Showing papers on "Epworth Sleepiness Scale published in 2000"

Sensitivity and specificity of the multiple sleep latency test (MSLT), the maintenance of wakefulness test and the epworth sleepiness scale: failure of the MSLT as a gold standard.

Abstract: Excessive daytime sleepiness (EDS) is an important symptom that needs to be quantified, but there is confusion over the best way to do this. Three of the most commonly used tests: the multiple sleep latency test (MSLT), the maintenance of wakefulness test (MWT) and the Epworth sleepiness scale (ESS) give results that are significantly correlated in a statistical sense, but are not closely related. The purpose of this investigation was to help clarify this problem. Previously published data from several investigations were used to calculate the reference range of normal values for each test, defined by the mean+/-2 SD or by the 2.5 and 97.5 percentiles. The 'rule of thumb' that many people rely on to interpret MSLT results is shown here to be misleading. Previously published results from each test were also available for narcoleptic patients who were drug-free at the time and who by definition had EDS. This enabled the sensitivity and specificity of the three tests to be compared for the first time, in their ability to distinguish the EDS of narcolepsy from the daytime sleepiness of normal subjects. The receiver operator characteristic curves clearly showed that the ESS is the most discriminating test, the MWT is next best and the MSLT the least discriminating test of daytime sleepiness. The MSLT can no longer be considered the gold standard for such tests.

Obstructive sleep apnea is common in medically refractory epilepsy patients

Abstract: Background: Previous reports have documented the coexistence of obstructive sleep apnea (OSA) and epilepsy and the therapeutic effects of treatment on seizure frequency and daytime sleepiness. The authors’ objective was to determine the prevalence of OSA and its association with survey items in a group of patients with medically refractory epilepsy undergoing polysomnography (PSG). Methods: Thirty-nine candidates for epilepsy surgery without a history of OSA underwent PSG as part of a research protocol examining the relationship of interictal epileptiform discharges to sleep state. Subjects also completed questionnaires about their sleep, including validated measures of sleep-related breathing disorders (Sleep Apnea Scale of the Sleep Disorders Questionnaire [SA/SDQ]) and subjective daytime sleepiness (Epworth Sleepiness Scale [ESS]). Results: One-third of subjects had OSA, defined by a respiratory disturbance index (RDI) ≥ 5. Five subjects (13%) had moderate to severe OSA (RDI > 20). Subjects with OSA were more likely to be older, male, have a higher SA/SDQ score, and more likely to have seizures during sleep than those without OSA (p Conclusions: In our sample, previously undiagnosed obstructive sleep apnea was common, especially among men, older subjects, and those with seizures during sleep. The impact of treating OSA on seizure frequency and daytime sleepiness in medically refractory epilepsy patients warrants further controlled study.

Sleep-disordered breathing among patients with first-ever stroke.

Abstract: Sleep-disordered breathing (SDB) in the form of obstructive sleep apnea is a possible risk factor for stroke. We carried out a cross-sectional survey out in a rehabilitation center among patients with first-ever stroke to further determine the incidence and types of SDB and its relationship to known risk factors ¶for stroke. Full polysomnography was performed in 147 consecutive patients (95 men, 52 women, age ¶61 ± 10 years) admitted to our neurological Rehabilitation Department 46 ± 20 days after first-ever stroke. Subjective sleepiness (Epworth Sleepiness Scale), vascular risk factors, anthropometric data, and polysomnographic findings were compared between stroke patients with varying degrees of SDB. With a cutoff point for the respiratory disturbance index (RDI) of 5, 10, 15, or 20 the respective prevalence of SDB was 61%, 44%, 32%, and 22%. The type of SDB was generally obstructive, with dominant central apneas in only 6% of patients. Patients with an RDI of 20 or higher had less REM sleep, thicker necks, and a more central type of obesity. Even in patients with an RDI of 20 or higher subjective sleepiness, although higher than in those without SDB, was not a predominant symptom. Snoring and anthropometric data suggest that obstructive SDB may have existed prior to stroke. ¶The prevalence of hypertension and coronary heart disease were higher among stroke patients with an RDI of 20 or higher than in those without SDB. We conclude that the prevalence of SDB among patients with stroke is high. Examination of stroke should include screening for SDB.

A randomized, controlled crossover trial of two oral appliances for sleep apnea treatment.

