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Showing papers on "Polysomnography published in 1994"


Journal ArticleDOI
TL;DR: Analysis of 175 polygraphically recorded sleep episodes revealed that the circadian pacemaker and the sleep homeostat contribute about equally to sleep consolidation, and that the phase relationship between these oscillatory processes during entrainment to the 24-h day is uniquely timed to facilitate the ability to maintain a consolidated bout of sleep at night and a consolidated bouts of wakefulness throughout the day.

605 citations


Journal ArticleDOI
TL;DR: How ambulatory blood pressure measurements obtained during an entire 24-hour period, while awake and asleep, differed among people with and without sleep-disordered breathing in the general population is determined.
Abstract: Objective: To measure the independent association of sleep-disordered breathing (sleep apnea and habitual snoring) and hypertension in a healthy adult population. Design: A cross-sectional study of...

552 citations


Journal ArticleDOI
01 Mar 1994-Sleep
TL;DR: The development of the Sleep Disorders Questionnaire (SDQ) from the Sleep Questionnaire and Assessment of Wakefulness of Stanford University is described in detail and the extraction of the best question items from the SQAW and their subsequent rewording in the SDQ are described.
Abstract: The development of the Sleep Disorders Questionnaire (SDQ) from the Sleep Questionnaire and Assessment of Wakefulness (SQAW) of Stanford University is described in detail. The extraction of the best question items from the SQAW and their subsequent rewording in the SDQ to insure greater completion rates are described. Two item test-retest reliability studies are reported on 71 controls and on 130 sleep-disorder patients, which confirmed adequate reliability. To create multivariate scoring scales, SDQ was then given in a multicenter study to 519 persons, 435 of whom were sleep-disorder patients with full polysomnography. Canonical Discriminant Function Analysis was employed, which resulted in four clinical-diagnostic scales: SA for sleep apnea, NAR for narcolepsy, PSY for psychiatric sleep disorder and PLM for periodic limb movement disorder. Each was adjusted for male and female responses and transformed to a percentile using the observed distribution of raw scores. Using Receiver Operating Characteristics analysis, cutoff points were determined for each scale to maximize its sensitivity and specificity. Positive and negative predictive values were also calculated. The SA and NAR scales proved to be the most discriminating.

521 citations


Journal ArticleDOI
TL;DR: The Pittsburgh Sleep Diary is an instrument with separate components to be completed at bedtime and waketime that was shown to have sensitivity in detecting differences due to weekends, age, gender, personality and circadian type, and validity in agreeing with actigraphic estimates of sleep timing and quality.
Abstract: Increasingly, there is a need in both research and clinical practice to document and quantify sleep and waking behaviors in a comprehensive manner. The Pittsburgh Sleep Diary (PghSD) is an instrument with separate components to be completed at bedtime and waketime. Bedtime components relate to the events of the day preceding the sleep, waketime components to the sleep period just completed. Two-week PghSD data is presented from 234 different subjects, comprising 96 healthy young middle-aged controls, 37 older men, 44 older women, 29 young adult controls and 28 sleep disorders patients in order to demonstrate the usefulness, validity and reliability of various measures from the instrument. Comparisons are made with polysomnographic and actigraphic sleep measures, as well as personality and circadian type questionnaires. The instrument was shown to have sensitivity in detecting differences due to weekends, age, gender, personality and circadian type, and validity in agreeing with actigraphic estimates of sleep timing and quality. Over a 12-31 month delay, PghSD measures of both sleep timing and sleep quality showed correlations between 0.56 and 0.81 (n = 39, P < 0.001).

481 citations


Journal ArticleDOI
TL;DR: Severely or morbidly obese men are at extremely high risk for sleep apnea and should be routinely evaluated in the sleep laboratory for this condition, while for severely or morbidley obese women the physician should include a thorough sleep history in the clinical assessment.
Abstract: Objectives: To describe the frequency and severity of sleep apnea in obese patients without a primary sleep complaint and to assess the sleep patterns of obese patients without apnea and compare them with the sleep patterns of nonobese controls. Design and Setting: Prospective case series with historical controls in an obesity and sleep disorders clinic. Subjects: Two hundred obese women and 50 obese men (mean body mass index, 45.3) consecutively referred for treatment of their obesity and 128 controls matched for age and sex. Main Outcome Measures: Eight-hour sleep laboratory recording, including electroencephalogram, electro-oculogram, electromyogram, and respirations. Subjectively reported sleep-related symptoms and signs were also recorded. Results: Twenty men (40%) and six women (3%) demonstrated sleep apnea warranting therapeutic intervention. Another four men (8%) and 11 women (5.5%) showed sleep apneic activity that warranted recommendation for evaluation in the sleep laboratory. In contrast, none of the 128 controls demonstrated sleep apneic activity severe enough for therapeutic intervention. The best clinical predictors of sleep apnea in the obese population were severity of snoring, subjectively reported nocturnal breath cessation, and sleep attacks. Obese patients, both men and women, without any sleep-disordered breathing demonstrated a significant degree of sleep disturbance compared with nonobese controls. Wake time after sleep onset, number of awakenings, and percentage of stage 1 sleep were significantly higher in obese patients than in controls, while rapid eye movement sleep was significantly lower. Conclusion: Severely or morbidly obese men are at extremely high risk for sleep apnea and should be routinely evaluated in the sleep laboratory for this condition, while for severely or morbidly obese women the physician should include a thorough sleep history in the clinical assessment. (Arch Intern Med. 1994;154:1705-1711)

