bluuebunny/crossref_metadata_2025 huggingface dataset:
0457 Cardiopulmonary Coupling as an alternative to classic Home Sleep Apnea Testing: Head to Head Assessment
Authors: Simmons Jerald , Thomas Robert , Gregory Keri , Feuquay Cole , Mann Chris
Published: May 2023

Introduction

Standard HSATs directly measure airflow and chest-movements to diagnose OSA. Indirect measures such as Cardiopulmonary-Coupling (CPC) now FDA approved as “Software-as-a-medical-device” are gaining utilization. The FDA assessment of CPC was from NPSG oximetry recordings to which it was compared. SleepImage (SI) recently made CPC commercially available using ring-based oximetry. Out of lab “real-life” validation or head-to-head comparisons of SI-CPC-ring based HSATs to traditional nasal cannula / strain gauge sensor HSTs has ever been published. We performed a Head-to-head study of SI-CPC Ring system to two different HSTs, ApneaLink (AL) by ResMed and Z-Machine (ZM) by General Sleep Corporation. The ZM also provides an EEG derived assessment of sleep stage.

Methods

Patients undergoing AL or ZM HSAT studies were simultaneously placed on SI-CPC-ring devices. Statistical assessments consisted of Bland-Altman-plots and correlation-coefficients to assess for similarity of these devices. Here we report 3%AHI (analogous to the 1A AHI) and 4% AHI analogous to the 1B AHI). Additionally Total-Sleep-Time(TST) and Sleep Efficency(Slp-Eff) are reported with the ZM, which utilized EEG to provide these parameters.

Results

AL-vs-SI-CPC N=44. ZM-vs-SI-CPC N=50. The Bland-Altman-plot and correlation-coefficients demonstrates SI-CPC provided statistically similar results. AL-3%AHI ( Ⴟ 20.3, +/-21.8) vs SI-sAHI3% ( Ⴟ 24.2, +/-25.2) MD: -6.641 (CI -10.127 to -3.154) Range 3.800 to 110.000, R= 0.923 AL-4%AHI (Ⴟ 15.8 +/-21.4 ) vs SI-sAHI4% (Ⴟ 15.8 +/-25.5) MD: 0.132 (CI -2.489 to 2.753) Range 0.000 to 105.600, R= 0.952 ZM-3%AHI (Ⴟ 15.2 +/-30.0) vs SI-sAHI3% (Ⴟ 13.8 +/-19.4) MD: 1.334 (CI -2.709 to 5.377) Range -27.121 to 29.789 R=0.92 ZM-4%AHI (Ⴟ 1.5 +/-27.7) vs SI-sAHI4% (Ⴟ 8.9 +/-17.4) MD: 1.598 (CI -1.917 to 5.113) Range -23.135 to 26.331 R=0.95 ZM-TST (Ⴟ 355 +/-92) vs SI-TST (Ⴟ 355 +/-86.0) MD: 0.076 (CI -24 to 24) Range -171 to 171 R=0.59 ZM-Slp-Eff (Ⴟ 0.818 +/-0.115) vs SI-Slp-Eff (Ⴟ 0.826 +/-0.120) MD: -0.008 (CI -0.044 to 0.027) Range -0.258 to 0.241 R=0.44

Conclusion

HSATs with SI-CPC-ring is an easier method to administer than HSATs using air-flow and chest-sensors. This head-to-head study may enhance adoption of this type of testing, using indirect measures since the SI-CPC-ring system is not inferior, as demonstrated in our study.

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0459 Cardiovascular Endpoints for Obstructive Sleep Apnea with Twelfth Nerve Stimulation: Measures of Sleep-Related Function
Authors: Tangutur Akshay , Cai Yi , Keenan Brendan , Basner Mathias , Dedhia Raj
Published: May 2023

Introduction

Obstructive sleep apnea (OSA) is an increasingly prevalent sleep-related breathing disorder linked to cognitive dysfunction and daytime sleepiness. Positive airway pressure (PAP) therapy, the first-line treatment for OSA, may improve cognitive function and sleepiness, but responses vary. Hypoglossal nerve stimulation (HGNS) is a novel and effective PAP alternative, but its effect on mitigating cognitive decline secondary to OSA is unknown. In the first sham-controlled HGNS trial, we evaluated the effect of HGNS therapy on cognitive measures and patient-reported outcomes (PROs) in patients with moderate-severe OSA.