Abstract: Our purpose was to compare the effectiveness and side effects of a novel, single-piece mandibular advancement device (OSA-Monobloc) for sleep apnea therapy with those of a two-piece appliance with lateral Herbst attachments (OSA-Herbst) as used in previous studies. An OSA-Monobloc and an OSA-Herbst with equal protrusion were fitted in 24 obstructive sleep apnea patients unable to use continuous positive airway pressure (CPAP) therapy. After an adaptation period of 156 +/- 14 d (mean +/- SE), patients used the OSA-Monobloc, the OSA-Herbst, and no appliance in random order, using each appliance for 1 wk. Symptom scores were recorded and sleep studies were done at the end of each week. Several symptom scores were significantly improved with both appliances, but to a greater degree with the OSA-Monobloc. Epworth Sleepiness Scale scores were 8.8 +/- 0.7 with the OSA-Herbst, and 8.6 +/- 0.8 with the OSA-Monobloc devices, and 13.1 +/- 0.9 without therapy (p < 0.05 versus both appliances). The apnea/hypopnea index was 8.7 +/- 1.5/h with the OSA-Herbst and 7.9 +/- 1.6/h with the OSA-Monobloc device, and 22.6 +/- 3.1/h without therapy (p < 0.05 versus both appliances). Side effects were mild and of equal prevalence with both appliances. Fifteen patients preferred the OSA-Monobloc, eight patients had no preference, and one patient preferred the OSA-Herbst device (p < 0.008 versus OSA-Monobloc). We conclude that both the OSA-Herbst and the OSA-Monobloc are effective therapeutic devices for sleep apnea. The OSA-Monobloc relieved symptoms to a greater extent than the OSA-Herbst, and was preferred by the majority of patients on the basis of its simple application.

Does Snoring Predict Sleepiness Independently of Apnea and Hypopnea Frequency

Abstract: Obstructive apneas and hypopneas during sleep are a well recognized cause of excessive daytime sleepiness. Snoring is also associated with excess sleepiness, although it is not known whether this reflects an independent effect of snoring or whether snoring is simply a marker for obstructive sleep apnea. To further explore the relation of snoring to sleepiness, we conducted a cross-sectional cohort study of community-dwelling adults participating in the Sleep Heart Health Study. The study sample comprises 2,737 men and 3,040 women with a mean age of 64 (SD 11) yr. Sleepiness was quantified using the Epworth Sleepiness Scale (ESS). Snoring history was obtained via a self-completion questionnaire. The respiratory disturbance index (RDI), defined as the number of apneas plus hypopneas per hour of sleep, was measured during in-home polysomnography. The ESS score increased progressively with increasing RDI, from a mean of 7.1 (4.2) in subjects with RDI /= 15 (p /= 11, increased from 15% in never-snorers to 39% in those who snored six to seven nights per week. The relation of snoring to sleepiness was seen at all levels of RDI, with no significant change in the relation of snoring to ESS score after adjustment for RDI in multivariate models. The effects of snoring and RDI on sleepiness were little affected by adjustment for age, sex, race, body mass index, or questionnaire evidence of insufficient sleep time or nocturnal leg jerks or cramps. We conclude that both snoring and RDI are independently associated with excess sleepiness in community-dwelling, middle-aged and older adults.

Exercise training effect on obstructive sleep apnea syndrome.

Abstract: The role, if any, of exercise training in the management of individuals with obstructive sleep apnea syndrome (OSAS) is unclear. Anecdotally, patients have reported improvement in symptoms with regular participation in an exercise regime. In this study, we evaluated the effects of an exercise training program and weight loss on physical and subjective measures associated with OSAS. Nine subjects with mild to moderate OSAS completed a six month supervised exercise program. Pre and post-training measures on polysomnographic testing, physical training, anthropometric measures, quality of life (QOL), daytime somnolence and mood states were assessed. A significant decrease in the AHI (p=0.002) was noted along with improvements (p<0.05) in total sleep time, sleep efficiency, number of awakenings/hour, arousals/hour, apnea index and mean exercise training workloads. Significant decreases (p<.001) in weight (-6.2 kg) and body mass index (-1.6) were observed. Evaluation of QOL measures by the Health Status Questionnaire, Profile of Mood States and Epworth Sleepiness Scale showed significant changes in health status, affective state, and a decrease in daytime somnolence. Regular exercise training had a positive impact on the AHI, aerobic capacity, body mass index and QOL. However, exercise training alone was not an adequate intervention strategy for most individuals with OSAS but may serve well as an adjunct treatment strategy in the conservative management of individuals with mild to moderate OSAS.

Hypersomnia after head-neck trauma: a medicolegal dilemma.

