types of chronic insomnia may also be related to SDB. We hypothesize that an arousal-based mechanism, perhaps initiated by post-traumatic stress and/or chronic insomnia, may promote the development of SDB in a trauma survivor and perhaps other patients with chronic insomnia. We discuss potential neurohormonal pathways and neuroanatomatical sites that may be involved in this proposed interaction between insomnia and SDB. [ABSTRACT FROM AUTHOR]

Objectives: A cohort of postmenopausal women complaining of chronic insomnia for over 6 months and free of hypnotic intake was recruited mostly from the community. Three hundred and ninety-four women were included. The following questions were addressed: How many presents sleep disordered breathing (SDB)? Which type of SDB (upper airway resistance syndrome [UARS] or obstructive sleep apnea syndrome [OSAS]) is the most frequent? Is there a specific upper airway anatomical abnormality in SDB patients predisposing to the syndrome?Population: Subjects were recruited in the community or referred by the Sleep Clinic and all had complaint of chronic poor sleep.Methodology: First step. Questionnaires, visual analog scales, clinical interview, clinical evaluation with work-up, actigraphy, and ambulatory monitoring were used. Second step. Otolaryngologic evaluation, ambulatory sleep monitoring, and reading of results were used. Subjects negative for SDB at ambulatory monitoring had polysomnography (PSG) with pressure transducer/nasal cannula system and esophageal manometry measurements.Results: Population. Three hundred and ninety-four individuals responded to all entry criteria. Ambulatory monitoring identified 194 subjects with OSAS. Two hundred individuals were not recognized with SDB and were submitted to PSG. This further testing showed that 68 subjects had normal breathing, 62 had UARS, and 100 mild OSAS. Based on otolaryngological evaluation, subjects were classified based on the presence or absence of narrow upper airway, and the location of narrowing was assessed.Conclusion: A total of 326 postmenopausal women complaining of chronic insomnia had a SDB, usually with low apnea-hypopnea index (AHI). This total represents about 83% of the studied women. Questions of the role of SDB in the complaint of chronic insomnia are raised. [ABSTRACT FROM AUTHOR]

Objective: The question addressed here is: Can a discrete sleep disordered breathing (SDB) play a role in the insomnia complaint of postmenopausal chronic insomniacs? To respond to the query, two groups of individuals derived from a cohort of postmenopausal chronic insomniacs recruited mostly from the community were enlisted in a treatment protocol. These subjects were all individuals identified with normal breathing (n=68) and all those recognized with Upper Airway Resistance Syndrome (UARS) (n=62) pooled from a cohort of 349 postmenopausal insomniacs. Treatment protocol: The 62 UARS were allocated to either treatment of chronic insomnia by behavioral approaches or treatment of SDB. Based on ENT evaluation, health professionals in charge of patients selected either treatment with nasal CPAP or treatment of nasal turbinates. A stratification correction was performed to obtain a near equal number of both treatment modalities in each of the two subgroups. The 68 individuals with normal breathing were randomly allocated to immediate behavioral treatment of insomnia or delay treatment of insomnia. The delay treatment received a list of 10 sleep hygiene recommendations by mail. Methodology: Questionnaires, visual analog scales (VAS), Epworth Sleepiness Scale (ESS), clinical interviews, clinical evaluation with oto-laryngologic clinical assessment of a presence/absence of narrow upper airway and location of narrowing. Actigraphy and polysomnography (PSG) with pressure transducer/and nasal cannula system and esophageal manometry. Data analyses: All recording data were scored blind to patient''s condition. Results: Two subjects in the SBD-CPAP treated group (Group B) and two subjects in the delayed treatment group (Group D) dropped out. Total sleep time was improved compared to baseline in all groups, including the delayed treatment group. One group was significantly better (ANOVA, P=.05) with a more important δ score compared to baseline, and this was the behaviorally treated non-SDB. Sleep latency was significantly decreased in the behaviorally treated group (with or without SBD), P=.05, compared to SBD-treated and delayed treatment groups. Sleep latency was, however, improved in all groups. VAS for “quality of sleep” was higher at 6 months in all the groups when compared to “baseline” values. VAS for “daytime fatigue” showed significant differences among the four groups (ANOVA, P=.01); the overall score at the end of treatment was significantly better in the SDB-treated group than the other three groups. SBD was treated either by radio frequency on nasal turbinate or by nasal CPAP. CPAP-treated patients had a lower VAS score than nasal turbinate treatment, but the difference was only a trend. The δ improvement (6-month baseline condition) in “daytime fatigue” of each subgroup was calculated and compared within and between groups. Despite the small number of subjects, the turbinate-treated subgroup was significantly different from Groups B, C and D (ANOVA, P=.05). When a similar comparison was made with the nasal CPAP group, there was only a nonsignificant trend when compared to Groups B, C and D. Conclusion: Abnormal breathing during sleep significantly enhanced complaints of daytime fatigue in postmenopausal chronic insomniacs and this complaint improved with SDB treatment. This improvement is significantly better compared to SDB insomniacs treated with a behavioral regimen. Behavioral treatment, however, gave the best response in the non-SDB chronic insomnia group and improved better long sleep latency even in the SDB group. These results suggest the need to find an appropriate treatment for SBD even if mild and to recognize the role of SDB in relation to symptoms seen with chronic insomnia. [Copyright &y& Elsevier]