Methods

In a double-blind, sham-controlled, randomized crossover therapy trial, patients already stabilized on HGNS therapy underwent four weeks of active and four weeks of sham HGNS, each with a 1-week washout period. Sham therapy was defined as the lowest voltage at which HGNS was sensed by the patient or visualized by the clinician. Cognitive measures (Psychomotor Vigilance Test [PVT], Digit Symbol Substitution Task [DSST]) and sleep-related PROs (Epworth Sleepiness Scale [ESS], Snoring Visual Analog Scale [VAS], Insomnia Severity Index [ISI], Functional Outcomes of Sleep Questionnaire [FOSQ]) were assessed after each 4-week period and compared between active and sham therapy.

Results

Sixty randomized patients were included. On average, participants were elderly (67.3±9.9 years), overweight (BMI 28.7±4.6 kg/m2) and had severe OSA prior to HGNS therapy (AHI 33.1±14.9 events/hour). Patients’ AHI decreased to 23.0±15.6 events/hour with sham therapy (p=0.0001) and 18.1±14.8 events/hour with active therapy (p< 0.0001), with a 4.9 event/hour decrease between active and sham therapy (p=0.014). There were no significant differences in performance measures on PVT or DSST between active and sham HGNS. All sleep-related PROs were statistically significant with moderately large (effect sizes ~0.41-0.56) improvements following active HGNS.

Conclusion

The HGNS system permits a unique investigation of the therapy “on/off” effect on measures of cognitive function. In the first sham-controlled, randomized crossover trial of patients using HGNS, all sleep-related PROs, but not objective measures of cognition, were significantly different between sham and active (therapeutic) levels. These findings warrant additional investigation examining the relationship between subjective and objective measures of function in OSA.

Support (if any)

American Heart Association (17SDG33670349) American Sleep Medicine Foundation (176-JF-17) National Institutes of Health (P01-HL094307)
0460 Challenges with Administrative Claims Data to Assess Health Disparities in Patients with Obstructive Sleep Apnea
Authors: Cole Kate , Dexter R Benjamin , Alpert Naomi , More Suyog , Cameron Ann , Kaye Leanne , Lyson Helena , Barrett Meredith , McConnell Will , Sterling Kimberly
Published: May 2023

Introduction

Health disparities adversely affect people based on characteristics that are historically linked to discrimination or exclusion. There is limited research on understanding consequences of health disparities in the diagnosis and treatment of obstructive sleep apnea (OSA). This retrospective study sought to investigate health disparities affecting OSA patients using real-world data.

Methods

A national sample of administrative claims data from OSA patients who had a claim for a sleep test (home sleep test or polysomnography) was used. Gender, insurance payer, race/ethnicity, and 3-digit zip code were characterized from the claims data at the time of the first sleep test to describe differences across patients.

Results

The sample included about 2 million patients with 44.9% female, an average age 51.0 years, and an insurance payer breakdown of 74% commercial, 18% Medicaid, and 8% Medicare Advantage. There were a number of challenges that made it difficult to draw conclusions about the impact of health disparities in this data. The source of gender data was unknown; therefore, we do not know if it represents identified gender or biological sex. Race/ethnicity data was listed as “unknown” for 89% of commercial patients, 18% of Medicaid patients, and 36% of Medicare Advantage patients. Data reporting did not allow for details on multiple races or separation of race and ethnicity. Using 3-digit zip codes proved to be unreliable for drawing conclusions about a patient’s residence and access to care as 3-digit zip code areas are heterogenous and could cover a small section of a major city, a large rural portion of a state, or both. Lastly, ICD-10 Z codes, which describe social determinants of health (SDOH), appear to be underutilized.