Abstract: Objectives: To evaluate the severity of daytime sleepiness in patients with a history of head trauma who complain of daytime somnolence, to investigate polygraphic abnormalities during nocturnal sleep, and to determine whether daytime sleepiness was the cause or consequence of the head trauma. Methods: The authors performed a systematic evaluation of 184 patients comprised of clinical interviews, sleep disorders questionnaires, sleepiness and depression scales, medical and neurologic evaluations, sleep logs with actigraphy, nocturnal polysomnography, and the Multiple Sleep Latency Test (MSLT). Assessments of sleepiness before the accident were based on bed partner interviews, coworker and employer reports, health reports, driving records, and employment history that included absenteeism. Results: Post-traumatic complaint of somnolence was associated with variable degrees of impaired daytime functioning in more than 98% of patients. Patients who were in a coma for 24 hours, who had a head fracture, or who had immediate neurosurgical interventions were likely to have scores > 16 points on the Epworth Sleepiness Scale (ESS) and ≤ 5 minutes on the MSLT. Pain at night was an important factor in nocturnal sleep disruption and daytime sleepiness. Sleep-disordered breathing was a common finding and was the only finding in whiplash patients with daytime sleepiness. Extensive evaluation of pretrauma behavior supported the conclusion that the onset of symptomatic sleep-disordered breathing was associated with the trauma. The patients who showed a “compulsive presleep behavior” were severely impaired in performing their daily activities. Conclusions: A systematic approach is required when dealing with patients complaining of hypersomnia following a head–neck trauma.

Excessive daytime sleepiness in patients suffering from different levels of obstructive sleep apnoea syndrome.

Abstract: Excessive daytime sleepiness (EDS) is a frequent symptom of patients with obstructive sleep apnoea (OSA). EDS is a high-risk factor for accidents at work and on the road. Thirty untreated patients with different levels of severity of OSA were studied concerning night sleep and EDS. The criterion for severity was the respiratory disturbance index (RDI): 15 patients were classified as 'moderately' apnoeic (RDI 40). Following night-time polysomnography, objective and subjective aspects of EDS were studied. To assess objective EDS the Maintenance of Wakefulness Test (MWT) and a computer-based vigilance performance test were used. Subjective EDS was determined using the Stanford Sleepiness Scale (SSS), the Epworth Sleepiness Scale (ESS) and the Visual Analogue Scales for Performance (VAS-P) and Tiredness (VAS-T). Well-being was assessed using the Scale of Well-Being by von Zerssen (Bf-S/Bf-S'). Severe apnoea patients spent more time in stage 1 and less in slow-wave sleep. MWT latencies tended to be shorter in the severe apnoea group. Vigilance testing revealed no group differences. Patients with moderate apnoea described themselves as more impaired in all subjective scales, but only SSS scores reached statistical significance. Our results suggest that there is no simple correlation between polysomnographic and respiratory sleep variables at night on the one hand, and the extent of EDS on the other hand. Furthermore, subjective and objective evaluation of EDS does not yield the same results. New approaches which allow a more detailed analysis of night sleep and daytime function are required to identify high-risked patients.

Sleep-apnea in patients with end-stage renal disease and objective results.

Abstract: BACKGROUND: A high prevalence of sleep apnea syndrome (SAS) of 54%-80% has been reported in patients with end-stage renal disease (ESRD). However, these studies were either done in highly selected small patient groups or without objective data using questionnaires only. PATIENTS AND METHODS: We, therefore, studied the prevalence of SAS in a large, unselected group of patients with ESRD. During a 6-month period 77 out of 84 unselected patients with ESRD filled out the sleep apnea questionnaire of the University of Marburg and the Epworth Sleepiness Scale. In 55 of these patients, snoring sounds, heart rate, body position and transcapillary arterial oxygen saturation were recorded with an ambulatory device during the night after hemodialysis. RESULTS: In the questionnaires, 70.3% of the patients reported of an excessive day-time sleepiness, 40.5% of unwillingly falling asleep during the daytime and 35.2% rated their ability to concentrate as decreased. 30.9% (40% male/15% female) of the patients showed evidence of sleep-disordered breathing with an apnea-hypopnea-index (AHI) equal or more than 5/hour. 16.4% (20% male/10% female) of the patients met the diagnostic criteria of SAS. Neither dialysis and biochemical data nor anamnestic parameters measured by the questionnaires correlated significantly with sleep-disordered breathing. CONCLUSION: The prevalence of SAS in this large unselected patient group was not as high as previously reported, but it is still considerably higher than in the general population. Objective recordings are essential, as questionnaires overestimate the prevalence of SAS in patients with ESRD. As SAS promotes hypertension and impairs quality of life, ESRD patients might benefit from a treatment of concomitant SAS.

Night-time sleep and daytime sleepiness in narcolepsy.

