Population-based epidemiologic studies have uncovered the high prevalence and wide severity spectrum of undiagnosed obstructive sleep apnea, and have consistently found that even mild obstructive sleep apnea is associated with significant morbidity. Evidence from methodologically strong cohort studies indicates that undiagnosed obstructive sleep apnea, with or without symptoms, is independently associated with increased likelihood of hypertension, cardiovascular disease, stroke, daytime sleepiness, motor vehicle accidents, and diminished quality of life. Strategies to decrease the high prevalence and associated morbidity of obstructive sleep apnea are critically needed. The reduction or elimination of risk factors through public health initiatives with clinical support holds promise. Potentially modifiable risk factors considered in this review include overweight and obesity, alcohol, smoking, nasal congestion, and estrogen depletion in menopause. Data suggest that obstructive sleep apnea is associated with all these factors, but at present the only intervention strategy supported with adequate evidence is weight loss. A focus on weight control is especially important given the expanding epidemic of overweight and obesity in the United States. Primary care providers will be central to clinical approaches for addressing the burden and the development of cost-effective case-finding strategies and feasible treatment for mild obstructive sleep apnea warrants high priority.

Epidemiology of obstructive sleep apnea: a population health perspective.

ContextExcess body weight is positively associated with sleep-disordered breathing
(SDB), a prevalent condition in the US general population. No large study
has been conducted of the longitudinal association between SDB and change
in weight.ObjectiveTo measure the independent longitudinal association between weight change
and change in SDB severity.DesignPopulation-based, prospective cohort study conducted from July 1989
to January 2000.Setting and ParticipantsSix hundred ninety randomly selected employed Wisconsin residents (mean
age at baseline, 46 years; 56% male) who were evaluated twice at 4-year intervals
for SDB.Main Outcome MeasuresPercentage change in the apnea-hypopnea index (AHI; apnea events + hypopnea
events per hour of sleep) and odds of developing moderate-to-severe SDB (defined
by an AHI ≥15 events per hour of sleep), with respect to change in weight.ResultsRelative to stable weight, a 10% weight gain predicted an approximate
32% (95% confidence interval [CI], 20%-45%) increase in the AHI. A 10% weight
loss predicted a 26% (95% CI, 18%-34%) decrease in the AHI. A 10% increase
in weight predicted a 6-fold (95% CI, 2.2-17.0) increase in the odds of developing
moderate-to-severe SDB.ConclusionsOur data indicate that clinical and public health programs that result
in even modest weight control are likely to be effective in managing SDB and
reducing new occurrence of SDB.

https://jamanetwork.com/journals/jama/articlepdf/193382/JOC01411.pdf

Longitudinal study of moderate weight change and sleep-disordered breathing.

Our understanding of the nature and consequences of upper-airway obstruction in adults during sleep has evolved considerably over the past two decades. Sleep apnea — defined as repeated episodes of obstructive apnea and hypopnea during sleep, together with daytime sleepiness or altered cardiopulmonary function — is common.1 Epidemiologic studies estimate that the condition affects 2 to 4 percent of middle-aged adults.2 Only a small portion of the cases in this group of adults have been diagnosed; this is related to insufficient awareness of sleep apnea among physicians and the public at large.3 Definitions The manifestations of upper-airway closure during sleep . . .