Conclusion

Currently, using administrative claims as a real-world data source to assess health disparities is difficult due to data incompleteness, lack of adequate data definitions, and data aggregations made to protect patient privacy. Strategies to increase usability of claims data for investigating health disparities may include improvements in payer data reporting, increased utilization of SDOH Z codes, and linking to other more patient-centric data sources. Analyzing large samples of real-world data may help identify disparities and improve care for all patients.

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0461 CPAP adherence in commercial bus drivers in a public transportation company
Authors: Hamada Eriko , Yamauchi Motoo , Fujita Yukio , Muro Shigeo
Published: May 2023

Introduction

We have been serving a sleep health promotion in a local public transportation company. One of the projects is OSA screening for all commercial bus drivers. In addition, since April 2018, we have made provision for the CPAP adherence, that is, all of the bus drivers have been monitored adherence, and if CPAP adherence was poor for two consecutive times, an interview with us is mandated. In case of the drivers whose adherence is not improved after the interview, they must be away from driving until CPAP adherence is improved. Thus, we hypothesized such a provision makes CPAP adherence better as compared with real-world data of CPAP adherence in Japan (45.6%) which was our presentation at the SLEEP 2022.

Methods

Pulse oximetry-based OSA screening is performed for all of the commercial bus drivers in the public transportation company. In case of 3% oxygen desaturation index ≥15, In-lab diagnostic PSG is performed. The drivers who are prescribed CPAP must submit CPAP adherence data sheet basically every month. Using the data of current employed bus drivers, we calculated the prevalence of OSA and recent CPAP adherence for a total of more than 90 days. CPAP adherence was defined as CMS criteria.

Results

The total number of commercial bus drivers in the company was 1237, of which 131 were diagnosed with OSA, 123 were CPAP users. The prevalence of OSA was 10.6%. Among 123 of CPAP users, 7 drivers lost the CPAP adherence data sheet, 1 driver was absent for a long time due to a malignant disease, and 2 drivers have recently started CPAP therapy, so CPAP adherence for 90 days could not be obtained, Eventually, CPAP adherence was assessed with 113 CPAP users. Eighty-seven drivers achieved CMS criteria, thus CPAP adherence was 77.0% which is comparable to the recent cloud-based CPAP adherence data in the US (72.6%).

Conclusion

CPAP adherence in this study was higher than in the real-world data in Japan. Our sleep health promotion of CPAP therapy in this company successfully increased CPAP adherence.

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0462 CPAP-Experienced Patient Perceptions of CPAP & Novel Nasopharyngeal Airway Device as CPAP Alternative for Obstructive Sleep Apnea
Authors: Marten Thomas , Joshi Sonal , Raven Sarah , Chen Alyssa , Plott Jeffrey , Nourmohammadi Zahra , O'Brien Louise , Zopf David
Published: May 2023

Introduction

Untreated obstructive sleep apnea (OSA) can impact numerous critical organ systems with drastic health ramifications while decreasing daily quality of life of individuals and their family. While Continuous Positive Airway Pressure (CPAP) can be highly effective, adherence is remarkably low. This is a preliminary initiative to gauge patient perceptions of a new non-surgical nasopharyngeal airway (NPA) device in development for OSA.

Methods

An IRB-approved single-site study surveyed 10 patients with polysomnography-confirmed OSA and at least 3 months’ experience using CPAP therapy. An independent expert in patient-reported outcomes helped develop the instrument to understand perceptions and attitudes towards CPAP and gauge initial reactions to the NPA-OSA device. This was reviewed by three Sleep Medicine experts for content validity. An NPA-OSA device description and insertion training video were provided to elicit feedback. Sixty-minute telephone interviews were conducted with OSA patients and transcribed by the independent expert.