Abstract: This report describes night-time sleep and daytime sleepiness in a large (N=530) sample of patients meeting the International Classification of Sleep Disorders criteria for diagnosis of narcolepsy. Sleep data were obtained from polysomnographic recordings on two consecutive nights. Sleepiness was assessed using the Multiple Sleep Latency Test, the Maintenance of Wakefulness Test and the Epworth Sleepiness Scale. Analysis revealed that sleep was mild to moderately disturbed on both recording nights. A first-night effect was suggested by decreased REM latency and increased percentage REM and slow-wave sleep on the second night. Sleepiness and sleep disturbance varied across patient subgroups created based on patient ethnicity and on the presence/absence of cataplexy, sleep apnoea, and periodic limb movements. Covariation of sleep and sleepiness measures across patients was significant but weak. Strong association was found between subgroup means of sleep and sleep disturbance measures. The findings reported here show that sleepiness and sleep disturbance vary across patient subgroups and that sleep disturbance is related to, although unable to account, for the pathological sleepiness of narcolepsy.

Midline Radiofrequency Tissue Reduction of the Palate for Bothersome Snoring and Sleep-Disordered Breathing: A Clinical Trial

Abstract: This study is a prospective, nonrandomized clinical trial initiated to assess the safety and efficacy of radiofrequency tissue reduction of the palate for the treatment of bothersome snoring and sleep-disordered breathing. Twelve healthy volunteers with socially disruptive snoring underwent a baseline polysomnogram along with a battery of visual analog scales (VASs) to measure daytime sleepiness, snoring level, pain, and disturbances of speech and swallowing. After radiofrequency tissue reduction of the palate, they were re-evaluated with a mean follow-up after the final procedure of 15.7 ± 5.1 (mean ± SD) weeks. As rated by the bed partner, a significant reduction in the level of snoring occurred in all 12 patients, with a mean pretreatment snoring level of 8.3 ± 2.1 to a mean posttreatment snoring level of 2.1 ± 1.4. (Student t test, P < 0.0001) These patients required an average of 2.3 treatment sessions each. Nine of 12 had a reduction in snoring from a bothersome level (VAS range 5-10) to a nonbothersome level (VAS range 0-3). Daytime sleepiness as measured by the Epworth Sleepiness Scale (0-24) decreased from 10.8 ± 4.4 to 8.3 ± 4.1 (P = 0.011). Posttreatment pain was considered absent or minimal in 11 of 12 patients and was managed with acetaminophen. No significant adverse events or complications were reported. (Otolaryngol Head Neck Surg 2000;122:387-94.)

Prevalence of sleepiness and its relation to autonomic evidence of arousals and increased inspiratory effort in a community based population of men and women.

Abstract: Degrees of sleep apnoea and daytime sleepiness are quite common in community populations. However the relationship between the two is poor, although sleepiness does correlate better with a history of snoring. It has been suggested that sleep can be fragmented by upper airways obstructive events, short of full apnoeas or hypopnoeas, and that these events may not provoke full cortical arousal, but be detectable through activation of the autonomic system. Failure to detect both these could mask a relationship between 'sleep apnoea' and daytime sleepiness. We have therefore measured sleepiness (Epworth Sleepiness Scale) in addition to both autonomic 'arousals' and inspiratory effort (using pulse transit time) in 473 men and women at home. Although sleepiness was related to a history of snoring, it was not significantly predicted by the measures of autonomic 'arousal', or inspiratory effort. Reported snoring and objectively measured snoring correlated poorly. As in other studies, nocturnal hypoxic dips were correlated with obesity, age, alcohol consumption, drug usage and a history of snoring. These data make it unlikely that sleep fragmentation from subtle variants of sleep apnoea and 'autonomic' (or 'subcortical') arousals are an important source of daytime sleepiness in the community.

Daytime sleepiness in epilepsy patients: evaluation by means of the Epworth sleepiness scale.

Abstract: Sirs: Epilepsy patients on antiepileptic drugs (AEDs) are known to complain frequently of drowsiness [1]. In clinical practice the evaluation of daytime sleepiness in epilepsy patients is based mainly on the patient’s report at the clinical interview. Most clinicians tend to shortly attribute drowsiness in epilepsy patients to AEDs. Recently Vaughan et al. [6] and Malow et al. [5] used the Epworth Sleepiness Scale (ESS) [3] to evaluate daytime sleepiness in epilepsy patients, with the following principal findings: (a) the degree of daytime sleepiness of epilepsy patients did not differ significantly from that of control subjects affected with other neurological disorders, (b) coexisting symptoms suggestive of obstructive sleep apnea (OSA) and/or restless legs syndrome (RLS) are stronger predictors of subjective daytime sleepiness than AEDs or type and frequency of epileptic seizures. We prospectively evaluated sleepiness by means of the ESS in a series of Italian epilepsy patients followed over a 12-month period. The series consisted of 244 patients (117 men, 127 women; mean age 33.5±11.2 years; mean body mass index 23.7±3.7) whose biometric and clinical details are presented in Table 1. Controls consisted of 205 healthy subjects, comparable in age, sex, and biometric parameters (98 men, 107 women; mean age 31.8±13.4 years; mean body mass index 21.7±3.3). Each subject completed both an Italian version of the ESS [2] and a multiple-choice questionnaire of 112 items concerning sleep habits, quantity, quality of nocturnal sleep, and sleep disorders. Raw scores of ESS in epilepsy and control groups are presented in Table 2. Mean global raw ESS scores in epilepsy and control groups (5.6±3.4 and 5.7±3.6, respectively) did not differ significantly using one-way analysis of variance. In 27 epilepsy patients (11%) and 20 controls (10%) the global ESS score exceeded the upper limit of the normal range of the ESS (i. e., their score was > 10; not significantly different by χ2 test). Analysis of variance or calculation of Pearson’s correlation coefficient, depending on the categorial or continuous nature of the variables, was carried out to examine the possible effects of background and epilepsy variables on ESS score in the epilepsy patients. The following variables were significantly correlated to the global ESS score: loud/habitual snoring and/or observed apneas during nocturnal sleep (F=6.1, df=1 P< 0.01) and recurrence of seizures during the past year LETTER TO THE EDITORS

