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Background Sleep-related problems are highly prevalent comorbidities in Attention-Deficit/Hyperactivity Disorder (ADHD). Objective This study aimed to investigate the associations between sleep-disordered breathing (SDB) and behavioral and cognitive functions in children with and without ADHD. Methods A total of 341 children were included (ADHD group: 155, control group: 186; age: 6–10 years). The participants' sleep-related symptoms were assessed using a parent-rated questionnaire, and they were categorized into low- and high-risk SDB groups based on their scores. Behavioral symptoms were assessed using the Behavioral Assessment System for Children, Second Edition (BASC-2), and cognitive sustained attention and inhibitory control were assessed using a computer-based continuous performance test. Results In the ADHD group, the high-risk SDB children showed significantly higher scores than the low-risk SDB group in externalizing problems (F = 4.22; P = 0.042), including hyperactivity (F = 4.65; P = 0.033) and attention problems (F = 8.19; P = 0.005), but not internalizing problems. Meanwhile, in the control group, the high-risk SDB children showed significantly higher scores than the low-risk SDB group in internalizing problems (F = 9.89; P = 0.002), depression (F = 9.45; P = 0.002), and somatization (F = 7.83; P = 0.006), as well as in externalizing problems (F = 7.72; P = 0.006), including hyperactivity (F = 6.23; P = 0.013), aggression (F = 5.00; P = 0.027), and conduct problems (F = 6.79; P = 0.010). Contrary to the behavioral outcomes, none of the attention performance subscale scores showed significant differences between the high- and low-risk SDB groups in either the ADHD or control group. Conclusions The present findings suggest that SDB is associated with behavioral problems in children with ADHD and controls, with stronger associations in control children. On the contrary, SDB has no association with cognitive attention performance. This study extends our understanding of the associations of SDB with behavioral symptoms and cognitive functions in children.

STUDY OBJECTIVES: Mandibular advancement devices (MADs) are a noninvasive treatment option for patients with obstructive sleep apnea (OSA) and act by increasing the upper airway volume. However, the exact therapeutic mechanism of action remains unclear. The aim of this study was to assess MAD mechanisms using functional imaging that combines imaging techniques and computational fluid dynamics and assess associations with treatment outcome. METHODS: One hundred patients with OSA were prospectively included and treated with a custom-made MAD at a fixed 75% protrusion. A low-dose computed tomography scan was made with and without MADs for computational fluid dynamics analysis. Patients underwent a baseline and 3-month follow-up polysomnography to evaluate treatment efficacy. A reduction in apnea-hypopnea index ≥ 50% defined treatment response. RESULTS: Overall, 71 patients completed both 3-month follow-up polysomnography and low-dose computed tomography scan with computational fluid dynamics analysis. MAD treatment significantly reduced the apnea-hypopnea index (16.5 [10.4–23.6] events/h to 9.1 [3.9–16.4] events/h; P < .001, median [quartile 1–quartile 3]) and significantly increased the total upper airway volume (8.6 [5.4–12.8] cm(3) vs 10.7 [6.4–15.4] cm(3); P = .003), especially the velopharyngeal volume (2.1 [0.5–4.1] cm(3) vs 3.3 [1.8–6.0] cm(3); P < .001). However, subanalyses in responders and nonresponders only showed a significant increase in the total upper airway volume in responders, not in nonresponders. CONCLUSIONS: MAD acts by increasing the total upper airway volume, predominantly due to an increase in the velopharyngeal volume. Responders showed a significant increase in the total upper airway volume with MAD treatment, while there was no significant increase in nonresponders. Findings add evidence to implement functional imaging using computational fluid dynamics in routine MAD outcome prediction. CLINICAL TRIAL REGISTRATION: Registry: ClinicalTrials.gov; Name: Predicting Therapeutic Outcome of Mandibular Advancement Device Treatment in Obstructive Sleep Apnea; URL: https://clinicaltrials.gov/ct2/show/NCT01532050; Identifier: NCT01532050. CITATION: Van Gaver H, Op de Beeck S, Dieltjens M, et al. Functional imaging improves patient selection for mandibular advancement device treatment outcome in sleep-disordered breathing: a prospective study. J Clin Sleep Med. 2022;18(3):739–750.

STUDY OBJECTIVES: Obstructive sleep apnea (OSA) is defined by pauses in breathing during sleep, but daytime breathing dysregulation may also be present. Sleep may unmask breathing instability in OSA that is usually masked by behavioral influences during wakefulness. A breath-hold (BH) challenge has been used to demonstrate breathing instability. One measure of breathing stability is breathing rate variability (BRV). We aimed to assess BRV during rest and in response to BH in OSA. METHODS: We studied 62 participants (31 with untreated OSA: respiratory event index [mean ± SD] 20 ± 15 events/h, 12 females, age 51 ± 14 years, body mass index [BMI] 32 ± 8 kg/m(2); 31 controls: 17 females, age 47 ± 13 years; BMI 26 ± 4 kg/m(2)). Breathing movements were collected using a chest belt for 5 minutes of rest and during a BH protocol (60 seconds baseline, 30 seconds BH, 90 seconds recovery, 3 repeats). From the breathing movements, we calculated median breathing rate (BR) and interquartile BRV at rest. We calculated change in BRV during BH recovery from baseline. Group comparisons of OSA vs control were conducted using analysis of covariance with age, sex, and BMI as covariates. RESULTS: We found 10% higher BRV in OSA vs controls (P < .05) during rest. In response to BH, BRV increased 7% in OSA vs 1% in controls (P < .001). Resting BR was not significantly different in OSA and controls, and sex and age did not have any significant interaction effects. BMI was associated with BR at rest (P < .05) and change in BRV with BH (P < .001), but no significant BMI-by-group interaction effect was observed. CONCLUSIONS: The findings suggest breathing instability as reflected by BRV is high in OSA during wakefulness, both at rest and in response to a stimulus. Breathing instability together with high blood pressure variability in OSA may reflect a compromised cardiorespiratory consequence in OSA during wakefulness. CITATION: Pal A, Martinez F, Akey MA, et al. Breathing rate variability in obstructive sleep apnea during wakefulness. J Clin Sleep Med. 2022;18(3):825–833.

STUDY OBJECTIVES: Oral appliance (OA) therapy is a well-tolerated alternative to continuous positive airway pressure. However, it is less efficacious. A major unresolved clinical challenge is the inability to accurately predict who will respond to OA therapy. We recently developed a model to estimate obstructive sleep apnea pathophysiological endotypes. This study aimed to apply this physiological-based model to predict OA treatment responses. METHODS: Sixty-two men and women with obstructive sleep apnea (aged 29–71 years) were studied to investigate the efficacy of a novel OA device. An in-laboratory diagnostic followed by an OA treatment efficacy polysomnography were performed. Seven polysomnography variables from the diagnostic study plus age and body mass index were included in our machine-learning-based model to predict OA therapy response according to standard apnea-hypopnea index (AHI) definitions. Initially, the model was trained on data from the first 45 participants using 10-fold cross-validation. A blinded independent validation was then performed for the remaining 17 participants. RESULTS: Mean accuracy of the trained model to predict OA therapy responders vs nonresponders (AHI < 5 events/h) using 10-fold cross-validation was 91% ± 8%. In the independent blinded validation, 100% (AHI < 5 events/h); 59% (AHI < 10 events/h); 71% (50% reduction in AHI); and 82% (50% reduction in AHI to < 20 events/h) of the 17 participants were correctly classified for each of the treatment outcome definitions respectively. CONCLUSIONS: While further evaluation in larger clinical data sets is required, these findings highlight the potential to use routinely collected sleep study and clinical data with machine learning–based approaches underpinned by obstructive sleep apnea endotype concepts to help predict treatment outcomes to OA therapy for people with obstructive sleep apnea. CITATION: Dutta R, Tong BK, Eckert DJ. Development of a physiological-based model that uses standard polysomnography and clinical data to predict oral appliance treatment outcomes in obstructive sleep apnea. J Clin Sleep Med. 2022;18(3):861–870.