Study Objectives: The presence of flow limitation during sleep is associated with adverse health consequences independent of obstructive sleep apnea (OSA) severity (apnea-hypopnea index, AHI), but remains extremely challenging to quantify. Here we present a unique library and an accompanying automated method that we apply to investigate flow limitation during sleep., Methods: A library of 117,871 breaths (N = 40 participants) were visually classified (certain flow limitation, possible flow limitation, normal) using airflow shape and physiological signals (ventilatory drive per intra-esophageal diaphragm EMG). An ordinal regression model was developed to quantify flow limitation certainty using flow-shape features (e.g. flattening, scooping); breath-by-breath agreement (Cohen's ƙ); and overnight flow limitation frequency (R2, %breaths in certain or possible categories during sleep) were compared against visual scoring. Subsequent application examined flow limitation frequency during arousals and stable breathing, and associations with ventilatory drive., Results: The model (23 features) assessed flow limitation with good agreement (breath-by-breath ƙ = 0.572, p < 0.001) and minimal error (overnight flow limitation frequency R2 = 0.86, error = 7.2%). Flow limitation frequency was largely independent of AHI (R2 = 0.16) and varied widely within individuals with OSA (74[32-95]%breaths, mean[range], AHI > 15/h, N = 22). Flow limitation was unexpectedly frequent but variable during arousals (40[5-85]%breaths) and stable breathing (58[12-91]%breaths), and was associated with elevated ventilatory drive (R2 = 0.26-0.29; R2 < 0.01 AHI v. drive)., Conclusions: Our method enables quantification of flow limitation frequency, a key aspect of obstructive sleep-disordered breathing that is independent of the AHI and often unavailable. Flow limitation frequency varies widely between individuals, is prevalent during arousals and stable breathing, and reveals elevated ventilatory drive. Clinical trial registration: The current observational physiology study does not qualify as a clinical trial., (© Sleep Research Society 2021. Published by Oxford University Press on behalf of the Sleep Research Society. All rights reserved. For permissions, please email: journals.permissions@oup.com.)

This case report is the first description of the treatment response to an oral appliance (OA) in a patient with upper airway resistance syndrome (UARS). OAs are devices inserted into the mouth in order to modify the position of the mandible and tongue, thus relieving pharyngeal obstruction during sleep in obstructive sleep apnea (OSA) patients. Findings from this case report suggest that an OA may be a useful treatment option for UARS patients. [ABSTRACT FROM AUTHOR]