Results

Ten patients (4 male), participated with an age range from 31 to 82 years. Nine used CPAP nightly, although described situations when they would not. All participants described significant dissatisfaction with some aspect of their CPAP treatment (e.g., restrictions on sleep position, difficulty cleaning and traveling, reliance on electricity), though most cope and appreciate therapeutic benefit. Respondents were motivated to find new treatment options for OSA, but were not actively seeking new options. Surgical treatment was considered by most, but with fear of unsuccessful outcomes/complications. A few of the respondents had previously used oral appliances with limited success. When introduced to the NPA device, most participants were interested in trying it. Positive attributes were non-invasive, portable and not requiring electricity. Ultimately, participants believed that the device had the potential to improve sleep. Primary concerns were the potential of pain during insertion, discomfort during use, and treatment effectiveness. All those interviewed were interested in participating in a clinical trial using the device.

Conclusion

Patients successfully using CPAP may still be dissatisfied and motivated to explore new options. The NPA-OSA device was considered a compelling option.

Support (if any)

This work was funded by the University of Michigan Coulter program.
0463 Deep Learning Classification of Future PAP Adherence based on CMS and other Adherence Criteria
Authors: Rusk Samuel , Nygate Yoav , Fernandez Chris , Shi Jiaxiao M , Arguelles Jessica , Klimper Matthew T , Watson Nathaniel F , Stretch Robert , Zeidler Michelle , Sekhon Anupamjeet , Becker Kendra , Kim Joseph , Hwang Dennis
Published: May 2023

Introduction

Improving positive airway pressure (PAP) adherence is crucial to sleep apnea therapy success. Although behavioral interventions may be deployed to increase PAP adherence, operationalization remains an ongoing clinical challenge. Treatment outcomes may be optimized by forecasting PAP use to identify patients at risk for non-adherence enabling early intervention. We build upon our previous work by leveraging a larger dataset, additional metadata, and new Deep Learning approaches to forecast future PAP adherence.

Methods

We collected a cohort of N=21,397 subjects with daily PAP usage recorded during 2015-2021. We defined the input to models as the number of minutes the PAP machine was used during each day for the first 30-days. The ground truth was defined as the PAP adherence of the patients at the 3-month, 6- month, and 1-year endpoints. Adherence was calculated based on a 30-day window as ≥4-hours of usage for ≥70% of nights. We evaluated a Deep Neural Network (DNN) model with 10-fold cross- validation to forecast future adherence by leveraging previous daily usage information. Results were compared to a naive method which assumes adherence at each time point equals adherence during the first 30-days.

Results

The DNN models predicted adherence with a sensitivity of 90%, 81%, 77% and a specificity of 90%, 81%, 77%, for 3-month, 6-month, and 1-year endpoints, with ROC-AUC values of 0.97, 0.89, and 0.84 respectively. The models converged to ROC-AUC performance >0.90 for the first 90-days within the first 7 to 14-days of PAP use.

Conclusion

DNN models demonstrated strong predictive performance for PAP adherence, as defined by the CMS adherence criteria, measured by sensitivity, specificity, and overall ROC-AUC results at clinically relevant 90-day, 6-month, and 1-year timepoints. AI approaches show promise as early predictors of the likelihood to meet key therapy utilization thresholds within the first 1-2 weeks of therapy, enabling early PAP intervention or transition to alternative therapies.

Support (if any)

AASM Foundation SRA205-SR-19
0465 Difficulty initiating and maintaining sleep is associated with increased blood pressure in people with obstructive sleep apnea
Authors: Lechat Bastien , Scott Hannah , Sweetman Alexander , Escourrou Pierre , Eckert Danny
Published: May 2023

Introduction

Approximately 30-50% of people with obstructive sleep apnea (OSA) have difficulty initiating and/or maintaining sleep (DIMS). The co-occurrence of OSA and DIMS is associated with worse mental health and quality of life compared to OSA alone. This study investigated potential associations between OSA and regular sleep disturbances (defined over multiple months) with blood pressure and hypertension.