Aim: In children with Prader-Willi syndrome (PWS), growth hormone (GH) improves height and body composition; however, may be associated with worsening sleep-disordered breathing (SDB). Some studies have reported less SDB after GH initiation, but follow-up with polysomnography is still advised in most clinical guidelines. Methods: This retrospective, multicentre study, included children with PWS treated with GH at seven PWS treatment centres in Australia over the last 18 years. A paired analysis comparing polysomnographic measures of central and obstructive SDB in the same child, before and after GH initiation was performed with Wilcoxon signed-rank test. The proportion of children who developed moderate/severe obstructive sleep apnoea (OSA) was calculated with their binomial confidence intervals. Results: We included 112 patients with available paired data. The median age at start of GH was 1.9 years (range 0.1–13.5 years). Median obstructive apnoea hypopnoea index (AHI) at baseline was 0.43/h (range 0–32.9); 35% had an obstructive AHI above 1.0/h. Follow-up polysomnography within 2 years after the start of GH was available in 94 children who did not receive OSA treatment. After GH initiation, there was no change in central AHI. The median obstructive AHI did not increase significantly (P = 0.13), but 12 children (13%, CI95% 7–21%) developed moderate/severe OSA, with clinical management implications. Conclusions: Our findings of a worsening of OSA severity in 13% of children with PWS support current advice to perform polysomnography after GH initiation. Early identification of worsening OSA may prevent severe sequelae in a subgroup of children.

STUDY OBJECTIVES: (1) To determine the sensitivity and specificity of the home sleep apnea test (HSAT) performed in typically developing children who were diagnosed with moderate to severe obstructive sleep apnea during overnight attended laboratory polysomnography (LPSG). (2) To determine the utility of a screening questionnaire to identify children at increased risk for obstructive sleep apnea. METHODS: Participants completed 2 consecutive study nights, the first night with the HSAT followed by LPSG on the second night. The SHOOTS questionnaire, composed of 6 questions (snoring, hyperactivity, obesity, observed apnea, tonsillar hypertrophy, and sleepiness) concerning sleep-disordered breathing, was administered by the clinician before the first study night. RESULTS: Thirty-eight participants completed both studies. The mean age was 13.8 ± 3.0 years. Twenty (53%) were male. Most participants were obese. The mean LPSG total sleep time was 7.34 ± 1.19 hours; the mean HSAT total recording time was 8.86 ± 1.73 hours (P < .001). The median obstructive apnea-hypopnea index for LPSG and HSAT was 6.6 and 0.8 events/h, respectively. For an obstructive apnea-hypopnea index ≥ 3.1 events/h by HSAT, the sensitivity was 71.43% (95% confidence interval, 41.9–91.6) and the specificity was 95.83% (95% confidence interval, 78.9–99.9) for identifying those with an LPSG obstructive apnea-hypopnea index of ≥ 10 events/h. For a SHOOTS score with ≥ 4 “yes” responses, the sensitivity and specificity were 85.7% (95% confidence interval, 57.2–98.2) and 54.2% (95% confidence interval, 32.8–74.4), respectively, for identifying those with an LPSG obstructive apnea-hypopnea index ≥ 10 events/h. CONCLUSIONS: Using HSAT, we clinically applied cutoff values to identify moderate to severe obstructive sleep apnea in typically developing children. The SHOOTS questionnaire may aid in identifying children at risk for obstructive sleep apnea and who are candidates for HSAT. CITATION: Revana A, Vecchio J, Guffey D, Minard CG, Glaze DG. Clinical application of home sleep apnea testing in children: a prospective pilot study. J Clin Sleep Med. 2022;18(2):533–540.

Background: Given the role of adenoid in the pathogenesis of otitis media with effusion (OME) and sleep-disordered breathing (SDB), the present study aimed to investigate the sleep quality and the impact of adenoidectomy on improvement of sleep symptoms in children with OME. Methods: Children with SDB or OME, aged 3–12 years, were prospectively enrolled before undergoing adenoidectomy in a tertiary medical center. The symptom severity of obstructive sleep apnea syndrome (OSAS) was evaluated by OSA-18 questionnaire on the day before and 6 months after surgery. Results: In total, 79 pediatric patients including 50 children with SDB and 29 children with OME were enrolled. The mean total OSA-18 score was 56.5 ± 15.1 and ten (34.5%) children experienced moderate to severe symptoms of OSAS as indicated by OSA-18 score ≥ 60 in OME group. After surgery, patients in both SDB and OME groups experienced improvement (both p

STUDY OBJECTIVES: References for the evaluation of obstructive sleep apnea often exceed the sleep clinic’s capacity. We aimed to assess the noninferiority of a nurse-communicated model compared with a traditional physician-led model for the initial management of uncomplicated obstructive sleep apnea in the sleep clinic. METHODS: In this noninferiority, open-label randomized controlled trial, patients referred for the evaluation of uncomplicated obstructive sleep apnea (home sleep apnea test with respiratory event index ≥ 20 events/h) were randomized to a nurse-communicated or a physician-led management. The primary endpoint was noninferiority in the mean change from baseline of the Epworth Sleepiness Scale score at 3 and 6 months, assuming a noninferiority margin of −2.0 points. Secondary outcomes included quality of life (Quebec Sleep Questionnaire) and positive airway pressure adherence. RESULTS: Two hundred participants were randomized to a nurse-communicated (n = 101) or physician-led management (n = 99). Overall, 48 participants were lost at follow-up (27.7% and 20.4% in the nurse-communicated and physician-led groups, respectively). Most participants were treated with positive airway pressure (78.2% and 80.6% in the nurse-communicated and physician-led management groups, respectively). There was substantial missing data for the Epworth Sleepiness Scale (33% and 58% at 3 and 6 months in the nurse-communicated group and 29% and 55% in the physician-led group) and Quebec Sleep Questionnaire (86% and 91% at 3 and 6 months and 79.6% and 85.7% in the physician-led group). The difference in mean change between groups for the Epworth Sleepiness Scale was −0.71 (95% confidence interval −2.25 to 0.83) at 3 months and −0.21 (95% confidence interval −1.85 to 1.45) at 6 months. For each domain of the Quebec Sleep Questionnaire at 3 and 6 months, the lower bound of the 95% confidence interval was greater than the prespecified noninferiority margin. Positive airway pressure adherence was similar between groups. CONCLUSIONS: Among patients with uncomplicated obstructive sleep apnea, nurse-communicated management was noninferior to physician-led management in terms of sleepiness, quality of life, and positive airway pressure adherence at 6 months. CLINICAL TRIAL REGISTRATION: Registry: ClinicalTrials.gov; Name: Management of Sleep Apnea Patients by a Clinical Nurse (Supernurse), URL: https://clinicaltrials.gov/ct2/show/NCT03455920; Identifier: NCT03455920. CITATION: Lajoie AC, Privé A, Roy-Hallé A, Pagé D, Simard S, Séries F. Diagnosis and management of sleep apnea by a clinical nurse: a noninferiority randomized clinical trial. J Clin Sleep Med. 2022;18(1):89–97.

Rationale: Determining whether an individual has obstructive or central sleep apnea is fundamental to selecting the appropriate treatment. Objectives: Here we derive an automated breath-by-breath p...

Sleep health and tracking sleep with contemporary wearables have become more popular. Sleep disorders, in particular, sleep-disordered breathing, have a higher prevalence than estimated previously. Many patients with apnea and hypopnea events suffer whereas others do not report complaints or show cardiovascular consequences. Assessment with wearables may support efforts to distinguish which type of apnea is related to aging and which to cardiovascular comorbidities. Innovative methods offer smart solutions for problems that are insufficiently addressed. Telemedical concepts help bring patients to sleep medicine expertise at an early stage. To use these methods clinically, they must be certified as medical devices.