473 citations


Journal ArticleDOI
TL;DR: Gender differences in the relative frequency of sleep-disordered breathing (SDB) have been observed in surveys of patient groups referred for clinical evaluation compared with population surveys, and no differences in body mass index were noted between males and females with SDB recruited from the community.
Abstract: Gender differences in the relative frequency of sleep-disordered breathing (SDB) have been observed in surveys of patient groups referred for clinical evaluation compared with population surveys. In this study, we assessed the associations of gender, SDB, and symptoms of SDB in 389 participants (16 to 84 yr of age) in an ongoing genetic-epidemiologic study of sleep apnea. Subjects included index probands with laboratory-confirmed obstructive sleep apnea syndrome (laboratory sample, n = 36) and their family members and neighbors (the community sample). SDB was assessed with overnight in-home monitoring of airflow, oximetry, heart rate, and chest wall impedance, and symptoms were assessed with standardized questionnaires. In the entire sample, SDB, defined as a respiratory disturbance index [RDI] > or = 15, was more prevalent among males (38%) than among females (15%) (p or = 15 was observed among 26% of males and 13% of females. In the laboratory sample, females tended to be younger and were significantly heavier than males. However, in the community sample, females with SDB were older than male apneic subjects (63.4 +/- 13.9 versus 47.2 +/- 15.6 years, mean +/- SD; p < 0.01), and included a majority of postmenopausal women (75%). No differences in body mass index were noted between males and females with SDB recruited from the community.(ABSTRACT TRUNCATED AT 250 WORDS)

471 citations


Journal ArticleDOI
TL;DR: Predictors of sleep apnea included neck circumference, hypertension, habitual snoring, and bed partner reports of nocturnal gasping/choking respirations, and this model was superior to physician impression, slightly inferior to more detailed linear and logistic models, and comparable to previously reported models.
Abstract: Nocturnal polysomnography, the standard diagnostic test for sleep apnea, is an expensive and limited resource. In order to help identify the urgency of need for treatment, we determined which clinical features were most useful for establishing an accurate estimate of the probability that a patient had sleep apnea. Of 263 physician-referred patients, 200 were eligible for the study and 180 (90%) completed it. All patients had their histories recorded with a standard questionnaire, and underwent anthropomorphic measurements and nocturnal polysomnography. Sleep apnea was defined as more than 10 episodes of apnea or hypopnea per hour of sleep. Multiple linear and logistic regression models predictive of sleep apnea were compared with physicians' subjective impressions and previously reported models. Likelihood ratios were calculated for several levels of a sleep apnea clinical score produced by one of the linear models. Predictors of sleep apnea in the final model (R2 = 0.34) included neck circumference, hype...

466 citations


Journal ArticleDOI
TL;DR: Current cigarette smokers are at greater risk for sleep-disordered breathing than are never smokers, and smoking cessation should be considered in the treatment and prevention of sleep- Disordered breathing.
Abstract: Background: Recent evidence indicates that the prevalence of sleep-disordered breathing is remarkably high (24% for men and 9% for women) and that the public health burden attributable to sleep-disordered breathing is substantial. This investigation examines current and former cigarette smoking as potential risk factors for sleep-disordered breathing. Methods: Data were from 811 adults enrolled in the University of Wisconsin Sleep Cohort Study, Madison. The Sleep Cohort Study is a longitudinal, epidemiologic study that uses nocturnal polysomnography to investigate sleep-disordered breathing and other disorders of sleep. The presence and severity of sleep-disordered breathing was quantified by the frequency of apneas and hypopneas per hour of sleep. Results: Logistic regression analyses were used to control for potential confounding factors. Compared with never smokers, current smokers had a significantly greater risk of snoring (odds ratio, 2.29) and of moderate or worse sleep-disordered breathing (odds ratio, 4.44). Heavy smokers (≥40 cigarettes per day) had the greatest risk of mild sleep-disordered breathing (odds ratio, 6.74) and of moderate or worse sleep-disordered breathing (odds ratio, 40.47). Former smoking was unrelated to snoring and sleep-disordered breathing after adjustment for confounders. Conclusions: Current cigarette smokers are at greater risk for sleep-disordered breathing than are never smokers. Heavy smokers have the greatest risk while former smokers are not at increased risk for sleep-disordered breathing. Thus, smoking cessation should be considered in the treatment and prevention of sleep-disordered breathing. (Arch Intern Med. 1994;154:2219-2224)

441 citations


Journal ArticleDOI
TL;DR: In this paper, an elapsed timer and mask pressure transducer recorder were installed in NCPAP units of 47 OSA patients for monitoring compliance and effective use of the mask.
Abstract: Nasal continuous positive airway pressure (NCPAP) improves sleepiness and prognosis in obstructive sleep apnea (OSA). Our objective was to document NCPAP compliance and the percentage of time that the effective pressure shown to eliminate 95% of the obstructive apneas and hypopneas was maintained. We built and covertly installed an elapsed timer and mask pressure transducer recorder in NCPAP units of 47 OSA patients. Subjects were seen at 2- to 8-wk intervals over 6 months. Group mean age was 51 yr; 38 males, with mean body mass index of 42; all complained of daytime sleepiness. Initial full night polysomnography demonstrated a mean apnea-hypopnea index (AHI) of 58 +/- 2.6 SEM (range, 10 to 115). Nine subjects discontinued therapy within 3 months for various reasons. In the remaining subjects (n = 38) the actual mean nightly hours of use was 4.7 which represents 68% of the stated total sleep time (compliance). However, effective mean hours of use was 4.3 which represents 91% of the time that prescribed effective pressure was maintained at the mask. The AHI did not correlate with compliance, but did correlate with effective use (R = 0.27048, p = 0.0006). Subjective initial complaints of daytime sleepiness correlated with compliance only during the first visit (R = 0.38590, p = 0.05). No predictors for compliance were found.