Methods

A validated under-mattress sleep analyzer (WITHINGS) monitored sleep in 12,287 participants over ~6-months at home. The mean apnea-hypopnea index (AHI), sleep onset latency (SOL) and wake after sleep onset (WASO) were calculated over the recording period. OSA was defined as an average AHI ≥ 15 events/hour. DIMS was defined as an average SOL ≥30 min and/or WASO ≥ 45min. Participants were categorized into those with neither condition (control), OSA-alone, DIMS-alone, and OSA+DIMS. Blood pressure measurements were recorded using a home monitor to define hypertension based on mean systolic blood pressure ≥140 mmHg and/or a mean diastolic blood pressure ≥90 mmHg. Associations between OSA+DIMS and hypertension were investigated using regression analyses controlled for age, sex, and BMI.

Results

Participants were middle-aged (Mean±SD; 50±12 y), mostly men (88%) and overweight (BMI; 28±6 kg∙m-2). The prevalence of DIMS-alone, OSA-alone and OSA+DIMS was 10%, 21% and 8%, respectively. OSA-alone was associated with (mean [95%CI]) 4.5 [4.1, 5.0] and 2.6 [2.3, 2.93] mmHg higher systolic and diastolic blood pressure values compared to control. OSA+DIMS was associated with a 5.9 [5.3, 6.6] and 3.7 [3.3, 4.2] mmHg difference compared to control, and the increased difference was greater than OSA-alone (systolic: +1.4 [0.8, 2.0]; diastolic: +1.12 [0.7, 1.6] mmHg; p-values < 0.001).Furthermore , OSA-alone and OSA+DIMS were associated with a 37 [22 to 54] and a 60 [36 to 88] % increase in hypertension prevalence compared to control, respectively. OSA+DIMS had a greater increase in hypertension prevalence (17% [-1 to 38%]) compared to OSA-alone.

Conclusion

OSA when combined with difficulties initiating and maintaining sleep, consistent with insomnia symptomology, was associated with higher blood pressure and increased hypertension prevalence compared to OSA-alone.

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0466 Effect of Obstructive Sleep Apnea and CPAP on Telomere Length and its Associated Mechanisms
Authors: Tempaku Priscila , D'Almeida Vânia , Silva Sylvia , Bittencourt Lia , Tufik Sergio
Published: May 2023

Introduction

Growing evidence suggests the contribution of obstructive sleep apnea (OSA) in the molecular pathways of aging related to the maintenance of telomere length. The present study aimed to investigate the effect of OSA and its treatment with continuous positive airway pressure (CPAP) on the variation of telomere length and its associated mechanisms.

Methods

For this, a 6-month randomized, double-blind and sham-controlled clinical trial was conducted. Participants were randomized to CPAP or sham-CPAP and attended 7 visits, in which they underwent clinical assessment and had their blood collected to determine mean leukocyte telomere length (LTL) and the dosage of metabolic and inflammatory markers.

Results

Among 127 individuals that we contacted, 46 met the inclusion criteria. At baseline, individuals in both groups were homogeneous, including LTL (p=0.106). Adherence during the intervention was 5.29 ± 1.09 in the sham-CPAP group and 5.71 ± 0.19 in the CPAP group. After 6 months of intervention, we observed a statistically significant effect of the treatment (p=0.001) on LTL, in which the sham-CPAP group (1.0117 ± 0.1552, 0.9457 ± 0.0747, 0.8482 ± 0.2163) showed a more significant reduction than the CPAP group (1.0960 ± 0.1122, 1.0521 ± 0.1094, 1.0675 ± 0.1225). Furthermore, we found a negative correlation between delta LTL and dela TNF-α at Visit 7 and Visit 1 (rho=-0.216, p=0.003) due to the sham-CPAP intervention (rho=-0.383, p=0.009) in relation to the use of CPAP (rho=0.021, p=0.800).

Conclusion

We can conclude that CPAP, when compared to sham-CPAP placebo, caused an effect on LTL stability, potentially by the modulation of TNF-α.

