In this guideline on the diagnosis of obstructive sleep apnea in adults, the American College of Physicians recommends a sleep study for patients with unexplained daytime sleepiness, polysomnograph...

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Management of Obstructive Sleep Apnea in Adults: A Clinical Practice Guideline From the American College of Physicians

Summary: Insomnia is a condition which affects millions of individuals, giving rise to emotional distress, daytime fatigue, and loss of productivity. Despite its prevalence, it has received scant clinical attention. An adequate evaluation of persistent insomnia requires detailed historical information as well as medical, psychological and psychiatric assessment. Use of a classification system for sleep disorders and familiarity with major diagnostic groups will facilitate the clinician's evaluation and treatment. Thorough assessment also requires attention to the unique aspects of presentation and specific set of etiologies which are associated with particular age groups.

An American Academy of Sleep Medicine Review

Arguments over the definition of obstructive sleep apnoea/hypopnoea syndrome (OSAHS) have still not been satisfactorily resolved. As a result, robust estimates of the prevalence of OSAHS are not possible. New approaches are needed to identify those who have "CPAP responsive" disease, enabling more accurate estimates to be made of the prevalence of the sleep apnoea syndrome in the community.

https://thorax.bmj.com/content/thoraxjnl/59/1/73.full.pdf

Sleep · 1: Obstructive sleep apnoea/hypopnoea syndrome: definitions, epidemiology, and natural history

The acoustics of snoring.

Orthognathic surgery has been associated with airway narrowing and induction of sleep-related breathing disorders. Therefore, the pharyngeal airway dimensions of 32 orthognathic surgery cases were prospectively investigated, and the relationship between the surgery and sleep quality assessed. Digitized lateral cephalometric radiographs were used to compare oropharyngeal airway morphologies before and after surgery. Patients were assessed in two main surgical groups based on sagittal jaw relationship. A questionnaire was used to assess changes in daytime sleepiness. The mandibular surgery cases were also assessed by overnight domiciliary sleep monitoring. A significant decrease in the retrolingual airway dimension was found in all patients after mandibular setback surgery and a significant increase in this dimension after mandibular advancement. The questionnaire and sleep study revealed no significant changes in snoring incidence or apnoeic events after mandibular setback surgery. For the mandibular advancement group, a change in sleep quality was found, but only in cases with signs of a pre-existing sleep disorder.

The Effects of Orthognathic Surgery on Pharyngeal Airway Dimensions and Quality of Sleep

Objective measurements of several sound level indices were made on 32 subjects referred because of snoring and who subsequently underwent uvulopalatopharyngoplasty (UPPP). The measurements were repeated approximately 6 months post-UPPP. The indices were compared with the subjective assessment of snoring by both the subject and his/her bed partner. Correlations between objective and subjective assessments were generally weak and were strongest when the supine posture only was considered. The index which correlated best with subjective assessment was the level which 1% of the sound level samples exceeded.

Comparison of methods for assessing snoring.

Thirty-two patients undergoing uvulopalatopharyngoplasty (UPPP) for snoring have been studied prospectively using objective measurement of snoring levels. A significant reduction was found, especially in the supine posture. The quantitative reduction was small and correlations between subjective and objective changes in snoring volume were weak.

Objective measurement of the results of uvulopalatopharyngoplasty

It is desirable to screen snoring patients for obstructive sleep apnoea (OSA) prior to surgical treatment. We postulated that the addition of a sound profile would increase the value of overnight oxygen saturation (SaO2) as a screening method. Thirty-nine polysomnographic studies including sound level measured by calibrated meter were performed on snorers being considered for uvulopalato-pharyngoplasty (UPPP). Polysomnography showed an apnoea/hypopnoea index (AHI) > or = 15 per hour of sleep in seven subjects. Two experienced observers independently, without knowledge of other data, classified paper records of SaO2 alone and SaO2 plus sound level obtained during polysomnography as OSA 'unlikely', 'equivocal' or 'definite'. The addition of sound to SaO2 reduced the number of equivocal results from 14 to six and increased the number classified as 'definite' or 'unlikely'. The sensitivity of oximetry +/- sound increased as the threshold AHI used in the definition of OSA increased; addition of sound improved recognition of mild OSA without impairing specificity.

The use of sound recording and oxygen saturation in screening snorers for obstructive sleep apnoea.

Laser palatoplasty (LPP) is widely used for the treatment of non-apnoeic snoring, despite the lack of objective data supporting its use. We report measurements of snoring in a prospective study of LPP, and we compare the results with a previous study of uvulopalatopharyngoplasty (UPPP). Twenty patients with an apnoea/hypopnoea index < 20 h-1 underwent LPP for habitual snoring. Overnight sound recordings were compared before and 6 months after operation using three objective indices; L, (the level exceeded by the loudest 1% of sound), L5 (the level exceeded by the loudest 5% of sound) and P50 (% total sleep time above 50 dBA). The subjective impression of snoring severity (Wilcoxon test, P < 0.001), and objective indices L1 and P50 (t-test, P < 0.001) showed significant reductions after LPP. The mean change in L1 was 4.2 dBA, comparable to that we previously reported for UPPP, while P50 was reduced to less than one-third its preoperative value. No other sleep variables changed significantly following LPP. We conclude that LPP results in reduced snoring volume comparable to that following UPPP.

Objective benefit of laser palatoplasty for non-apnoeic snoring.

Psychometric tests are an objective way of examining cognitive functioning, and have shown impairment in patients with obstructive sleep apnoea. Non-apnoeic snoring may cause reduced concentration, but psychometric tests have been used rarely in this population. We investigate whether their use can demonstrate an improvement in cognitive performance in 20 non-apnoeic snorers following Laser Palatoplasty (LPP). The subjects completed psychometric tests, Beck Anxiety and Depression Inventories and an Epworth Sleepiness Scale on two occasions before LPP and once postoperatively. The only index to show any significant change with LPP was the Beck Depression Inventory (P < 0.005), which was reduced by a mean of 1.6 units following surgery. There was also a highly significant improvement in information processing between the preoperative tests, for which no explanation could be found. Our results suggest that commonly applied psychometric tests are unable to demonstrate significant improvements following surgery for non-apnoeic snoring. However, we have demonstrated for the first time a significant reduction in depression following surgery, which is evidence that snoring is more than a social nuisance.

P. R. Close

Papers

Comparison of methods for assessing snoring.

Objective measurement of the results of uvulopalatopharyngoplasty

The use of sound recording and oxygen saturation in screening snorers for obstructive sleep apnoea.

Objective benefit of laser palatoplasty for non-apnoeic snoring.

Psychometric performance before and after laser palatoplasty for non-apnoeic snoring.