350 citations


Journal ArticleDOI
TL;DR: It is concluded that SEE decreases and weight improves after resolution of OSAS and it is speculated that the poor growth seen in some children with OSAS is secondary to increased caloric expenditure caused by increased work of breathing during sleep.

334 citations


Journal ArticleDOI
TL;DR: The results indicate that OSA occurs commonly in obese NIDDM patients with excessive sleepiness or heavy snoring, and treatment of their OSA may improve insulin responsiveness.
Abstract: Patients with noninsulin-dependent diabetes mellitus (NIDDM) are often obese and frequently complain of tiredness. These features are also characteristically seen in patients with obstructive sleep apnea (OSA). Therefore, it was the aim of this study to assess the prevalence of OSA among a group of obese NIDDM patients who have some clinical features of OSA. The effect of reversal of OSA by nasal continuous positive airway pressure (CPAP) treatment on insulin responsiveness was also investigated. From a population of 179 NIDDM patients with a body mass index (BMI) greater than 35 kg/m2, we performed ambulatory sleep monitoring on 31 (15 males and 16 females) who admitted to either heavy snoring or excessive sleepiness. Results were reviewed by a sleep physician blinded to the clinical status of the patients, and 22 (70%) were found to have moderate or severe OSA, with mean oxygen desaturation indexes of 10.3 +/- 5.3 and 30.7 +/- 13.2 episodes/h, respectively. A subgroup of 10 patients (seven males and three females) with a mean BMI of 42.7 +/- 4.3 kg/m2 was treated with nightly CPAP for 4 months. These subjects all had significant OSA, with frequent obstructive apneas (mean, 47 +/- 31.6 episodes/h) and oxygen desaturation (mean minimum O2 saturation, 74 +/- 9.5%), as determined by polysomnography. One patient was excluded from analysis because of infrequent use of CPAP. Insulin responsiveness in terms of glucose disposal measured by hyperinsulinemic euglycemic clamps improved from 11.4 +/- 6.2 to 15.1 +/- 4.6 mumol/kg.min (P < 0.05) during CPAP treatment. These results indicate that OSA occurs commonly in obese NIDDM patients with excessive sleepiness or heavy snoring. Treatment of their OSA may improve insulin responsiveness.

Journal ArticleDOI
01 Oct 1994-Sleep
TL;DR: Examination of clinical sleep disorder diagnoses in 257 patients found substantial site-related differences in diagnostic patterns, confirming the importance of psychiatric and behavioral factors in clinicians' assessments of insomnia patients across all three diagnostic systems.
Abstract: Three diagnostic classifications for sleep disorders have been developed recently: the International Classification of Sleep Disorders (ICSD), the Diagnostic and Statistical Manual, 4th edition (DSM-IV), and the International Classification of Diseases, 10th edition (ICD-10). No data have yet been published regarding the frequency of specific diagnoses within these systems or how the diagnostic systems relate to each other. To address these issues, we examined clinical sleep disorder diagnoses (without polysomnography) in 257 patients (216 insomnia patients and 41 medical/psychiatric patients) evaluated at five sleep centers. A sleep specialist interviewed each patient and assigned clinical diagnoses using ICSD, DSM-IV and ICD-10 classifications. "Sleep disorder associated with mood disorder" was the most frequent ICSD primary diagnosis (32.3% of cases), followed by "Psychophysiological insomnia" (12.5% of cases). The most frequent DSM-IV primary diagnoses were "Insomnia related to another mental disorder" (44% of cases) and "Primary insomnia" (20.2% of cases), and the most frequent ICD-10 diagnoses were "Insomnia due to emotional causes" (61.9% of cases) and "Insomnia of organic origin" (8.9% of cases). When primary and secondary diagnoses were considered, insomnia related to psychiatric disorders was diagnosed in over 75% of patients. The more narrowly defined ICSD diagnoses nested logically within the broader DSM-IV and ICD-10 categories. We found substantial site-related differences in diagnostic patterns. These results confirm the importance of psychiatric and behavioral factors in clinicians' assessments of insomnia patients across all three diagnostic systems. ICSD and DSM-IV sleep disorder diagnoses have similar patterns of use by experienced clinicians.