Support (if any)

Our studies are supported by Associação Fundo de Incentivo à Pesquisa (AFIP), Fundação de Amparo à Pesquisa de São Paulo (FAPESP), Coordenação de Aperfeiçoamento de Pessoal de Nível Superior (CAPES) and Conselho Nacional de Desenvolvimento Científico Tecnológico (V.A. and S.T. received CNPq fellowships).
0467 Effect of Transoral awake state neuromuscular stimulation therapy on sleep efficiency in patients with mild OSA
Authors: Kumar Kelash , Kallamadi Rekha , Khalil Wajahat , Irfan Muna
Published: May 2023

Introduction

Obstructive sleep apnea can cause fragmented sleep which decreases total sleep time thus decreasing sleep efficiency. Studies have shown improvement in sleep efficiency with the treatment and adherence to therapy for sleep apnea. Due to the CPAP shortage, alternative treatment options for sleep apnea have opted including Transoral awake state neuromuscular stimulation is a novel FDA-approved therapy for mild sleep apnea.

Methods

Transoral awake state neuromuscular stimulation device procured through the regulatory process at VA Minneapolis is offered to veterans with Mild OSA (AHI 5-15) on a home sleep study. A retrospective data analysis was done on the sleep efficiency of veterans who completed the initial 6 weeks of at least 20 minutes of daily followed by maintenance of 2 weeks of twice weekly use. Sleep efficiency was calculated by total sleep time divided by total recording time multiplied by 100.

Results

A total of 112 patients with mild OSA were offered devices as an alternative option for treatment during the period of December 2021 to August 2022. Of these, 22 veterans completed a post-therapy home sleep study. The average age of patients is 53.22 years (ranging from 27-75). The average mean sleep efficiency Pre-therapy was 78.86% (ranging from 62.55% - 95.29%) post-therapy was 82.97% (ranging from 63.52% - 92.23%) A paired t-test was obtained for sleep efficiency which showed a mean difference of 4.11% with a p-value of 0.150 which is statistically non-significant.

Conclusion

Sleep efficiency can be affected by multiple co-morbid conditions among veterans though our study did show a mean difference of 4.11% pre- and post-therapy it was not statistically significant with a p-value of 0.150 that could be related to the small sample size. We proposed that to evaluate sleep efficiency a large sample size is needed with no other co-morbid conditions which can affect sleep efficiency.

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0468 Effects of apnea-induced SWS disruption with and without supplemental oxygen on overnight spatial memory in CPAP-treated OSA
Authors: Mullins Anna , Valencia Daphne , Kam Korey , Parekh Ankit , Fakhoury Ahmad , Castillo Bresne , Ayappa Indu , Rapoport David , Varga Andrew
Published: May 2023

Introduction

Sleep disturbance from obstructive sleep apnea (OSA) impairs overnight memory processing. This may be mediated by changes to slow wave sleep (SWS) as less slow wave activity (SWA) is associated with worse overnight spatial and declarative memory. We developed a within-subjects model of SWS-specific CPAP-withdrawal to create 3 polysomnologically (PSG)-verified conditions of 1) stable-SWS on CPAP, 2) SWS-fragmentation with intermittent hypoxemia (OSAsws), and 3) SWS-fragmentation with reduced hypoxemia (OSAsws+O2). Using these conditions, we sought to dissociate of effects of SWS disruption and intermittent hypoxemia on overnight spatial navigational memory.

Methods

We included 33 patients (7 female, average age 54yrs) with moderate-to-severe OSA (AHI4%>20/hr) who were CPAP-treatment adherent. During each PSG visit, they explored one of three 3D maze environments, performing 3 timed trials before and after each of 3 randomized and counterbalanced SWS disruption conditions [1)CPAP, 2)OSASWS & 3)OSASWS+O2]. %SWS, OSA severity during SWS, frontal SWA(0.5-4 Hz), and overnight change in maze completion times were compared according to PSG condition using Friedman Rank Sum and Conover’s tests. The relationship between SWA and maze performance was tested using Pearson correlation coefficient.