STUDY OBJECTIVES: Whether the association between sleep-disordered breathing (SDB) and cardiovascular disease is independent of comorbid risk factors for cardiovascular disease is controversial. The objective of this study was to elucidate whether the association between SDB severity and the surrogate markers of cardiovascular disease events differs in relation to the number of comorbidities. METHODS: This cross-sectional study included 7,731 participants. Severity of SDB was determined by the oxygen desaturation index adjusted by actigraph-measured objective sleep time. Participants were stratified according to SDB severity and the number of comorbidities (hypertension, diabetes, dyslipidemia, and obesity), and the associations between the maximum value of intima-media thickness of the common carotid artery (CCA-IMT-max), brachial-ankle pulse wave velocity, and cardio-ankle vascular index were evaluated. RESULTS: Among participants with no risk factors, CCA-IMT-max increased according to SDB severity (n = 1022, P < .0001). Even after matching the background, the median CCA-IMT-max value was 14% higher in moderate-severe SDB patients than those without SDB (n = 45 in each group, P = .020). The difference was not significant for brachial-ankle pulse wave velocity and cardio-ankle vascular index. On the other hand, a significant difference in CCA-IMT-max was not found in those with multiple comorbidities. Consistently, multiple regression analysis revealed an independent association between CCA-IMT-max and moderate-severe SDB for all study participants (β: 0.0222, 95% confidence interval: 0.0039–0.0405, P = .017), but the association was not significant for stratified participants with multiple comorbidities. CONCLUSIONS: SDB severity is associated with the CCA-IMT-max level, but the independent association becomes weaker for those with multiple comorbidities. CITATION: Nakatsuka Y, Murase K, Matsumoto T, et al. Markers of cardiovascular disease risk in sleep-disordered breathing with or without comorbidities: the Nagahama Study. J Clin Sleep Med. 2021;17(12):2467–2475.

Obese youth with sleep-disordered breathing are treated with positive airway pressure to improve sleep and cardiovascular status. While improvements in sleep parameters have been confirmed, a study by Katz et al. showed no major improvement in ambulatory blood pressure. The aim of this ancillary study was to analyze short-term blood pressure variability, following positive airway pressure treatment, as a more sensitive marker of cardiovascular health. We analyzed 24-h blood pressure variability data in 17 children, taken at baseline and after 12 months of treatment. These data were derived from an already published prospective, multicenter cohort study conducted in 27 youth (8-16 years) with obesity who were prescribed 1-year of positive airway pressure for moderate-severe sleep-disordered breathing. Significant decreases were found in 24 h systolic blood pressure (p = 0.040) and nighttime diastolic blood pressure (p = 0.041) average real variability, and diastolic blood pressure (p = 0.035) weighted standard deviation. Significant decreases were noted in nighttime diastolic blood pressure time rate variability (p = 0.007). Positive airway pressure treatment resulted in a significant decrease in blood pressure variability, suggesting a clinically significant improvement of sympathetic nerve activity in youth with obesity and sleep-disordered breathing. IMPACT: Cardiovascular variability, as measured by blood pressure variability, is improved in children following positive airway pressure treatment. Our novel findings of improved blood pressure time rate variability are the first described in the pediatric literature. Future studies aimed at analyzing target organ damage in this patient population will allow for a better understanding as to whether alterations in blood pressure variability translate to decreasing target organ damage in children, as seen in adults.

Identifying patients at risk for poor clinical outcomes following acute heart failure (AHF) is essential. However, data regarding the prognostic effect of sleep-disordered breathing (SDB) and treatment with positive airway pressure (PAP) on clinical outcomes of hospitalized patients following AHF is lacking. This study investigated the prognostic effect of SDB, PAP treatment, and compliance with PAP treatment on patient clinical outcomes. Polysomnography was performed in hospitalized patients whose left ventricular ejection fraction was

Background and Objectives: To investigate the effects of recurrent tonsillitis on postoperative outcomes after powered intracapsular tonsillectomy and adenoidectomy (PITA) in children with obstructive sleep-disordered breathing (oSDB).Materials and Methods: Children who underwent PITA in Kyung Hee University Hospital at Gangdong from 2016 to 2018 were classified into two oSDB groups according to comorbid chronic/recurrent acute tonsillitis (CHT). To evaluate the efficacy of the PITA technique, quality of life (QoL) was measured using the obstructive sleep apnea questionnaire (OSA-18) for 3 months after surgery. To evaluate the disadvantages of the PITA technique, we followed complications such as throat pain, otalgia, nausea, vomiting, and postoperative bleeding for 1 week after surgery. Finally, we compared the pre- and postoperative QoL and analyzed the incidence of postoperative complications in the oSDB with CHT (SDBwCHT) and oSDB without CHT (SDBsCHT) groups.Results: Of the 802 enrolled patients, 135 were classified as SDBwCHT and 667 as SDBsCHT. Both groups exhibited marked improvements in QoL after PITA. The SDBwCHT group showed a change of OSA-18 score from 70.7±17.0 to 31.2±11.4. The SDBsCHT group showed a change of OSA-18 score from 70.0±17.1 to 31.0±9.9. The groups did not demonstrate statistical differences in complication rates and severity of symptoms during the first postoperative week.Conclusion: Although comorbid CHT delayed improvement in postoperative symptoms, PITA is a useful technique to treat children with oSDB, regardless of CHT.

Huijun Wang,1– 3,&ast; Guodong Lin,4,&ast; Yanru Li,1– 3 Xiaoqing Zhang,1– 3 Wen Xu,1– 3 Xingjun Wang,4 Demin Han1– 3 1Department of Otorhinolaryngology Head and Neck Surgery, Beijing Tongren Hospital, Capital Medical University, Beijing, People’s Republic of China; 2Obstructive Sleep Apnea-Hypopnea Syndrome Clinical Diagnosis and Therapy and Research Centre, Capital Medical University, Beijing, People’s Republic of China; 3Key Laboratory of Otolaryngology-Head and Neck Surgery, Ministry of Education, Capital Medical University, Beijing, People’s Republic of China; 4Department of Electronic Engineering, Tsinghua Shenzhen International Graduate School, Tsinghua University, Shenzhen, People’s Republic of China&ast;These authors contributed equally to this workCorrespondence: Demin HanBeijing Tongren Hospital, Capital Medical University, No. 1 Dongjiaominxiang Street, Dongcheng District, Beijing, 100730, People’s Republic of ChinaTel +86-010-58269335Fax +86-010-58269331Email deminhan_ent@hotmail.comXingjun WangTsinghua Shenzhen International Graduate School, University Town of Shenzhen, Nanshan District, Shenzhen, 518055, People’s Republic of ChinaTel +86-18038153071Email wangxingjun@tsinghua.edu.cnPurpose: To develop an automatic sleep stage analysis model for children and evaluate the effect of the model on the diagnosis of sleep-disordered breathing (SDB).Patients and Methods: Three hundred and forty-four SDB patients aged between 2 to 18 years who completed polysomnography (PSG) to assess the severity of the disease were enrolled in this study. We developed deep neural networks to stage sleep from electroencephalography (EEG), electrooculography (EOG) and electromyogram (EMG). The model performance was estimated by accuracy, precision, recall, F1-score, and Cohen’s Kappa coefficient (&kgreen;). And we compared the difference in calculation of sleep parameters among the technicians, the model ensemble, and the single-channel EEG model.Results: The numbers of raw data divided into training, validation, and testing were 240, 36, and 68, respectively. The best performance appeared in the model ensemble of which the accuracy was 83.36% (&kgreen;=0.7817) in 5-stages, and the accuracy was 96.76% (&kgreen;=0.8236) in 2-stages. The single-channel EEG model showed the classification satisfyingly as well. There was no significant difference in TST, SE, SOL, time in W, time in N1+N2, time in N3, and OAHI between technician and the model (P> 0.05). On the datasets from sleep-EDF-13 and sleep-EDF-18, the average classification accuracies achieved were 92.76% and 91.94% in 5-stages by using the proposed method, respectively.Conclusion: This research established the model for pediatric automatic sleep stage classification with satisfying reliability and generalizability. In addition, it could be applied for calculating quantitative sleep parameters and evaluating the severity of SDB.Keywords: sleep-disordered breathing, SDB, deep learning, sleep stage, children