Purpose: Upper airway resistance syndrome (UARS) is a sleep related breathing disorder that was first described in 1993. This goal of this study is to determine the efficacy of surgical intervention for UARS., Materials and Methods: Systematic review of the literature and a case series of UARS patients at a large integrated healthcare system. Meta-analysis was performed., Results: For the systematic review, 971 abstracts were reviewed and 3 articles were included, yielding 49 subjects. All of the included studies were of level 3 or 4 evidence. Significant improvement in Epworth Sleepiness Scale (ESS) score was noted after surgery in two level 4 studies. No significant change in ESS was noted in one level 3 study. Our retrospective chart review of eleven UARS patients compared preoperative and postoperative ESS scores, as well as sleep study data. Patients underwent a variety of surgical procedures. Our findings show a significant improvement in mean ESS scores after surgery, from 11.0 (±3.5) to 7.0 (±4.8) with p = 0.01, though no difference in apnea hypopnea index (AHI) and respiratory disturbance index (RDI) were identified. Meta-analysis was performed on 2 studies from the systematic review and our cases series data. UARS surgery showed a mean change in ESS of -5.89 (95% CI, -8.29 to -3.50)., Conclusions: This systematic review, meta-analysis and retrospective case series indicate that surgery may improve ESS scores in patients with UARS. AHI and RDI are unlikely to be impacted by surgery., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Study Objectives: Determine if changes in K-complexes associated with sustained inspiratory airflow limitation (SIFL) during N2 sleep are associated with next-day vigilance and objective sleepiness., Methods: Data from thirty subjects with moderate-to-severe obstructive sleep apnea who completed three in-lab polysomnograms: diagnostic, on therapeutic continuous positive airway pressure (CPAP), and on suboptimal CPAP (4 cmH2O below optimal titrated CPAP level) were analyzed. Four 20-min psychomotor vigilance tests (PVT) were performed after each PSG, every 2 h. Changes in the proportion of spontaneous K-complexes and spectral characteristics surrounding K-complexes were evaluated for K-complexes associated with both delta (∆SWAK), alpha (∆αK) frequencies., Results: Suboptimal CPAP induced SIFL (14.7 (20.9) vs 2.9 (9.2); %total sleep time, p < 0.001) with a small increase in apnea-hypopnea index (AHI3A: 6.5 (7.7) vs 1.9 (2.3); p < 0.01) versus optimal CPAP. K-complex density (num./min of stage N2) was higher on suboptimal CPAP (0.97 ± 0.7 vs 0.65±0.5, #/min, mean ± SD, p < 0.01) above and beyond the effect of age, sex, AHI3A, and duration of SIFL. A decrease in ∆SWAK with suboptimal CPAP was associated with increased PVT lapses and explained 17% of additional variance in PVT lapses. Within-night during suboptimal CPAP K-complexes appeared to alternate between promoting sleep and as arousal surrogates. Electroencephalographic changes were not associated with objective sleepiness., Conclusions: Sustained inspiratory airflow limitation is associated with altered K-complex morphology including the increased occurrence of K-complexes with bursts of alpha as arousal surrogates. These findings suggest that sustained inspiratory flow limitation may be associated with nonvisible sleep fragmentation and contribute to increased lapses in vigilance., (© Sleep Research Society 2021. Published by Oxford University Press on behalf of the Sleep Research Society. All rights reserved. For permissions, please email: journals.permissions@oup.com.)

Over the past 10 years, our ability to recognize, treat, and identify the morbidity associated with the upper airway resistance syndrome (UARS) has improved vastly. The diagnosis of this syndrome is dependent on a high degree of clinical suspicion, and in the presence of an already known pulmonary disease such as asthma, the identification of UARS may be elusive. Treatment of this condition has received more recent attention in the literature, with oral appliance therapy as a viable treatment option in place of the usual positive-pressure ventilation devices. [ABSTRACT FROM AUTHOR]

This case report details the treatment outcome of an oral appliance (OA) used in a patient suffering from excessive daytime sleepiness (EDS) caused by an upper airway resistance syndrome (UARS). The patient demonstrated significant improvement in the multiple sleep latency test (MSLT) and the maintenance of wakefulness test (MWT) after treatment with an OA. The presented case suggests that an OA may be considered as a further treatment option for UARS. [ABSTRACT FROM AUTHOR]