Results

%SWS was significantly greater during CPAP compared to CPAP-withdrawal conditions (CPAP=17.2%, OSAsws=13.3%, OSAsws+O2=13.8%, p< 0.02). Apnea hypopnea index (AHI3A) in SWS during CPAP-withdrawal was significantly greater compared to CPAP (CPAP=0/hr, OSAsws=24.4/hr, OSAsws+O2=19.3/hr, p< 0.00001). Hypoxic burden in SWS was significantly reduced in the OSAsws+O2 condition vs OSAsws (23 %min/hr vs 37 %min/hr, p < 0.001). No significant differences were observed between the three conditions for SWA or overnight change in maze completion times. When including all PSG visits, greater SWA was significantly associated with better overnight maze improvements (R=0.28,p< 0.01) which approached significance for the CPAP condition in isolation (R=0.33,p=0.068).

Conclusion

SWS-specific CPAP-withdrawal resulted in recurrence of mild OSA in SWS; supplemental oxygen reduced the hypoxic burden, but SWA did not differ between OSA with hypoxemia and without. There was, however, an overall positive relationship between SWA and maze performance. These observations suggest that the effect on spatial navigation of hypoxia in OSA is mediated by disruption of SWA.

Support (if any)

R01AG056682, AASM Focused Project Award.
0470 Factors Associated with Discordant Initial Home Sleep Apnea Testing and Polysomnography
Authors: Escobar Andres , Reyes Stephan , Majid Ruckshanda
Published: May 2023

Introduction

Nocturnal polysomnography (PSG) is the gold standard for diagnosing obstructive sleep apnea (OSA). Home sleep apnea tests (HSAT) have been incorporated in the diagnostic algorithm in patients with a high pre-test suspicion of OSA. While many studies have compared HSATs with PSGs, it is not well understood what factors may be responsible for inconclusive HSAT results.

Methods

We performed a retrospective chart review of adult patients who underwent a non-diagnostic HSAT evaluation, who subsequently tested positive for OSA (on PSG) between 1/1/2022 and 11/1/2022. We collected demographic and sleep study data. Patients who did not have a follow up PSG were excluded.

Results

A total of 20 patients were reviewed. 80% had a negative HSAT with a positive subsequent PSG. The average age was 33.9 years (SD +/- 11.3 years). 43% were male and 50% were Caucasian. The average BMI was 29 kg/m2 (SD +/- 5.3 kg/m2). The average Epworth Sleepiness Scale score (ESS) was 8 (median 6.5) with only 31% reporting an ESS >10. The average HSAT recording time was 449.1 minutes. The average respiratory disturbance index (RDI) on the follow up PSG was 17.7 events/hour of sleep (SD +/- 12). Only 1 patient was diagnosed with severe OSA. 38% were diagnosed with anxiety in this cohort. Other co-morbidities were insignificant. Of all the HSATs performed, 40% were denied for an initial PSG evaluation and converted to an HSAT evaluation.

Conclusion

HSATs are validated in patients with a high pretest probability of OSA. Anxiety was found in one third of patients included (possibly contributing to a negative initial HSAT). Patient demographics however were also not remarkable for a high risk of OSA in this group (e.g. non-obese, < 55 years, female). The subsequent diagnosis for OSA was also only mild or moderate (93.8%) in this lower risk cohort. Hence, another explanation for the initial negative HSAT evaluation may have been the insurance denial of the initial PSG request (40%). Denials of low risk patients for PSG may contribute to a misuse of resources. We also need to educate referring physicians to follow appropriate HSAT ordering criteria (based on high OSA risk factors).