Obstructive Sleep Apnea

ContextObstructive sleep apnea (OSA) has been increasingly implicated in the
initiation and progression of cardiovascular diseases.ObjectiveTo systematically review the interactions of OSA with cardiovascular
pathophysiology and diseases.Data Sources and Study SelectionThe MEDLINE database from January 1966 to March 2003 was searched using
the Medical Subject Headings sleep, sleep apnea, obesity, hypertension, heart failure, cardiac
arrhythmia, coronary artery disease, stroke, sympathetic activity, endothelium, inflammation, and continuous positive airway pressure (CPAP) to identify peer-reviewed studies of OSA. Priority was given
to large prospective cohort studies and to randomized controlled trials.Data ExtractionWe identified 154 original investigations and reviews of sleep-related
breathing disorders. Data from these studies were examined for relevance and
extracted by one of the authors.Data SynthesisApproximately 1 in 5 adults has at least mild OSA (apnea-hypopnea index
[ie, the number of apneic and hypopneic events per hour], 5-15), and 1 in
15 adults has at least moderate OSA (apnea-hypopnea index, 15-30). Repetitive
apneic events disrupt the normal physiologic interactions between sleep and
the cardiovascular system. Such sleep fragmentation, as well as abnormalities
evident in patients with OSA (eg, increased sympathetic activation, vascular
endothelial dysfunction, increased oxidative stress, inflammation, increased
platelet aggregability, metabolic dysregulation), may be implicated in the
initiation and progression of cardiac and vascular disease. Persuasive data
implicate OSA in the development of hypertension, and OSA also may contribute
to cardiac ischemia, congestive heart failure, cardiac arrhythmias, and perhaps
also to cerebrovascular disease and stroke.ConclusionsObstructive sleep apnea is common, readily diagnosed, and usually treatable.
It frequently coexists undiagnosed in patients with cardiovascular disease,
activates disease mechanisms known to elicit cardiac and vascular damage,
and may be implicated in progression of cardiovascular disease and resistance
to conventional therapeutic strategies. In the absence of definitive evidence
from large-scale trials and a better understanding of potential cost-effectiveness,
the likely benefits of diagnosis and treatment of OSA are presently best appraised
on an individualized patient basis.

https://jamanetwork.com/journals/jama/articlepdf/197410/jcc30007.pdf

Obstructive sleep apnea: implications for cardiac and vascular disease.

Background and Methods Drowsiness and lack of concentration may contribute to traffic accidents. We conducted a case–control study of the relation between sleep apnea and the risk of traffic accidents. The case patients were 102 drivers who received emergency treatment at hospitals in Burgos or Santander, Spain, after highway traffic accidents between April and December 1995. The controls were 152 patients randomly selected from primary care centers in the same cities and matched with the case patients for age and sex. Respiratory polygraphy was used to screen the patients for sleep apnea at home, and conventional polysomnography was used to confirm the diagnosis. The apnea–hypopnea index (the total number of episodes of apnea and hypopnea divided by the number of hours of sleep) was calculated for each participant. Results The mean age of the participants was 44 years; 77 percent were men. As compared with those without sleep apnea, patients with an apnea–hypopnea index of 10 or higher had an odds ratio ...

https://www.nejm.org/doi/pdf/10.1056/NEJM199903183401104

The association between sleep apnea and the risk of traffic accidents. Cooperative Group Burgos-Santander.

Although patients with obstructive sleep apnea often report falling asleep while driving, the frequency of auto accidents involving these patients has not been rigorously studied. Therefore, we compared the driving records of 29 patients with obstructive sleep apnea with those of 35 subjects without sleep apnea. The patients with sleep apnea had a sevenfold greater rate of automobile accidents than did the subjects without apnea (p < 0.01). The percentage of persons with one or more accidents was also greater in the patients with apnea than in the control subjects without apnea (31% versus 6%, p < 0.01). The percentage of persons having one or more accidents in which they were at fault was also greater in the patients with apnea than in the control subjects (24% versus 3%, p < 0.02). The automobile accident rate of the patients with sleep apnea was 2.6 times the accident rate of all licensed drivers in the state of Virginia (p < 0.02). In addition, 24% of patients with sleep apnea reported falling asleep ...