The multiple sleep latency test and Epworth sleepiness scale in the assessment of daytime sleepiness.

Abstract: Dr Murray Johns' recent article argues that the Epworth Sleepiness Scale (ESS) not only costs about 1000 times less than the Multiple Sleep Latency Test (MSLT) but also serves as a superior gold standard measure of excessive daytime sleepiness (Johns, 2000). The article provides no new data but relies on published ESS and MSLT results from normal and narcoleptic subjects to calculate sensitivities and speci®cities of the ESS and MSLT for these states, which are assumed to represent fully alert and pathologically sleepy individuals. Receiver-operator curves then show that the ESS assigns subjects to their correct groups with nearly perfect accuracy, whereas the MSLT does not perform as well. Unfortunately, these analyses are ̄awed. The narcoleptics were de®ned, in large part, by their subjective complaint of excessive daytime sleepiness (American Sleep Disorders Association 1997; Mitler et al. 1998; US Moda®nil in Narcolepsy Multicentre Study Group 1998). The normal subjects' MSLT data were derived from a study in which no subject with subjective daytime sleepiness could be included (Levine et al. 1988). Normal subjects' ESS data (Johns and Hocking 1997) were taken from the 72 (22%) of 331 Australians who were, as described by Johns, `selected by strict criteria derived from a detailed sleep questionnaire' (Johns 2000); this sample, de®ned by self-report, could be labeled `super subjective normals'. The result is that in John's re-analysis, the normal subjects had no subjective sleepiness and the narcoleptics did have subjective sleepiness, by de®nition. Subjects were grouped more by virtue of their subjective sleepiness than by objective criteria. Johns then showed that the subjectively derived ESS assigned persons to their subjectively de®ned groups more accurately than did the objective MSLT. The ESS previously has been shown to correlate well with patients' own perceptions of their sleepiness, and to have weak or no correlation with objective measures of sleepiness (Chervin and Aldrich 1999): Johns' recent analysis only seems to con®rm these observations. Several additional problems with the ESS are not addressed in Johns' article. Increasing evidence suggests that in the assessment of sleepiness, the ESS is subject to undesirable confounding variables, including gender (Chervin and Aldrich 1999), psychological in ̄uences (Olson et al. 1998), and subjective perception of fatigue, tiredness, and lack of energy (Chervin, 2000a). Although Johns repeatedly argues, based on face validity, that the ESS measures sleep propensity in eight speci®c situations rather than just one (like the MSLT) (Johns 1991, Johns 1993; Johns 1994; Johns 1998; Johns 2000) he has provided no criterion validity to substantiate this argument. In one study that did test his hypothesis, subjective responses to the ESS item that asks about `lying down to rest in the afternoon when circumstances permit' failed to show any robust association with objective measures in this speci®c situation, namely the afternoon naps of MSLTs (Chervin et al. 1997). Finally, Johns' recent article was somewhat selective in its review of existing literature. The largest existing studies of sleep apneics assessed with both MSLTs and Epworth scales showed no statistically signi®cant associations between the two measures (Chervin and Aldrich 1999; Benbadis et al. 1999). Some studies suggest that apnea severity as determined by polysomnography is associated with MSLT-measured sleepiness but not with ESS scores (Chervin et al. 1997; Chervin and Aldrich 1999; Kingshott et al. 1995). A recent study of 1824 individuals did show a highly signi®cant ± but impressively weak ± association between apnea severity and ESS scores (Gottlieb et al. 1999). For example, the subjects with little or no sleep apnea had a mean ESS score of 7.2 ‹ 4.3 while those with the most severe apnea had a mean score of 9.3 ‹ 4.9. Johns is correct in writing that the MSLT is unlikely to be a perfect gold standard, but in that respect the test is similar to many other medical gold standards. His point is also well taken that the 5 and 10 minute `rule of thumb' for MSLT interpretation should not be misused. Strict cut-points on a continuous unimodal measure will almost always serve a patient poorly if results are not carefully integrated and weighed with data derived from the patient's medical history (Chervin, 2000b). Neither the MSLT nor the ESS have been well-validated against objective sleepiness-related outcomes of importance to patients, such as motor vehicle crashes or work performance. Until those important data become available, Correspondence: Ronald D. Chervin, MD, MS, Michael S. Aldrich Sleep Disorders Laboratory, University Hospital 8D8702, Box 0117, 1500 E. Medical Center Dr, Ann Arbor, MI 48109±0117, USA. Tel.: (1) 734 647 9064; e-mail: chervin@umich.edu J. Sleep Res. (2000) 9, 399±401