Journal ArticleDOI
TL;DR: It was concluded that objective measures of sleep continuity were closely reflected in perceived sleep quality and that sleep quality essentially means sleep continuity.
Abstract: The present study sought to investigate the meaning of subjectively good sleep, using a longitudinal and intraindividual design. Eight subjects slept in an isolation unit according to an irregular schedule of 6 h sleeps and 1 h naps, designed to give normal amounts of time in bed (1/3 of total), but variable sleep quality. Eight sleeps and eight naps were used for longitudinal simple and multiple regression analyses with standard polysomnographical sleep variables as predictors and subjective sleep quality as dependent variables. The results showed that subjective sleep quality (and related variables) was closely related to sleep efficiency, but not sleep stages. At least 87% efficiency was required for ratings of 'rather good' sleep. In addition, sleep quality ratings improved with closeness (of the awakening) to the circadian acrophase (17.00-21.00 hours) of the rectal temperature rhythm. The subjective ease of awakening differed from most other other variables in that it was related to low sleep efficiency. Objective and subjective homologues of sleep length and sleep latency showed high mean intraindividual correlations (r = 0.55 and 0.64, respectively). It was concluded that objective measures of sleep continuity were closely reflected in perceived sleep quality and that sleep quality essentially means sleep continuity.

Journal ArticleDOI
TL;DR: The data implicate sleep in the modulation of natural immunity and demonstrate that even modest disturbances of sleep produce a reduction of NK cell activity.
Abstract: Sleep disturbance, measured by either subjective report or electroencephalographic (EEG) assessment of sleep, correlates with a reduction of natural killer (NK) cell activity in major depression. To test whether sleep loss independent of mood disturbance alters daytime values of cellular immune function, the effect of late-night partial sleep deprivation on NK cell activity was studied in 23 medically and psychiatrically healthy male volunteers. After a night of sleep deprivation between 3 and 7 AM, NK cell activity was reduced in 18 of the 23 subjects with average lytic activity reduced significantly (p < .01) to a level 72% of the mean of three separate baseline values. After a night of resumed nocturnal sleep, NK cell activity had returned to baseline levels. These data implicate sleep in the modulation of natural immunity and demonstrate that even modest disturbances of sleep produce a reduction of NK cell activity.

Journal Article
TL;DR: 10 mg of zolpidem was found to be safe and effective for the long-term treatment of chronic insomnia, demonstrating hypnotic efficacy without affecting sleep stages or producing tolerance effects, rebound effects, or detrimental effects on psychomotor performance.
Abstract: Background Zolpidem is a short-acting, nonbenzodiazepine hypnotic with rapid onset of action. Even though it is not a benzodiazepine, it binds to one of three types of central benzodiazepine receptors, showing selective binding to the type 1 benzodiazepine receptor subtype. Therapeutic hypnotic dosages do not disturb normal sleep patterns (sleep architecture). Method A randomized, double-blind, placebo-controlled, parallel group multicenter trial was conducted to determine the effectiveness of 10 mg and 15 mg of zolpidem in the long-term (35 nights) treatment of chronic insomnia in 75 patients. Sleep stage effects and motor and cognitive effects during the 35-night treatment period and the 3-night posttreatment period were also investigated. Results Within the first week of treatment, 10 mg of zolpidem had a significant effect on latency to persistent sleep and sleep efficiency. Efficacy was maintained throughout the 35 nights of drug administration. There was no evidence of residual effect with 10 mg of zolpidem. Stage 3-4 sleep was preserved at both the 10-mg and 15-mg zolpidem dosages. There was no evidence of tolerance at either dose and no significant treatment differences between the 10-mg zolpidem group and placebo in latency to persistent sleep or sleep efficiency during the posttreatment period. Also, the 10-mg zolpidem dosage was judged by the patients to have helped them fall asleep. Similar results were observed with the 15-mg zolpidem dosage. However, there were significant decreases in REM sleep at Weeks 3 and 4 with 15 mg of zolpidem compared with placebo. Overall, incidence rates of treatment-emergent adverse events in the zolpidem groups were similar to those in the placebo group. Conclusion This is the first sleep laboratory study using a parallel placebo group to demonstrate efficacy for longer than 4 weeks with a hypnotic agent. In this study 10 mg of zolpidem was found to be safe and effective for the long-term treatment of chronic insomnia, demonstrating hypnotic efficacy without affecting sleep stages or producing tolerance effects, rebound effects, or detrimental effects on psychomotor performance. The 15-mg zolpidem dosage provided no clinical advantage over the 10-mg zolpidem dosage.

Journal ArticleDOI
TL;DR: It is concluded that sleep fragmentation leads to a higher upper airway collapsibility than does sleep deprivation and contributes to the pathogenesis of this disease.
Abstract: Sleep deprivation can induce or worsen nocturnal respiratory disturbances. In patients with sleep apnea hypopnea, sleep abnormalities consist of repetitive episodes of arousals and awakenings that lead to sleep fragmentation. Because the propensity for upper airway collapse is increased in these patients, we wondered if sleep fragmentation could increase upper airway collapsibility and contribute to the pathogenesis of this disease. In eight normal subjects, upper airway collapsibility was assessed during sleep by progressively decreasing the pressure in a nasal mask while recording airflow, mask, and esophageal pressures. The critical pressure was determined by the relationship between breath-by-breath values of maximal inspiratory airflow of each flow-limited inspiratory cycle and the corresponding mask pressure. Critical pressure was measured twice in each subject: after one night of total sleep deprivation and after one night of sleep fragmentation using auditory stimuli. The two measures were done in random order 1 wk apart. A polysomnographic recording was obtained the night after each measurement of critical pressure. Sleep architecture was identical after sleep deprivation and fragmentation. Sleep-related breathing abnormalities were more frequent after sleep fragmentation than after sleep deprivation. Critical pressure was -17.1 +/- 6.8 cm H2O (mean +/- SEM) after sleep deprivation, and -12.3 +/- 6.3 cm H2O after sleep fragmentation (p < 0.05), corresponding to an earlier closing of the upper airway. We conclude that sleep fragmentation leads to a higher upper airway collapsibility than does sleep deprivation.