Automobile Accidents Involving Patients with Obstructive Sleep Apnea

STUDY OBJECTIVES: Drivers suffering from obstructive sleep apnea syndrome (OSAS) have an increased risk for being involved in motor-vehicle collisions. This study estimates, for the first time, the annual OSAS-related collisions, costs, and fatalities in the United States and performs a cost-benefit analysis of treating drivers suffering from OSAS with continuous positive airway pressure (CPAP). DESIGN: The MEDLINE-PubMed database (1980 to 2003) was searched for information on OSAS. A meta-analysis was performed of studies investigating the relationship between collisions and OSAS. Data from the National Safety Council were used to estimate OSAS-related collisions, costs, and fatalities and their reduction with treatment. Next, the annual cost of treating OSAS with CPAP was calculated. Finally, multiple 1-way sensitivity analyses were performed. SETTING: N/A. PATIENTS OR PARTICIPANTS: N/A. INTERVENTIONS: N/A. MEASUREMENTS AND RESULTS: More than 800,000 drivers were involved in OSAS-related motor-vehicle collisions in the year 2000. These collisions cost 15.9 billion dollars and 1,400 lives in the year 2000. In the United States, treating all drivers suffering from OSAS with CPAP would cost 3.18 billion dollars, save 11.1 billion dollars in collision costs, and save 980 lives annually. CONCLUSION: Annually, a small but significant portion of motor-vehicle collisions, costs, and deaths are related to OSAS. With CPAP treatment, most of these collisions, costs, and deaths can be prevented. Treatment of OSAS benefits both the patient and the public.

http://curemysleepapnea.com/partners/wp-content/uploads/sites/3/2013/11/Reducing-Motor-Vehicle-Collision-Costs.pdf

Reducing Motor-Vehicle Collisions, Costs, and Fatalities by Treating Obstructive Sleep Apnea Syndrome

Cognitive Impairment in Patients with Obstructive Sleep Apnea and Associated Hypoxemia

Sleepiness is a common cause of traffic crashes with a cost of billions of dollars per year. A recent study has found that 2 to 3% of drivers are habitually sleepy while driving. However, there has not been a controlled study to define the characteristics, driving performance, or automobile crash rate of habitually sleepy drivers. The prevalence of respiratory disorders during sleep, and whether these respiratory disorders contribute to the increased automobile crash frequency, is unknown in habitually sleepy drivers. We interviewed 4,002 randomly selected drivers to define the prevalence of drivers who are habitually sleepy while driving. We studied the habitually sleepy drivers and an age- and sex-matched control group of drivers. These studies included reporting of daytime sleepiness, automobile crashes, driving performance and sleep studies. Of the 4, 002 drivers interviewed, 145 (3.6%, confidence interval [CI] = 3.1 to 4.3) were habitually sleepy while driving. The habitually sleepy drivers reported a significantly higher frequency of auto crashes than control subjects (the adjusted odds ratio [OR] was 13.3, CI = 4. 1 to 43). The habitually sleepy drivers had a significantly higher prevalence of respiratory sleep disorders than control subjects. For a total respiratory events index (apneas, hypopneas, and other respiratory effort-related arousals) >/= 15 the adjusted OR was 6.0, CI = 1.1 to 32. In the habitually sleepy drivers group, the frequency of sleep apnea (apnea-hypopnea index) between subjects with or without auto crashes was not statistically different. However, if we consider total respiratory events index, this frequency of respiratory sleep disorders was significantly higher in subjects with automobile crashes (the adjusted OR for a total respiratory event index >/= 15 was 8.5, CI = 1.2 to 59). Habitually sleepy drivers are a large group of drivers (1 of 30 drivers) who are involved in several fold more automobile crashes than control subjects. As these excess auto crashes can be explained in part by the presence of respiratory disorders during sleep, which are treatable, many automobile crashes in these sleepy drivers may be preventable. Our findings suggest that asking about excessive sleepiness while driving may better predict which subjects with breathing disorders during sleep have crashes than asking about overall sleepiness.

https://www.atsjournals.org/doi/pdf/10.1164/ajrccm.162.4.9907019

Larry J. Findley

Papers

Automobile Accidents Involving Patients with Obstructive Sleep Apnea

Reducing Motor-Vehicle Collisions, Costs, and Fatalities by Treating Obstructive Sleep Apnea Syndrome

Cognitive Impairment in Patients with Obstructive Sleep Apnea and Associated Hypoxemia

Habitually sleepy drivers have a high frequency of automobile crashes associated with respiratory disorders during sleep.

Vigilance and automobile accidents in patients with sleep apnea or narcolepsy.