Objectives/hypothesis Adenotonsillectomy (AT) is generally considered the first line treatment for pediatric patients with obstructive sleep apnea (OSA). Pediatric patients with severe OSA have worse outcomes after AT than patients with milder OSA. It is currently unclear if this group of higher morbidity patients should be subdivided further. This study investigates patients with severe pediatric OSA to determine if there are differences in postsurgical outcomes based on initial severity of sleep disordered breathing, medical comorbidities, or demographic factors. Study design Retrospective cohort study at a single tertiary referral center. Methods Patients aged 2-18 who underwent polysomnogram (PSG) from October 2012 to January 2019, had an apnea-hypopnea index (AHI) >10, and subsequently underwent AT were identified using a filter through electronic medical record. A total of 112 patients underwent both pre- and postoperative PSG. Bivariate analysis was conducted via Pearson chi-square test. Univariate and multivariate analyses via binary logistic and multinomial linear regressions were performed using SPSS. Results Of the 112 patients included in this study, 68 patients were identified as having severe OSA (AHI = 10-20) and 44 as having very severe OSA (AHI > 20). Very severe OSA patients were significantly less likely to be cured of sleep disordered breathing or have their OSA reduced to mild OSA. Obese patients were found to have less reduction in AHI after AT. Conclusions The postsurgical outcomes of patients with severe and very severe OSA are significantly different indicating that patients traditionally categorized as having severe OSA may need to be further subcategorized. Level of evidence IV Laryngoscope, 2021.

There is a high prevalence of sleep-related breathing disorders in the form of obstructive and central sleep apnea as well as spontaneous oxygen desaturation in children with Prader–Willi syndrome (PWS). Most cases are asymptomatic and if untreated go on to develop unfavorable neurodevelopmental, cardiovascular, and cerebrovascular outcomes. Hence, sleep study or polysomnography (PSG) is recommended in all children at the time of diagnosis as well as with the development of certain risk factors including symptoms of sleep apnea, before and after initiation of recombinant growth hormone (rGH) therapy. The use of rGH in children with PWS has been shown to improve central sleep apnea but also shown to be associated with worsening of OSA. PSG is ideally performed in a sleep laboratory. Various types of PSG devices are available depending on the biological parameters that are desired to be monitored. Sleep disorders in children are distinct from those seen in adults and have different diagnostic scoring criteria necessitating a trained pediatric sleep specialist to analyze the PSG recording. Through the clinical case vignette of a 14-year-old girl with PWS, severe obesity, and sleep disordered breathing, this review aims to highlight the need, timing, types, analysis, and interpretation of sleep studies in infants and older children with PWS, particularly in relation to rGH therapy. There is a paucity of literature on sleep studies in children with PWS in the local setting. Thus this review also suggests the need for adapting the existing Western guidelines for PSG in Indian children with PWS.

Aufgrund der Interaktion zwischen den Organsystemen und wegen gemeinsamer Risikofaktoren leiden Patienten mit Lungenerkrankungen haufig zusatzlich an extrapulmonalen Erkrankungen. Im Rahmen dieses Beitrags sollen daher die Auswirkungen ausgewahlter Erkrankungen des respiratorischen Systems auf das Herz-Kreislauf-System und die Niere genauer betrachtet werden. Eine fortgeschrittene chronisch-obstruktive Lungenerkrankung (COPD) fuhrt haufig zu einer prognostisch ungunstigen Druckerhohung im Lungenkreislauf. Therapeutisch steht diesbezuglich die Therapie der zugrunde liegenden Lungenerkrankung im Vordergrund, die gezielte Therapie der pulmonalen Hypertonie sollte nur gemas der invasiven Diagnostik und individualisiert erfolgen. Bislang vollig unbeachtet bleibt, dass es erhebliche Uberschneidungen von COPD und Herzinsuffizienz mit erhaltener Ejektionsfraktion gibt, was beim diagnostischen Prozedere berucksichtigt werden sollte. Die obstruktive Schlafapnoe (OSA) wirkt sich auf vielfaltige Weise ungunstig auf das Herz-Kreislauf-System aus und ist ein unabhangiger Risikofaktor fur kardiovaskulare Erkrankungen. „Continuous positive airway pressure“ stellt die etablierte Therapie der OSA dar und verbessert Tagesmudigkeit und Lebensqualitat, ein Effekt auf kardiovaskulare Ereignisse konnte in randomisierten Studien insbesondere fur asymptomatische Patienten bislang allerdings nicht nachgewiesen werden. Patienten mit chronischer Hyperkapnie leiden haufig unter peripheren Odemen. Pathophysiologisch sind hier neben der pulmonalen Vasokonstriktion auch direkte Auswirkungen der Hyperkapnie auf die renale Durchblutung von Bedeutung. Die Rekompensation dieser Patienten erfordert neben der Gabe von Diuretika immer auch die Korrektur der Hyperkapnie mittels nichtinvasiver Beatmungstherapie.

Background Little is known about the prospective association between sleep disordered breathing (SDB) and depressive symptoms in Chinese adolescents. This study examined the independent predictive role of SDB symptoms in depressive symptoms in a large sample of adolescents. Methods A total of 11831 adolescents who participated in the baseline survey of Shandong Adolescent Behavior and Health Cohort and 7072 adolescents who were resurveyed 1 year later were included for the analyses. Adolescents completed a self-administered questionnaire about demographics, mental health, sleep problems, and family environment. SDB symptoms were assessed by 3 items about loud snoring, breathing pauses, and snorting/gasping. The Chinese Youth Self-Report anxious/depressed subscale was used to assess depressive symptoms. Results In the cross-sectional analyses, 11.8% adolescents had depressive symptoms, and elevated frequency of SDB symptoms were significantly associated with depressive symptoms. In the longitudinal study, 4.5% of adolescents had persistent depressive symptoms, the incidence rate of depressive symptoms at 1-year follow-up was 6.5%, and elevated frequency of any SDB symptoms (often: OR=2.23, 95%CI:1.50-3.32) at baseline was significantly associated with incident depressive symptoms after adjusting for potential confounders. The associations between SDB symptoms and depressive symptoms were similar for boys and girls. Limitation SDB symptoms and depressive symptoms were measured by self-report. Conclusion SDB symptoms are an independent and significant predictor of depressive symptoms in adolescents. Further research is needed to understand the biological mechanisms between SDB and mood dysregulation in adolescents.

Interest in telemedicine has increased exponentially. There is a growing body of published evidence on the use of telemedicine for patients using continuous positive airway pressure. Telemedicine-ready devices can support the transmission on use time, apnea-hypopnea index, and leakage. This approach enables early activation of troubleshooting. Automated, personalized feedback for patients and patient access to their own data provide unprecedented opportunities for integrating comanagement approaches, multiactor interactions, and patient empowerment. Telemedicine is likely cost effective, but requires better evidence. Notwithstanding barriers for implementation that remain, telemedicine has to be embraced, leaving the physician and patient to accept it or not.