Journal ArticleDOI
TL;DR: It is concluded that lung disease is not a prerequisite for PH in OSAS and the hypoxemia in PH patients could not be explained by impairment of lung function, greater body mass, or a higher prevalence of smoking.
Abstract: Todetermine whether pulmonary hypertension (PH) can occur in obstructive sleep apnea syndrome (OSAS) in the absence of lung or primary cardiac disease, we studied 27 patients (26 males, mean age 49 ± 10 yr) with OSAS (respiratory disturbance index [RDI] > 10 events/h) in whom clinically significant lung or cardiac diseases were excluded. Pulsed Doppler measurements of pulmonary hemodynamics, pulmonary function tests, arterial blood gas analysis, and polysomnography were performed. A total of 11 OSAS pa­ tients (41%) were found to have pulmonary hypertension. The levels of PH were relatively mild (Ppa ~ 26 mm Hg). There were no differences between PH and non-PH patients in body mass index (BMI), smok­ ing history, or lung function. PH patients were more hypoxemic when awake than non-PHpatients (Pao, = 72.2 ± 7.6 versus 17.6 ± 7.3 mm Hg, respectively; p < 0.05) but did not differ in severity of sleep apnea (RDI = 51.9 ± 25.1 versus 56.8 ± 26.2 events/h, respectively; p = NS) or indices of sleep desaturation. The hypoxemia in PH patients could not be explained by impairment of lung function, greater body mass, or a higher prevalence of smoking, and Pao2 in the study population was significantly correlated with Ppa (r = -0.46, P < 0.02) but not with FEV, or BMI. We conclude that lung disease is not a prerequisite for PH in OSAS. We speculate that the development of PH in OSAS patients depends more on individual differ­ ences in the response of the pulmonary circulation to the episodic alveolar hypoxia and respiratory acido­ sis associated with sleep apneas than on differences in the frequency or severity of the apneas. Repetitive elevation of Ppa during sleep into the PH range may lead to pulmonary vascular remodeling in "responders" and thereby daytime PH and hypoxemia. Sajkov 0, Cowie RJ, Thornton AT, Espinoza HA, McEvoy RD. Pulmonary hypertension and hypoxemia in obstructive sleep apnea syndrome. Am J Respir Crit Care Med 1994; 149:416-22.

Journal ArticleDOI
TL;DR: The study population was evaluated on the basis of a successful response to mandibular advancement, and the baseline MP-H was found to be significantly shorter in the responders than in nonresponders, while the soft palate length showed a significantly greater shortening in responders after treatment.
Abstract: Treatment options for obstructive sleep apnea (OSA) may involve potential side effects or discomfort; nasal continuous positive airway pressure (CPAP) may not be tolerated by 25% of patients. We therefore sought to determine the efficacy of mandibular advancement as a treatment for OSA, and to investigate whether clinical and radiographic parameters can predict the response to this treatment. Sixteen male and 3 female subjects with documented OSA who had failed or been unable to tolerate nasal CPAP underwent baseline polysomnography and cephalometry, and were then fitted with a removable Herbst appliance to achieve forward mandibular advancement during sleep. All subjects then underwent a second cephalometric evaluation and polysomnography with the appliance in place. Fourteen of 15 subjects demonstrated significant improvement in the degree of OSA, based on the apnea-hypopnia index (AHI) (34.7 +/- 5.3 to 12.9 +/- 2.4 events/h, p < 0.002). Comparison of pre- and posttreatment cephalometric values revealed no significant change in the posterior airway space (PAS) despite a reduction in mean AHI. There was a significant decrease in the mandible-hyoid distance (MP-H) with treatment for the group as a whole. When the study population was evaluated on the basis of a successful response to mandibular advancement (posttreatment AHI < 10), the baseline MP-H was found to be significantly shorter in the responders than in nonresponders. MP-H after mandibular advancement was likewise shorter in responders than in nonresponders. In addition, the soft palate length (PNS-P) showed a significantly greater shortening in responders after treatment.(ABSTRACT TRUNCATED AT 250 WORDS)