Polysomnographic respiratory findings in patients with Arnold-Chiari type I malformation and basilar invagination, with or without syringomyelia: preliminary report of a series of cases

Abstract: Patients with craniocervical disorders (CCD) show a wide variety of symptoms and signs suggesting cerebellar and/or high cervical lesion. The anatomic localization of respiratory centers and their possible injury may explain the presence of respiratory disturbances in these diseases. The aim of this preliminary study was to evaluate the polysomnographic findings in a group of patients with CCD, most of them with Arnold-Chiari malformation type I, since sleep apnea has been referred to in isolated cases in the literature. Eleven patients (seven females and four males) with CCD diagnosed by magnetic resonance imaging referred from the neurosurgery unit were submitted to clinical history, physical examination with sleep questionnaires, and scored on the Epworth Sleepiness Scale. Full night polysomnography was performed in an Oxford SAC system where EEG, electro-oculography, electrocardiography, chin and leg electromyography, chest and abdominal efforts, airflow, and oximetry were recorded continuously. Nine patients presented with Arnold-Chiari type I malformation, of whom six showed associated syringomyelia. The other two had basilar invagination. Ninety percent of these patients complained of sleep problems (snoring, choking, and witnessed apneas) and 72% presented hypersomnolence (ESS >9). The polysomnographic findings showed sleep fragmentation in 81% of the patients and a reduction of rapid eye movement sleep in 63%. The apnea/hypopnea index was above 5 in 72%, with a predominance of central apnea. Patients with craniocervical disorders present a higher probability of displaying sleep respiratory disturbances. Their sleep complaints should be assessed and patients should be submitted to an overnight sleep recording in order to identify sleep apnea.

Cautery-assisted palatal stiffening operation for the treatment of obstructive sleep apnea syndrome.

Abstract: Cautery-assisted palatal stiffening operation (CAPSO) is a recently developed single office-based procedure performed with local anesthesia for the treatment of palatal snoring. A midline strip of soft palate mucosa is removed, and the wound is allowed to heal by secondary intention. The flaccid palate is stiffened, and palatal snoring ceases. This prospective study evaluated the ability of CAPSO to treat obstructive sleep apnea syndrome (OSAS). Twenty-five consecutive patients with OSAS underwent CAPSO. Responders were defined as patients who had a reduction in apnea-hypopnea index (AHI) of 50% or more and an AHI of 10 or less after surgery. By these strict criteria, 40% of patients were considered to have responded to CAPSO. Mean AHI improved from 25.1+/-12.9 to 16.6+/-15.0 (P = 0.010). The Epworth Sleepiness Scale, a subjective measure of daytime sleepiness, improved from 12.7+/-5.6 to 8.8+/-4.6 (P<0.001). These results indicate that CAPSO is as effective as other palatal surgeries in the management of OSAS.

Does tongue size differ between patients with and without sleep-disordered breathing?

Abstract: Objectives/Hypothesis To determine whether there is a difference in the tongue size of patients with and without sleep-disordered breathing (SDB) and to evaluate whether tongue volume correlates with body mass index (BMI), neck circumference, age, Epworth Sleepiness Scale score, or apnea-hypopnea index (AHI). Study Design Nineteen patients (9 with SDB; 10 without SDB) were enrolled in this prospective study. Methods All patients completed a sleep questionnaire including the Epworth Sleepiness Scale and underwent a physical examination, portable sleep study, and magnetic resonance imaging (MRI) study. An examiner masked to the patients' disease status measured tongue volume from the MRI films. Results There was a trend for patients with SDB to have a larger tongue volume than patients without SDB (P = .065). Tongue volume only positively correlated with BMI (P = .005) and neck circumference (P = .013), but there was no correlation with age (P = .23) or AHI (P = .40). Conclusions There is a statistical trend for patients with SDB to have larger tongue size compared with non-SDB patients, but tongue size is independent of AHI and correlates significantly with BMI and neck circumference. We interpret these findings to suggest that variations in tongue size alone cannot account for disease severity and may simply reflect the larger body habitus often seen in patients with SDB.