Es hat sich viel getan in der Welt der Schlafmedizin in der Kardiologie, weshalb eine vollwertige Uberarbeitung des Positionspapiers „Schlafmedizin in der Kardiologie“ erforderlich wurde. In der aktuellen neuartigen Version finden sich nicht nur alle verfugbaren Studien, Literaturstellen und Updates zu Pathophysiologie, Diagnostik- und Therapieempfehlungen, sondern auch Ausblicke auf neue Entwicklungen und zukunftige Forschungserkenntnisse. Dieses uberarbeitete Positionspapier gibt Empfehlungen fur Diagnostik und Therapie von Patienten mit kardiovaskularen Erkrankungen mit schlafassoziierten Atmungsstorungen und erteilt daruber hinaus einen fundierten Uberblick uber verfugbare Therapien und Evidenzen, gibt aber ebenso Ratschlage wie mit Komorbiditaten umzugehen ist. Insbesondere enthalt dieses uberarbeitete Positionspapier aktualisierte Stellungnahmen zu schlafassoziierten Atmungsstorungen bei Patienten mit koronarer Herzerkrankung, Herzinsuffizienz, arterieller Hypertonie, aber auch fur Patienten mit Vorhofflimmern. Daruber hinaus finden sich erstmals Empfehlungen zur Telemedizin als eigenes, neues Kapitel. Dieses Positionspapier bietet Kardiologen sowie Arzten in der Behandlung von kardiovaskularen Patienten die Moglichkeit einer evidenzbasierten Behandlung der wachsend bedeutsamen und mit zunehmender Aufmerksamkeit behafteten Komorbiditat schlafassoziierter Atmungsstorungen. Und nicht zuletzt besteht mit diesem neuen Positionspapier eine enge Verknupfung mit dem neuen Curriculum Schlafmedizin der Deutschen Gesellschaft fur Kardiologie, weshalb dieses Positionspapier eine Orientierung fur die erworbenen Fahigkeiten des Curriculums im Umgang von kardiovaskularen Patienten mit schlafassoziierten Atmungsstorungen darstellt.

Background: Sleep-disordered breathing (SDB) is accompanied by large swings in blood pressureand the repetitive hypoxic period during sleep, which may accelerate anoxic optic nerve damageseen in glaucoma. There are many associated risk factors in primary open-angle glaucoma (POAG),but recently, SDB, though a neglected one, is coming up as a risk factor. However, various studieshave reported controversial findings. Objective: To evaluate the relationship between SDB andPOAG. Design: A hospital-based case-control study. Methods: A total of 400 patients between 30–70 years were recruited from eye OPD between 2008- 2010. They were divided into two groups, 200cases with established POAG and 200 age and sex-matched healthy subjects with normal IOP in thecontrol group. Detailed history, complete ophthalmic and ENT examination was made along withBMI, blood pressure and neck girth measurement. Both groups were interviewed with aquestionnaire regarding SDB and were recorded on the Epworth sleepiness scale (ESS). Results:The mean age being 55.02 ± 8.66 in the POAG group and male predominance noted both in POAGand SDB patients with ESS> 10 was statistically significant (p < 0.05). Also, patients in the POAGgroup with ESS > 10 had more IOP and BMI, greater neck girth, high BP and more ENT problemswith p-value < 0,001, which is highly significant, thus showing the relationship between SDB andPOAG. Conclusions: Increased community awareness and earlier detection of glaucoma and itscorrelation with SDB results in decreased morbidity.

STUDY OBJECTIVES: Sleep-disordered breathing (SDB) is common in patients with neuromuscular disorders (NMD), developing before chronic hypercapnia appears. Polysomnography (PSG) is the diagnostic gold standard but is often impractical and poorly accessible for individuals with NMD. We sought to determine the diagnostic accuracy, feasibility, and patient preference of home sleep apnea testing (HSAT) compared with PSG for the detection of SDB in NMD. METHODS: Participants with NMD at risk for SDB aged ≥ 13 years underwent HSAT followed by overnight PSG with concomitant laboratory sleep apnea testing (same device as HSAT). Sensitivity and specificity were calculated for standard apnea-hypopnea index cutoffs for mild (≥ 5 events/h), moderate (≥ 15 events/h), and severe SDB (≥ 30 events/h) and for an oxygen desaturation index ≥ 5 events/h. Receiver operating characteristic curves were built. A questionnaire assessed patient preference. RESULTS: Of 38 participants, 73% had moderate to severe SDB and 79% had technically acceptable HSAT. For an apnea-hypopnea index ≥ 15 events/h, HSAT sensitivity and specificity were 50% and 88%, respectively. For an oxygen desaturation index ≥ 5 events/h, HSAT sensitivity and specificity were 95% and 78%, respectively. The area under the receiver operating characteristic curve for an apnea-hypopnea index ≥ 15 events/h was 0.88 (95% confidence interval, 0.69–1.00) for HSAT. The HSAT underestimated the apnea-hypopnea index from PSG (bias, –10.7 ± 15.9 events/h). HSAT was preferred to PSG by 61% of participants. CONCLUSIONS: HSAT is feasible, preferred by patients, and reliable for detecting SDB in most patients, although it cannot definitively rule out SDB. Therefore, HSAT is a viable diagnostic approach for SDB in NMD when PSG is not feasible, recognizing that it does not accurately distinguish between upper-airway obstruction and hypoventilation. Additional work is needed to further optimize home sleep testing in NMD. CITATION: Westenberg JN, Petrof BJ, Noel F, et al. Validation of home portable monitoring for the diagnosis of sleep-disordered breathing in adolescents and adults with neuromuscular disorders. J Clin Sleep Med. 2021;17(8):1579–1590.

STUDY OBJECTIVES: (1) To determine the characteristics of term and preterm infants for whom polysomnography (PSG) was used as a primary diagnostic tool in infants with recurrent desaturation episodes, suspected obstructive apnea, or both, and the prevalence of abnormal studies. (2) To identify the interventions following PSGs. (3) To assess the added value of airway and swallow evaluations. METHODS: Retrospective cohort study of infants evaluated by PSG in the Neonatal Intensive Care Unit at New York-Presbyterian Hospital–Weill Cornell from January 2012 to April 2018. RESULTS: PSGs were performed on 31 infants; 15 (48%) term and 16 (52%) preterm infants. Indications for PSG were persistent desaturations (n = 24), suspected obstructive apnea (n = 15), and stridor (n = 2). Primary comorbid conditions were respiratory (n = 11), craniofacial (n = 9), airway anomalies (n = 6), and neurologic (n = 5). The apnea-hypopnea index was abnormal in 30 (97%) infants. Of those, 23 (74%) were severe, 7 (23%) were moderate, and 1 was normal (3%). Apneic events were predominantly obstructive in 23 infants and predominantly central in 6. The apnea-hypopnea index improved in all but 1 follow-up PSG. The PSG findings resulted in interventions in 24 (77%) infants, in addition to concomitant otolaryngology evaluations (abnormal in 20/25) and swallow studies (abnormal in 9/14). Clinical signs completely resolved in 22 (71%) infants. CONCLUSIONS: This is one of the first reports on the diagnostic value of inpatient PSGs in the neonatal intensive care unit in infants with recurrent desaturation episodes, suspected obstructive apnea, or both. Our findings indicate that PSG is an important tool in evaluating and targeting therapies in complex term and preterm infants with a wide variety of comorbidities. CITATION: Kim J, Gueye-Ndiaye S, Mauer E, Modi VK, Perlman J, Veler H. Polysomnography use in complex term and preterm infants to facilitate evaluation and management in the neonatal intensive care unit. J Clin Sleep Med. 2021;17(8):1653–1663.

The purpose of this review is to examine the gender differences in sleep disordered breathing focusing on biochemical, pathogenesis, clinical manifestation, and uncertainties. Obstructive sleep apnea is the most common form of sleep disordered breathing and a prevalent disease in the general population. Studies on obstructive sleep apnea have included both genders, but women have often been underrepresented. The paucity of recent publications focusing on gender differences in obstructive sleep apnea necessitated that this review explores earlier relevant literature. The data reviewed suggests women have higher than earlier reported prevalence of obstructive sleep apnea and have different pathophysiologic risk factors with various phenotypes such that current scoring criteria might misclassify abnormal breathing events and therefore, women might be underdiagnosed. The clinical presentation of obstructive sleep apnea in women differs from men. Variations in sleep architecture and respiratory events undermine the diagnosis of obstructive sleep apnea in women, ostensibly facilitating misdiagnoses and misclassification of disease burden.