Journal ArticleDOI
TL;DR: Case-control studies are recommended to assess the relation of endocrine factors to obstructive sleep apnea syndrome in a rigorous fashion and to distinguish symptomatic study subjects from asymptomatic subjects, and to exclude central apneas in calculating their estimates.
Abstract: Sleep-disturbed breathing, which includes apneas, hypopneas, and oxygen desaturations, occurs in asymptomatic individuals and increases with age. Obstructive apnea is the most frequent type of respiratory disturbance documented by polysomonography, the gold standard test for assessing sleep-disturbed breathing. Many of the prevalence studies done to date have had one or more methodological weaknesses, including selection biases, varying definitions of obstructive sleep apnea, failure to distinguish types of apneas, failure to control for confounding variables, and small sample size. Although there is consensus on the definitions of sleep-disturbed breathing, the appropriate number of apneas and hypopneas for diagnosing clinically significant obstructive sleep apnea is uncertain. While the cutoff of five or more apneas and hypopneas per hour is historically considered abnormal, the origins of this number are vague, and the longevity of those who have this value on polysomnography is not necessarily reduced. This is particularly true among those without symptoms of obstructive sleep apnea syndrome, which include excessive daytime sleepiness, snoring, nocturnal awakenings, and morning headaches. Investigators should be careful to distinguish symptomatic study subjects from asymptomatic subjects, and to exclude central apneas in calculating their estimates. In addition, various studies have used different definitions of sleep apnea syndrome, making comparisons of point estimates difficult. It would be more appropriate for researchers to estimate morbidity and mortality indices with confidence intervals, using several different cutoff points. Subject selection in all studies should follow a two-stage sampling procedure. All subjects with symptoms compatible with obstructive sleep apnea syndrome and a subsample of asymptomatic individuals should be studied with all-night polysomnography. If portable monitoring is used, the validity and reproducibility of this diagnostic method should be assessed. Subjects with significant comorbidity should be excluded from prevalence studies. Factors that clearly increase the risk of sleep-disturbed breathing and obstructive sleep apnea and its related symptoms include age, structural abnormalities of the upper airway, sedatives and alcohol, and probably family history. Although endocrine changes such as growth hormone, thyroid hormone, and progesterone deficiency also have been suggested as risk factors for exacerbating obstructive sleep apnea syndrome, there is minimal epidemiologic evidence to support this. Case-control studies are recommended to assess the relation of endocrine factors to obstructive sleep apnea syndrome in a rigorous fashion. A limited number of mortality studies have suggested decreased survival in persons with the obstructive sleep apnea syndrome, possibly primarily due to vascular-related disease.(ABSTRACT TRUNCATED AT 400 WORDS)

Journal ArticleDOI
01 Oct 1994-Sleep
TL;DR: There is evidence for an independent association between sleep apnea and not only blood pressure, but also fasting insulin levels, according to the cross-sectionally examined relationship of various levels of apneic activity and measure of obesity.
Abstract: This report concerns the relative contributions of body weight and sleep apnea to the following cardiovascular risk factors: blood pressure, fasting insulin and fasting glucose. We cross-sectionally examined the relationship of various levels of apneic activity [apnea-hypopnea index (AHI)] and a measure of obesity [body mass index (BMI)] to mean morning blood pressure and fasting serum insulin and fasting blood glucose concentrations sampled the morning after polysomnography. Subjects were 261 males (age 47 +/- 13 years, mean +/- SD), who were referred to a sleep laboratory for symptoms of sleep-disordered breathing. The dependent variables, mean morning blood pressure, insulin and fasting blood glucose (FBG) levels, were significantly related to both AHI (eta'2 = 0.10) and BMI (eta'2 = 0.18). AHI and BMI combined to account for approximately 30% of the variability in the best linear combination of these three factors. Further analysis indicated that mean morning blood pressure and fasting insulin levels each correlated positively with BMI and AHI, whereas FBG correlated only with BMI. We conclude that, although these data do not prove a causal relationship, there is evidence for an independent association between sleep apnea and not only blood pressure, but also fasting insulin levels.

Journal ArticleDOI
TL;DR: The modified hyoid suspension procedure appears to offer significant adjunctive treatment for hypopharyngeal obstruction in obstructive sleep apnea syndrome.
Abstract: Obstructive sleep apnea syndrome results from a loss of muscular activity of pharyngeal dilators and airway collapse at the hypopharynx-base of tongue or the oropharynx-soft palate. The hyoid arch and its muscle attachments strongly affect hypopharyngeal airway patency and resistance. On the basis of these concepts and previous experience, a modified hyoid suspension procedure is presented. Fifteen consecutively treated surgical patients underwent an isolated modified hyoid suspension procedure to correct hypopharyngeal obstruction. Oropharyngeal-palatal obstruction had previously been corrected or was thought not to be a component of the obstruction. Treatment outcomes were based on objective polysomnographic data and subjective clinical correction of excessive daytime sleepiness. The polysomnographic data included analysis of the respiratory disturbance index and lowest oxyhemoglobin desaturation. On the basis of these criteria, 12 of 15 patients (75%) had correction of their excessive daytime sleepiness and marked improvement in their sleep disorder breathing. The mean preoperative respiratory disturbance index was 44.7 +/- 22.6, and the lowest oxyhemoglobin desaturation was 82% +/- 6%. The postoperative respiratory disturbance index and lowest oxyhemoglobin desaturation were 12.8 +/- 6.9 and 86% +/- 5%, respectively. The modified hyoid suspension procedure appears to offer significant adjunctive treatment for hypopharyngeal obstruction in obstructive sleep apnea syndrome.