Effect of topical nasal azelastine on the symptoms of rhinitis, sleep, and daytime somnolence in perennial allergic rhinitis.

Abstract: Background Recent data suggested that daytime somnolence in patients with allergic rhinitis was secondary to disrupted sleep caused by nasal congestion. Medications, which decreased congestion, would be expected to improve sleep and daytime somnolence. Previously, we demonstrated that nasal steroids improved all three symptoms. The effect of topical nasal antihistamines on these symptoms has yet to be studied. Objective The objective of this 8-week, double-blind, placebo-controlled study was to determine whether topical nasal azelastine was effective at decreasing congestion, daytime somnolence, and improving sleep. Methods We recruited 24 subjects with perennial allergic rhinitis and randomized them in a double-blinded, crossover fashion, to receive placebo or azelastine two sprays BID, using Balaam's design. Questionnaires, daily diary, and Epworth Sleepiness Scale were used as tools. The last 2 weeks of each 4-week treatment period were summarized, scored, and compared by PROC MIXED in SAS. Results The analysis of the Rhinitis Severity Score showed significant improvement only of rhinorrhea in the azelastine group ( P = .03). The symptom severity of nasal congestion and daytime somnolence was not significantly different between placebo and azelastine. Subjects considered azelastine effective at improving their sleep ( P = .04), but daytime somnolence ( P = .06) and congestion ( P = .09) were not statistically improved. Conclusion Azelastine is effective in reducing rhinorrhea and improving sleep quality. We were unable to demonstrate that azelastine can significantly reduce the severity of congestion or daytime somnolence.

[Prevalence of sleep disorders in an employed Swiss population: results of a questionnaire survey].

Abstract: BACKGROUND The aim of the study was to demonstrate the variety of sleep disorders occurring in a working population in Switzerland and to estimate the prevalence of the main sleep disorders in this Swiss cohort. We also intended to demonstrate that with just a few systematic questions a straightforward diagnostic workup is possible in general practice. METHODS A questionnaire was sent to all 1473 clerks of the Berne main post office. The questions allowed a choice between "yes" or "no", or often (= +3), occasionally (= +2), rarely (= +) and never (= 0). Daytime sleepiness was assessed by the Epworth Sleepiness Scale. RESULTS 668 questionnaires (45%) were available for analysis. Daytime sleepiness, assessed by an Epworth score > or = 10, was found in 13% of the respondents. Short sleep ( 9 h sleep) in 5% of this population. Specific questions clearly suggested obstructive sleep apnoea in 6%, restless-legs syndrome in 4%, disorders of initiating and maintaining sleep in 19% and narcolepsy in 0.5% of respondents. CONCLUSION Chronic sleep insufficiency and sleep complaints appear to be frequent in this relatively young Swiss working population. The questionnaire-based estimated prevalence of the main sleep disorders is comparable to previously published international data.

Brief communication A clinical investigation of obstructive sleep apnea syndrome (OSAS) and upper airway resistance syndrome (UARS) patients

Abstract: Objective: (i) Evaluation of the clinical differences and similarities presented by patients diagnosed as OSAS and UARS subjects. (ii) Evaluation of the ability of a sleep disorders specialist to dissociate the two syndromes based upon clinical evaluation. Population: 314 subjects were included. They were referred to a sleep disorders clinic with complaints of loud snoring during a 3 month period. Method: The evaluation consisted of: (i) Clinical interview and evaluation. (ii) Administration of validated questionnaires (Sleep Disorders Questionnaire and Epworth Sleepiness Scale). (iii) Establishment of clinical diagnostic and results of polygraphic recording. Results: After clinical evaluation and polygraphic recordings (performed within 3 weeks of initial evaluation) patients were subdivided into two groups: 176 OSAS and 128 UARS. The misclassification of patients by specialists correlated with body mass index (BMI) measurement, with an over classification of patient as OSAS when a high BMI was noted and vice-versa for UARS. The only significant difference between OSAS and UARS patients was an older age and a wider neck circumference in the OSAS group than in UARS patients. Conclusion: Clinical presentation including daytime sleepiness complaint and ESS score is similar for patients with and without drop of oxygen saturation below 90% during sleep. There was always a male predominance within both syndromes, but more women were diagnosed with UARS than with OSAS. q 2000 Elsevier Science B.V. All rights reserved.

An auto-continuous positive airway pressure device controlled exclusively by the forced oscillation technique.