Sleep apnoea is common in patients with Basilar Invagination with Arnorld Chiari Malformation (ACM). Various studies have shown its incidence in the range of 60-70% among such patients. Most of the studies have shown improvement in sleep disturbances after decompressive surgeries for Chiari Malformations. There is no report of postoperative deterioration due to sleep apnoea in these patients. Authors report two cases of basilar invagination associated with ACM and Platybasia, who deteriorated probably due to worsening of pre-existing sleep disorders on 3rd and 7th postoperative days after their surgeries, despite clinico-radiological improvements during their early post-operative courses. Authors discuss literature related to sleep apnoea in basilar invagination associated with Chiari Malformations and share precautions, which are relevant and should be undertaken in such patients especially during early post-operative periods to avoid alarming complication which may occur even in experienced hands.

Only survey studies have linked specific individual psychiatric disorders such as anxiety, depression and schizophrenia to Restless Legs Syndrome (RLS), Periodic Limb Movements in Sleep (PLMS) or both. We therefore aim to polysomnographically characterize sleep in a sample of physician-based, newly diagnosed cases of RLS with various ICD-10 psychiatric diagnoses. Retrospective analysis of data from a convenience sample of psychiatric patients (n = 43) per standard clinical sleep disorder cut-offs was conducted. Next, a cluster analysis was performed on the sleep data, taking into account the psychiatric diagnosis, comorbid non-psychiatric somatic problems and medication. We found that 37.2% of our sample showed clinically significant PLMS ≥ 15 and 76.5% exhibited an apnea hypopnea index (AHI) ≥ 5. Sleep structure was unaltered apart from the PLMS-related parameters. Two clusters were statistically identified: Cluster 1 primarily representing recurrent major depressive issues and Cluster 2 representing present but not predominant mood symptomatology as well as mixed disorders with personality problems. The known confounders were controlled. A PLMS index ≥ 15 was differentially distributed among the two clusters with Cluster 1: 10 out of 17 with PLMS index ≥ 15, Cluster 2: 1 out of 16 with PLMS index ≥15, whilst AHI was not different. Patients in Cluster 1 have a higher rate of periodic leg movements than patients in Cluster 2. This suggests that the high association with PLMS is primarily driven by affective disorders. Our findings warrant questioning of RLS symptomatology in patients with psychiatric conditions.

To evaluate the impact of the COVID-19 pandemic on non-invasive positive airway pressure (PAP) usage among children with sleep-disordered breathing (SDB). PAP usage data in children with SDB aged 1 to 18 years old at The Hospital for Sick Children, Canada, were analyzed. The PAP usage data were recorded for 3 months prior to and 3 months following the COVID-19 lockdown in Ontario, Canada. The primary outcomes of interest were (i) percentage of days that PAP was used for ≥ 4 h and (ii) average daily usage of PAP based on days when PAP was used. A total of 151 children were included. The mean (± SD) age and BMI were 12.6 ± 4.1 years and 28.7 ± 12.4 kg/m2, respectively. The median (IQR) percentage of days of PAP usage for ≥ 4 h and average nightly PAP usage was significantly higher during compared with prior to the pandemic (76.7 [19.0–94.0] vs 62.0 [15.5–89.0]%, p = 0.02, and 406.0 [244.0–525.0] vs 367.0 [218.0–496.0] min, p = 0.006, respectively). Within this cohort, 95/151 (63%) children with SDB showed increased PAP usage and 56/151 (37%) either decreased the amount of time they used PAP or stopped PAP use altogether. COVID-19 pandemic has provided opportunities for increased PAP usage in a significant number of children with SDB. A subset of children with prior evidence for suboptimal PAP usage showed further decreases in PAP usage during the pandemic. This information is critical for clinicians to provide anticipatory guidance to encourage PAP usage both during the pandemic and beyond.

The combination of the noradrenergic agent atomoxetine plus the antimuscarinic oxybutynin has recently been shown to improve upper airway physiology and reduce obstructive sleep apnea (OSA) severity. However, the effects of different antimuscarinics when combined with atomoxetine is limited. This study aimed to determine the effects of atomoxetine combined with two different antimuscarinics with varying M-subtype receptor selectivity on OSA severity and upper airway physiology. Ten people with predominantly severe OSA completed a double-blind, randomized, placebo-controlled, cross-over trial. Participants completed three overnight in-laboratory sleep studies after either 80 mg atomoxetine + 5 mg solifenacin succinate (ato-sol) or 80 mg atomoxetine + 2 mg biperiden hydrochloride (ato-bip) or placebo. OSA severity, ventilatory stability (loop gain), respiratory-arousal threshold (via epiglottic manometry), next-day subjective sleepiness [Karolinska Sleepiness Scale (KSS)], and alertness were compared between conditions. Neither drug combination altered the apnea/hypopnea index versus placebo (P = 0.63). Ato-sol caused a shift toward milder respiratory events with reduced frequency of obstructive apneas (13 ± 14 vs. 22 ± 17 events/h; means ± SD, P = 0.04) and increased hypopneas during nonrapid eye movement (NREM) (38 ± 21 vs. 24 ± 18 events/h, P = 0.006) with improved nadir oxygenation versus placebo (83 ± 4 vs. 80 ± 8%, P = 0.03). Both combinations reduced loop gain by ∼10% versus placebo; sleep efficiency and arousal threshold were unaltered. Ato-bip reduced next-day sleepiness versus placebo (KSS = 4.3 ± 2.2 vs. 5.6 ± 1.6, P = 0.03). Atomoxetine + biperiden hydrochloride reduces perceived sleepiness, and atomoxetine + solifenacin modestly improves upper airway function in people with OSA but to a lesser extent versus recently published atomoxetine + oxybutynin (broad M-subtype receptor selectivity) findings. These results provide novel mechanistic insight into the role of noradrenergic and antimuscarinic agents on sleep and breathing and are important for pharmacotherapy development for OSA. NEW & NOTEWORTHY In contrast to recent findings of major reductions in OSA severity when atomoxetine is combined with a nonspecific antimuscarinic, oxybutynin (broad M-subtype receptor selectivity), addition of solifenacin succinate (M2 and M3 muscarinic receptor selectivity) or biperiden (M1 muscarinic receptor selectivity) with atomoxetine had modest effects on upper airway function during sleep, which provide mechanistic insight into the role of noradrenergic and antimuscarinic agents on sleep and breathing and are important for pharmacotherapy development for OSA.

STUDY OBJECTIVES: Sleep-disordered breathing (SDB) is prevalent and associated with an increased risk of morbidity and mortality. However, whether SDB has an adverse impact on wound healing in patients with diabetic foot ulcers (DFUs) is uncertain. The purpose of this study was to investigate the association of SDB with wound healing in patients with DFUs. METHODS: A total of 167 patients with DFUs were enrolled between July 2013 and June 2019 at West China Hospital (Chengdu, China) to assess the association of SDB with wound healing, ulcer recurrence, and all-cause mortality. RESULTS: Whereas there was no significant association between apnea-hypopnea index (AHI) and wound healing, total sleep time (per hour: hazard ratio [HR], 1.15; 95% confidence interval [CI], 1.01–1.30; P = .029), sleep efficiency (per 10%: HR, 1.20; 95% CI, 1.04–1.37; P = .012), and wakefulness after sleep onset (per 30 minutes: HR, 0.89; 95% CI, 0.82–0.97; P = .008) were associated with wound healing. Total sleep time (per hour: odds ratio, 0.71; 95% CI, 0.51–0.97; P = .035) and sleep efficiency (per 10%: odds ratio, 0.68; 95% CI, 0.47–0.97; P = .033) were also associated with ulcer recurrence. Mean oxygen saturation (per 3%: HR, 0.68; 95% CI, 0.49–0.94; P = .021) and percentage of sleep time with oxygen saturation < 90% (per 10%: HR, 1.25; 95% CI, 1.03–1.53; P = .026) were significantly associated with mortality. CONCLUSIONS: SDB is highly prevalent in patients with DFUs but its severity, as conventionally measured by AHI, is not associated with wound healing. Sleep fragmentation and hypoxemia are stronger predictors of poor wound healing, high ulcer recurrence, and increased risk of death in patients with DFUs. CITATION: Chen L, Ma W, Covassin N, et al. Association of sleep-disordered breathing and wound healing in patients with diabetic foot ulcers. J Clin Sleep Med. 2021;17(5):909–916.