Journal Article
TL;DR: Alpha-delta patterns occurred in almost all the patients who had also superficial and fragmented sleep with increased awakenings and reduced REM and slow wave sleep and clear abnormalities in sleep cycle organization.
Abstract: Objective Fibromyalgia syndrome (FMS) is a musculoskeletal disorder characterized by generalized pain, localized tender points, chronic fatigue and nonrestorative sleep. Since sleep disturbances frequently occur in FMS and alpha intrusion in nonrapid eye movement (NREM) sleep probably associates with the nonrefreshing sleep, we prospectively studied the delta and alpha activity and alpha-delta ratio across sleep cycles, performing polysomnography in 10 patients with FMS and in 14 healthy control subjects. Methods Night long polysomnography recordings were performed in all subjects. Sleep scoring was done visually according to Rechtschaffen and Kales criteria. By means of spectral analysis the conventional electroencephalogram (EEG) frequency bands were automatically computed for the all night recordings. For alpha and delta power the integrated and normalized values were calculated for each sleep cycle, the evolution of these activities across successive sleep cycles was studied. Results Alpha-delta patterns occurred in almost all the patients who had also superficial and fragmented sleep with increased awakenings and reduced REM and slow wave sleep. Delta decay across sleep cycles was different in FMS and alpha activity was greater and declined, whereas the controls were persistently low throughout their sleep. Alpha-delta ratio increased progressively in successive sleep cycles; this was again different from controls. Conclusion Patients with FMS presented a high frequency of subjective sleep disturbances, an increased incidence of alpha EEG NREM sleep and clear abnormalities in sleep cycle organization.

Journal ArticleDOI
TL;DR: Sleep disturbance in MS is common but poorly recognised, usually due to leg spasms, pain, immobility, nocturia or medication, and is much less commonly associated with nocturnal respiratory insufficiency.
Abstract: Twenty-eight consecutive patients with multiple sclerosis (MS) were clinically evaluated to determine the presence of sleep-related disorders. There were 12 males and 16 females aged between 22 and 67

Journal ArticleDOI
01 Oct 1994-Sleep
TL;DR: The study documents major alterations of the sleep EEG that are not evident from the sleep scores and that may be associated with the characteristic hormonal changes occurring during pregnancy.
Abstract: The impairment of sleep quality is a common complaint during pregnancy. To investigate the changes in sleep in the course of pregnancy, the sleep electroencephalogram (EEG) was recorded and analyzed in nine healthy women on 2 consecutive nights during each trimester of pregnancy. Waking after sleep onset increased from the second (TR2) to the third (TR3) trimester, whereas rapid eye movement (REM) sleep decreased from the first trimester (TR1) to TR2. Spectral analysis of the EEG in nonrapid eye movement (NREM) sleep revealed a progressive reduction of power density in the course of pregnancy. In comparison to TR1, the values in TR2 were significantly lower in the 10.25-11.0-Hz and 14.25-17.0-Hz bands. In TR3, the significant reduction extended over the ranges of 1.25-12.0 Hz and 13.25-16.0 Hz. The largest decrease (30%) occurred in the 14.25-15.0-Hz band. In REM sleep, the spindle frequency range was not affected, and a minor reduction of power density in some frequency bins below 12 Hz was present only in TR3. The study documents major alterations of the sleep EEG that are not evident from the sleep scores and that may be associated with the characteristic hormonal changes occurring during pregnancy.

Journal ArticleDOI
01 Oct 1994-Sleep
TL;DR: Results indicate that successful surgical treatment is possible in a high percentage of selected patients with certain craniofacial characteristics, andMaxillomandibular advancement should be offered as an alternative therapy to all patients with maxillary and/or mandibular deficiency or dolichofacial type in combination with narrow posterior airway space.
Abstract: In recent years obstructive sleep apnea syndrome has gained increasing interest. Treatment of choice is nasal continuous positive airway pressure ventilation during sleep for upper airway patency, which does not cure sleep apnea and has to be applied throughout a patient's lifetime. In respect to various underlying pathomechanisms, in certain cases with craniofacial disorders, causal therapy by craniofacial osteotomies seems possible. A series of 21 consecutive patients with maxillary and mandibular deficiency were treated primarily with a 10-mm maxillomandibular advancement by retromolar sagittal split osteotomy and Le Fort-I osteotomy, respectively. Obstructive sleep apnea syndrome was considerably improved in all patients. In 20 of 21 patients, the postoperative respiratory disturbance index (RDI) was reduced clearly to under 10, oxygen saturation rose and sleep quality improved. This was achieved by a maxillomandibular advancement of 10 mm without secondary refinements. In one patient the RDI could only be reduced to 20, probably due to insufficient maxillary advancement; oxygen desaturations still existed despite secondary corrections. These results indicate that successful surgical treatment is possible in a high percentage of selected patients with certain craniofacial characteristics. In addition to cardiorespiratory polysomnography there should be routine cephalometric evaluation of all patients. Maxillomandibular advancement should be offered as an alternative therapy to all patients with maxillary and/or mandibular deficiency or dolichofacial type in combination with narrow posterior airway space.