Abstract: The forced oscillation technique (FOT) has been demonstrated to be a very sensitive tool for the assessment of upper airway obstruction during nasal continuous positive airway pressure (CPAP) therapy for obstructive sleep apnoea (OSA). The present study was designed to evaluate the therapeutic efficacy of a novel auto-CPAP device based exclusively on the FOT. Following manual CPAP titration, 18 patients with OSA (mean apnoea/hypopnoea index (AHI) 48.0+/-28.1) were allocated to conventional CPAP and auto-CPAP treatment under polysomnographic control in randomized order. The patients were asked to assess their subjective daytime sleepiness using the Epworth Sleepiness Scale (ESS). The mean AHI during auto-CPAP treatment was 3.4+/-3.4 and was comparable with that obtained during conventional CPAP treatment (4.2+/-3.6). The analysis of sleep architecture, the arousal index (6.6+/-2.1 versus 7.3+/-4.4) or the ESS (5.6+/-1.8 versus 7.3+/-4.4) did not reveal any significant differences. However, the mean CPAP pressure during auto-CPAP treatment (0.84+/-0.26 kPa) and in particular the pressure applied in the lateral body position (0.74+/-0.35 kPa), was significantly lower than that employed in conventional CPAP treatment (0.93+/-0.16 kPa, both comparisons: p<0.05). The auto-continuous positive airway pressure device proved equally as effective as conventional continuous positive airway pressure. However, the mean treatment pressure was significantly reduced, especially when patients were sleeping in the lateral position.

Epworth drowsiness scale value in obstructive sleep apnea syndrome

Abstract: Hypersomnia is one of the most consulted symptoms among patients evaluated at sleep disorder centers and it is frequently related to obstructive sleep apnea syndrome (OSAS). Our hypothesis is that Epworth sleepiness scale (ESS) is the parameter with the greatest predictive value in the OSAS diagnosis. We compared patients with OSAS diagnosis to a control group. In both groups we compared ESS with body mass index (BMI), neck circumference (NC), waist perimeter (WP). Anthropometric index (BMI, NC and WC), were similar in both groups (p < 0.10). When we analyzed ESS, a score greater than 10 was observed in the OSAS group, with a significant difference between groups (p < 0.001). Epworth sleepiness scale yielded 60% of sensibility, 82% of specificity and a positive predictive value of 85%. The negative predictive value was 52%. Confidence index was 70%. The relationship between OSAS and ESS scale was significant (Pearson Chi-Square value 7.5). Odds Ratio for apneas was 15 and its confidence interval was lower than 1.5 and upper than 141. We conclude that with ESS score exceeding 10 points OSAS should be suspected.

Clinical approach to excessive daytime sleepiness.

Abstract: Subjective sleepiness is defined as an elemental feeling state by which the subject, and only him/her knows whether he/she is alert or sleepy. Subjective sleepiness has little been used for the clinical evaluation of sleepiness. Objective sleepiness is defined as a consequence of the homeostatic need for sleep. In the absence of a measurable marker of the fulfillment of the function of sleep, the evaluation of objective sleepiness has to rely on a behavioral approach based on the postulate that the more you need sleep (i.e., the sleepier you are), the more likely you are to fall asleep. However, as for many other fundamental human behaviors (drinking, eating, sexual behavior), it is likely that the sleeping behavior serves other purposes than its primary objective, which distorts the relationship between the observed sleeping behavior and the actual need for sleep. The likelihood to fall asleep can be measured by the speed with which a sleep episode occurs under standardized laboratory conditions (multiple sleep latency test, maintenance of wakefulness test, OSLER test), or by the frequency of unwanted sleep episodes under the more naturalistic conditions of daily life (Epworth Sleepiness Scale). These various approaches have advantages and drawbacks, but none of them can be considered the gold standard.

The role of history, Epworth Sleepiness Scale Score and body mass index in identifying non-apnoeic snorers

Abstract: Seventy-one adults referred with snoring over a 9-month period were assessed and their apnoeic-status determined by clinical assessment using symptoms suggestive of the obstructive sleep apnoea-hypopnoea syndrome, the Epworth Sleepiness Scale score (ESS) and body mass index (BMI). The results of clinical assessment were compared to that of overnight six-channel polysomnography where snoring noise level, pulse rate, capillary oxygen saturation, breathing effort, oronasal airflow and body position were monitored. Polysomnography detected an apnoea-hypopnoea index (AHI) of or = 15 episodes/h in 10 (14%) patients. Clinical assessment alone identified 57 patients with AHI of or = 15 episodes/h as 'apnoeic snorers'. The sensitivity of this method of clinical assessment in identifying the 'non-apnoeic snorers' from amongst patients referred with snoring was 93.4% and its specificity was 60% (P < 0.001).