We find ourselves at our present crossroads with a well-traveled toolkit, perhaps too well worn but with aspirational hopes and dreams for the field of sleep neurotherapeutics. This volume is organized thematically into six topical domains that parallel the major subspecialty areas of contemporary clinical sleep neurology practice, as well as novel directions and opportunities. The issue begins with an overview of the central disorders of hypersomnolence, including narcolepsy, idiopathic hypersomnia and other hypersomnia disorders, and the related use of the entire broad range of stimulant and wake-promoting pharmacotherapies. Next, the range of behavioral therapies, application of light and light restriction and melatonin therapies, and hypnotic pharmacotherapies useful in insomnia and circadian sleep–wake rhythm disorders are reviewed, followed by an overview of treatment options for sleep-related breathing disorders including positive airway pressure and the novel approach of hypoglossal neurostimulation for obstructive sleep apnea. The parasomnias and sleep-related movement disorders, including NREM disorders of arousal, REM parasomnias (nightmares and isolated sleep paralysis and idiopathic/isolated REM sleep behavior disorder, and restless legs syndrome are then discussed, and the applications of sleep neurotherapeutics in sleep and neurological disease are reviewed, including neurodevelopmental, epileptic, autoimmune encephalopathies, and neurodegenerative diseases. Last, the novel directions and opportunities in sleep neurology offered by cannabinoid therapies and machine learning/artificial intelligence methodology conclude this comprehensive survey of contemporary sleep neurology. We hope that you find this volume to be a useful and inspirational support tool for the work that matters most, your care of all our sleep neurology patients in the clinics. Supplementary Information The online version contains supplementary material available at 10.1007/s13311-021-01032-7.

Objective: Cleft palate (CP) can affect breathing, leading to sleep-disordered breathing (SDB). Sleep position can affect SDB, but the optimum sleep position for infants with CP is unknown. We aimed to determine the design of a pragmatic study to investigate the effect of the 2 routinely advised sleep positions in infants with CP on oxygen saturations. Design: A multicentered observational cohort. Setting: Four UK-based cleft centers, 2 advising supine- and 2 side-lying sleep positions for infants with CP. Participants: Infants with isolated CP born July 1, 2015, and December 31, 2016. Of 48 eligible infants, 30 consented (17 side-lying; 13 supine). Interventions: Oxygen saturation (SpO2) and end-tidal carbon dioxide (ETCO2) home monitoring at age 1 and 3 months. Qualitative interviews of parents. Outcome Measures: Willingness to participate, recruitment, retention, and acceptability/success (>90 minutes recording) of SpO2 and ETCO2 monitoring. Results: SpO2 recordings were obtained during 50 sleep sessions on 24 babies (13 side-lying) at 1 month (34 sessions >90 minutes) and 50 sessions on 19 babies (10 side-lying) at 3 months (27 sessions >90 minutes). The ETCO2 monitoring was only achieved in 12 sessions at 1 month and 6 at 3 months; only 1 was >90 minutes long. The ETCO2 monitoring was reported by the majority as unacceptable. Parents consistently reported the topic of sleep position in CP to be of importance. Conclusions: This study has demonstrated that it is feasible to perform domiciliary oxygen saturation studies in a research setting and has suggested that there may be a difference in the effects of sleep position that requires further investigation. We propose a study with randomization is indicated, comparing side-lying with supine-lying sleep position, representing an important step toward better understanding of SDB in infants with CP.

Parents frequently report behavioral problems among children who snore. Our understanding of the relationship between symptoms of obstructive sleep disordered breathing (oSDB) and childhood behavioral problems associated with brain structural alterations is limited. Here, we examine the associations between oSDB symptoms, behavioral measures such as inattention, and brain morphometry in the Adolescent Brain Cognitive Development (ABCD) study comprising 10,140 preadolescents. We observe that parent-reported symptoms of oSDB are associated with composite and domain-specific problem behaviors measured by parent responses to the Child Behavior Checklist. Alterations of brain structure demonstrating the strongest negative associations with oSDB symptoms are within the frontal lobe. The relationships between oSDB symptoms and behavioral measures are mediated by significantly smaller volumes of multiple frontal lobe regions. These results provide population-level evidence for an association between regional structural alterations in cortical gray matter and problem behaviors reported in children with oSDB., Parents often report behavioral problems in children with symptoms of sleep disordered breathing (oSDB), such as snoring. Here, the authors show that lower brain volumes within the frontal lobe are associated with parent-reported problem behaviors in children with parent-reported symptoms of oSDB.

La paralysie diaphragmatique unilaterale (PDU) peut potentiellement aggraver les troubles respiratoires du sommeil (TRS). La PDU est associee aux blocs du plexus brachial proximal, tel que les blocs interscalenique et supraclaviculaire. L’impact de la PDU chez les patients atteints de TRS n’est pas connu dans ce contexte. Les objectifs de cette revue exploratoire etaient d’explorer les associations entre la PDU et l’aggravation de la severite des TRS, l’oxygenation, et la fonction pulmonaire. Une recherche systematique a ete mise au point, evaluee par des pairs et appliquee aux bases de donnees Embase, Medline, CINAHL et Cochrane afin d’inclure les etudes portant sur des patients adultes (≥ 18 ans) atteints de TRS, ou les effets d’une PDU sur la severite des TRS, sur l’oxygenation et la fonction pulmonaire etaient examines. Six etudes (n = 100 patients) portant sur la PDU et les TRS ont ete incluses. La population etudiee provenait exclusivement de cliniques de respirologie-sommeil, et ne comptait aucun patient chirurgical. Comparativement au groupe temoin (aucune PDU), la PDU a ete associee a un index accru de troubles respiratoires, lesquels etaient les plus prononces pendant le sommeil paradoxal et en position de decubitus dorsal. Le sommeil en decubitus dorsal et le sommeil paradoxal ont ete associes a des evenements obstructifs et mixtes (obstructifs et centraux), respectivement. Comparativement au groupe temoin, la PDU a ete associee a une saturation en oxygene et a une tension arterielle d’oxygene moyennes et minimales inferieures pendant tous les stades de sommeil et dans toutes les positions. Chez la majorite des patients atteints de PDU, des reductions cliniquement significatives des valeurs du volume expiratoire force moyen en une seconde et de la capacite vitale forcee ont ete observees, des donnees compatibles avec une physiologie respiratoire restrictive. Nous avons observe une association entre la paralysie diaphragmatique unilaterale et une severite augmentee des troubles respiratoires du sommeil, particulierement pendant le sommeil paradoxal et en decubitus dorsal. Malgre l’identification de faiblesses dans la conception des etudes et d’un manque de donnees perioperatoires, les anesthesiologistes devraient garder a l’esprit cette association lorsqu’ils envisagent un bloc du plexus brachial proximal chez les patients souffrant de TRS.

Rationale: There are limited tools to identify which children are at greatest risk for developing sleep-disordered breathing (SDB)-associated behavioral morbidity.Objectives: To examine association...