Journal ArticleDOI
TL;DR: Abstinence and relapse were not consistently related to other clinical measures at the time of hospital admission such as age, duration and severity of alcoholism, marital status, employment, hepatic enzyme levels, cognitive performance, or depression ratings.
Abstract: Objective: To determine whether polygraphic sleep recordings, obtained at the time of admission to an inpatient alcohol treatment program, predict abstinence and relapse 3 months following hospital discharge in nondepressed patients with primary alcoholism. Design: Two independent, consecutive cohorts of patients (group 1, n=28; group 2, n=17) underwent all-night polygraphic sleep recordings and other clinical evaluations during the first and fourth weeks of a 1-month inpatient treatment program within a Veteran Affairs Medical Center. They were reevaluated 3 months following discharge to the community. None were treated with disulfiram or other medications during or after hospitalization. Patients: All subjects were male veterans with primary alcoholism and without significant preexisting, secondary, or comorbid diagnoses such as major medical problems, depression, antisocial personality, or drug addiction. Outcome Measures: Relapse was defined as any alcohol consumption between discharge from the hospital and 3-month follow-up. Results: Ten (36%) of 28 patients in group 1 were Relapsers at 3-month follow-up. Relapsers in group 1 showed significantly shorter Rapid Eye Movement (REM) latency, increased Rapid Eye Movement percent (REM%), and increased REM Density during their admission sleep studies compared with Abstainers. To replicate these observations, group 2 was then studied as a validation sample. Six (35%) of 17 patients relapsed. As in group 1, Relapsers had significantly shorter REM latency and increased REM% compared with Abstainers; REM Density was not significantly different in the Relapsers as compared with Abstainers in group 2. Using a principal components analysis based on these three REM sleep measures to determine "REM pressure," three separate discriminant function analyses (DFAs) were calculated: one for each group and one for all patients (n=45) together. The DFA from group 1 correctly classified 22 (78.6%) of the 28 patients in group 1 and 13 (76.5%) of the 17 patients in group 2 as Relapsers or Abstainers. The DFA from group 2 correctly classified 13 (76.5%) of the 17 patients in group 2 and 23 (82.1%) of the 28 patients in group 1. The DFA formed from both groups together correctly classified 36 (80%) of the 45 patients. When the REM sleep measures at hospital admission and discharge were compared, no statistically significant effect of time was observed. Abstinence and relapse were not consistently related to other clinical measures at the time of hospital admission such as age, duration and severity of alcoholism, marital status, employment, hepatic enzyme levels, cognitive performance, or depression ratings. Conclusion: Short REM latency, increased REM%, and, possibly, increased REM Density at the time of admission to a 1-month inpatient alcohol treatment program predict relapse in nondepressed patients with primary alcoholism by 3 months following hospital discharge.

Journal ArticleDOI
01 Feb 1994-Thorax
TL;DR: The sleep related breathing abnormality in Duchenne muscular dystrophy is initially obstructive and this has implications for management.
Abstract: BACKGROUND--In order to clarify the treatment of sleep hypoxaemias in Duchenne muscular dystrophy polysomnographic studies were performed on patients at home with the purpose of recruiting them into two clinical therapeutic trials. Observations concerning the nature of sleep hypoxaemia in these patients are presented. METHODS--Twenty one non-ambulant patients with Duchenne muscular dystrophy aged 13-23 years with no symptoms of sleep hypoventilation or apnoea were studied for two consecutive nights with eight channel polysomnography. A comparative study was performed in 12 age matched normal male subjects. The evolution of sleep hypoxaemia with age was studied in 14 patients with Duchenne muscular dystrophy. RESULTS--Thirteen of the 21 patients had hypoxaemia below 90% during sleep, and 12 of the 13 had discrete hypoxaemic dips in association with apnoeas; 60% of all apnoeas were obstructive in nature. The hypoxaemic periods became more frequent with increasing age and, in two patients at three year follow up, were more frequently associated with central or possibly "pseudocentral" apnoeas. Although the normal subjects had a few apnoeic episodes, none had sleep hypoxaemia below 90% saturation. CONCLUSION--The sleep related breathing abnormality in Duchenne muscular dystrophy is initially obstructive and this has implications for management.

Journal ArticleDOI
TL;DR: The consistency of end-apneic TTdi values despite the varying chemical drive supports the hypothesis that apnea termination in OSA is mediated by mechanoreceptor feedback from the respiratory system, most likely fromThe respiratory muscles.
Abstract: Previous work from our laboratory has indicated that mechanoreceptor feedback from the respiratory muscles may play an important role in arousal and apnea termination in obstructive sleep apnea (OSA). Other studies have pointed to a prominent role for chemoreceptor stimuli. We postulated that mechanoreceptor stimuli from the respiratory system are the primary determinant of apnea termination, and that chemoreceptor stimuli exert their effect indirectly through stimulation of ventilation and thus proprioceptive feedback. To test this, we measured the diaphragmatic tension-time index (TTdi) during obstructive sleep apneas in seven male subjects with severe untreated OSA. We compared the maximal TTdi values at end-apnea during administration of air, O2, and CO2. We reasoned that if mechanoreceptor stimuli mediate apnea termination, changing the degree of chemoreceptor stimulation during apneas should not alter the level of respiratory effort at end-apnea. O2 administration produced a significant increase in end-apneic arterial oxygen saturation (SaO2) and increased apnea duration. CO2 administration led to an increase in pre- and postapneic end-tidal carbon dioxide pressure (PETCO2), and tended to shorten apneas. However, the mean value for maximal end-apneic TTdi was 0.12 +/- 0.01 (SEM) during room air breathing and was unaltered by O2 (0.12 +/- 0.01) or CO2 (0.11 +/- 0.01) administration. The consistency of end-apneic TTdi values despite the varying chemical drive supports the hypothesis that apnea termination in OSA is mediated by mechanoreceptor feedback from the respiratory system, most likely from the respiratory muscles. The influence of chemoreceptor information may be mediated indirectly through an effect on ventilatory effort.

Journal ArticleDOI
TL;DR: 8-hour polysomnography in multiple sclerosis patients was evaluated to correlate sleep results with clinical and brain magnetic resonance imaging (MRI) data and found greater MRI lesion loads were detected in the infratentorial regions, particularly in cerebellum and brainstem.