Rationale: Approximately a third of patients with obstructive sleep apnea (OSA) treated with hypoglossal nerve stimulation (HGNS) therapy are incomplete responders, despite careful patient selection based on baseline characteristics and drug-induced sleep endoscopy. Here we use polysomnographic endotyping to assess the pathophysiological mechanisms underlying favorable versus incomplete responses to HGNS therapy. Methods: Baseline polysomnography data of the STAR trial were included. Raw baseline polysomnographic data from 91/126 patients were available for analysis. Traits—loop gain, arousal threshold, collapsibility, muscle compensation—were calculated from the baseline polysomnography data according to Sands et al. (AJRCCM 2018, SLEEP 2018). Logistic regression assessed AHI-adjusted associations between HGNS response (>50% reduction in AHI to

RATIONALE: Sleep disordered breathing (SDB) is associated with adverse health consequences that can be mitigated through timely and effective management. Guidelines provide wait time targets, but t...

RATIONALE: Respiratory management practices for Duchenne muscular dystrophy (DMD) vary across Canada, according to a web-based survey conducted in 2010. Since then, new guidelines for respiratory m...

STUDY OBJECTIVES: Cardiovascular comorbidities in obstructive sleep apnea (OSA) are difficult to treat, perhaps due to autonomic dysfunction. We assessed beat-to-beat blood pressure (BP) variability (BPV) in OSA while considering other markers derived from electrocardiogram and continuous BP signals. METHODS: We studied 66 participants (33 participants with OSA: respiratory event index [mean ± SEM]: 21.1 ± 2.7 events/h; 12 females, aged 51.5 ± 2.4 years; body mass index: 32.8 ± 1.4 kg/m(2); 33 healthy controls: 20 females; aged 45.3 ± 2.4 years; body mass index: 26.3 ± 0.7 kg/m(2)). We collected 5-minute resting noninvasive beat-to-beat BP and electrocardiogram values. From BP, we derived systolic, diastolic, and mean BP values, and calculated variability as standard deviations (systolic BPV, diastolic BPV, BPV). We also calculated diastole-to-systole time (time to peak). From the electrocardiogram, we derived QRS markers and calculated heart rate and heart rate variability. We performed a multivariate analysis of variance based on sex and group (OSA vs control), with Bonferroni-corrected post hoc comparisons (P ≤ .05) between groups. We calculated correlations of BPV with biological variables. RESULTS: Multivariate analysis of variance showed effects of diastolic BPV and BPV in OSA; post hoc comparisons revealed high diastolic BPV and BPV only in female participants with OSA vs controls. QRS duration was higher in OSA, with post hoc comparisons showing the effect only in males. BPV correlated positively with heart rate variability in controls but not in participants with OSA. BPV correlated positively with time to peak in females with OSA and OSA combined, whereas there was no BPV–time-to-peak correlation in healthy participants. CONCLUSIONS: The findings show sex-specific autonomic dysfunction reflected in beat-to-beat BP in OSA. The higher BPV may reflect poor baroreflex control or vascular damage in OSA, which are potential precursors to cardiovascular complications. CITATION: Pal A, Martinez F, Aguila AP, et al. Beat-to-beat blood pressure variability in patients with obstructive sleep apnea. J Clin Sleep Med. 2021;17(3):381–392.

Background Because of their high costs and low availability, sleep recordings cannot be used as routine procedures for sleep apnea screening. Therefore, it is important to have a performant screening tool allowing to select patients at higher risk for sleep apnea who need further investigations. The goal of the study is to compare the performances of the three commonly used sleep disordered breathing (SDB) screening questionnaires in a clinical sample. Methods Clinical data and sleep studies performed in consecutive adult patients referred to the Lausanne University sleep center for sleep recordings between November 2016 and February 2018 were analysed. Berlin, STOP-Bang and NoSAS screening scores were calculated and compared with the sleep studies’ results. Results NoSAS score showed a NPV of 0.88, a PPV of 0.43 and a correctly classified rate of 71% for an AHI >15/h. STOP-Bang score had a slightly higher negative predictive value (0.92) but a very low positive predictive value (0.30) and a poor correctly classified rate (47%). Berlin score showed globally poor results (NPV:0.85, PPV: 0.29 and a correctly classified rate: 56%). NoSAS score had the highest area under ROC curves (0.78) compared to STOP-bang (0.71) and Berlin (0.62). NoSAS score however yielded a slightly higher rate of false negative than STOP-Bang score. NoSAS false negatives were mainly female snorers with a low neck circumference. Conclusion NoSAS score showed a better discrimination capacity compared to Berlin and STOP Bang scores in an unselected clinical population referred to a sleep center.

Ju, Jia-Der, Cristian Zhang, Francis P. Sgambati, Lidia M. Lopez, Luu V. Pham, Alan R. Schwartz, and Roberto A. Accinelli. Acute altitude acclimatization in young healthy volunteers: nocturnal oxygenation increases over time whereas periodic breathing persists. High Alt Med Biol. 22:14–23, 2021. Study Objectives: This study aimed to examine the acute effects of high altitude (HA) on sleep disordered breathing (sleep apnea and nocturnal hypoxemia) and acute mountain sickness and to characterize acclimatization over time. Methods: Ten native lowlanders residing at sea level (SL) completed the Lake Louise Score (LLS) and underwent nocturnal polygraphy (ApneaLink Plus) for nine consecutive nights (N1–N9) at HA (2,761 m) and two nights before and after HA. Nocturnal oxygen profiles were assessed by measuring the mean nocturnal oxyhemoglobin saturation (S(p)O(2)) during sleep, and sleep apnea severity as assessed by measuring the Apnea–Hypopnea Index (AHI). Mixed-effects linear regression was used to model responses in outcomes (mean nocturnal S(p)O(2), logAHI, and LLS) between HA and SL. Changes in S(p)O(2) and AHI were examined in subgroups with mild versus marked nocturnal S(p)O(2) and low versus high AHI during exposure to HA and compared between subgroups. Results: Compared with SL, the mean nocturnal S(p)O(2) was lower (p

Background/aim: The NoSAS score is a new tool for the identification of high-risk patients for sleep-disordered breathing (SDB). The aim of this study was to validate the NoSAS score in a sleep clinical population in Turkey and compare its performance with the Epworth Sleepiness Scale (ESS), STOP-Bang, and Berlin questionnaires for high-risk SDB. Materials and methods: This was a retrospective study. Patients who had a full-night PSG examination between 01.03.2017 and 01.01.2018 at the sleep center of our hospital were included in the study. Demographic characteristics, anthropometrics measurements, ESS, STOP-Bang, and Berlin scores were collected from the existing data of the patients. The NoSAS score was subsequently calculated based on available data. Predictive parameters for each screening questionnaires were calculated to compare the discriminative power of those for high-risk SDB.Results: A total of 450 patients were included in the study. The sensitivity, specificity, PPV, and NPV of the NoSAS score were 81%, 51.2%, 88.2%, and 37.5% for an AHI (apnea–hypopnea index) ? 5 event/h and 84.5%, 38.2%, 66%, and 63.4% for an AHI ? 15 event/h, respectively. AUC percentages for the NoSAS score, STOP-Bang questionnaire, Berlin questionnaire, and ESS were 0.740, 0.737, 0.626, and 0.571 for an AHI ? 5 events/h and 0.715, 0.704, 0.574, and 0.621 for an AHI ? 30 events/h. The NoSAS score had a false negative rate of 2.9% for severe SDB.Conclusion: The NoSAS score had a good degree of differentiation for SDB and can be used as an easily applicable, subjective, and effective screening tool in a sleep clinical population in Turkey. Not only in moderate to severe SDB but also in mild SDB, the NoSAS score performed better than the other 3 screening tools.Key words: NoSAS score, sleep-disordered breathing, STOP-Bang, Berlin questionnaire