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0471 Having a Surgical Aortic Valve Replacement? You Very Likely Have Obstructive Sleep Apnea
Authors: Oldham Mark , Pigeon Wilfred , Yurcheshen Michael , Lee Hochang
Published: May 2023

Introduction

Patients with advanced aortic stenosis (AS) have a high risk of sleep-related breathing disorders (SRBD), yet prior research is limited to type III sleep apnea tests. Whereas the American Academy of Sleep Medicine recommends polysomnography for SRBD diagnosis in patients with significant cardiorespiratory disease, unattended studies are often more acceptable, especially to surgical candidates. We conducted this study to address the need for comprehensive sleep testing in patients with advanced AS.

Methods

We conducted unattended type II sleep tests in 23 adults aged 50 and older scheduled for surgical aortic valve replacement (SAVR) and not using positive airway pressure. We obtained demographics and medical history and administered Clinical Dementia Rating, Pittsburgh Sleep Quality Index, Epworth Sleepiness Scale, and 9-item Patient Health Questionnaire. We characterize this pre-surgical sample and report SRBD prevalence.

Results

Average age of the sample was 68.3 ± 7.2 (mean ± SD), and 74% were male. Charlson comorbidity index was 2.0 ± 2.0. Three (13%) had a global CDR of 0.5, consistent with mild cognitive impairment. Mean PSQI scores were 7.0 ± 3.6, ESS 6.7 ± 4.0, and PHQ-9 4.6 ± 5.3. No subject had an AHI < 5: 7 had a score of 5–14, 8 of 15–29, and 8 of 30 or greater. Mean obstructive AHI was 25.3 ± 20.7, central AHI 1.9 ± 3.4, and respiratory arousal index 8.7 ± 6.2. Total sleep time 362.7 ± 82.6 min with sleep efficiency of 82.1% ± 8.6%. Sleep stage data to be presented.

Conclusion

All subjects in this sample not using positive airway pressure had an AHI ≥ 5. Sixteen subjects (70%) had an AHI ≥ 15, indicating moderate to severe sleep apnea due to predominantly obstructive events. These results strongly suggest that patients with severe AS, especially those undergoing SAVR, would benefit from evaluation for SRBD.

Support (if any)

This research was supported in part by the National Institute on Aging, K23AG072383. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health. Additional support provided by University of Rochester Medical Center funds through the Departments of Psychiatry and Cardiology/Cardiac Surgery.
0473 Multi-outcome of mandibular advancement device in Obstructive Sleep Apnea with different polysomnographic phenotype
Authors: Lee Chien-Feng , Chen Yunn-Jy , Chen Yu-Ching , Lee Pei-Lin , Yu Chong-Jen
Published: May 2023

Introduction

The association of mandibular advancement device (MAD) treatment response and polysomnographic phenotype in patients with obstructive sleep apnea (OSA) has not been fully elucidated. We hypothesized MAD response would be associated with two polysomnographic phenotypes, including sleep stage and positional dependency in treatment-naïve patients with moderate-severe obstructive OSA.

Methods

This retrospective study recruited OSA patients with AHI ≥15/h, aged 20 to 80, treatment naïve, and received MAD treatment for more than three months. Positional phenotype included supine predominant (supine-p) and non-positional OSA. Sleep stage phenotype included REM-predominant (REM-p), NREM-predominant (NREM-p), and stage-independent (SI) OSA. MAD response was defined as criterion 1: residual AHI< 5/h with >50% reduction, and criterion 2: residual AHI< 10/h with >50% reduction. Outcomes included the change in PSG parameters, habitual latency of sleep onset and sleep hour, Epworth sleepiness scale, excessive daytime sleepiness, depression, physical, vitality and mental health domain of SF-36, and in-lab bedtime and wake blood pressure (BP).

Results

379 patients with median age of 52.2 years, BMI of 26 kg/m2, 78.1% of men, and AHI of 28.2/h were recruited. Supine-p and REM-p OSA had lower baseline AHI and desaturation. The overall response rate were 34.7% (criterion 1 ) and 56% (Criterion 2). Supine-p OSA had higher response rate than non-positional OSA (criterion 1: 42.2% vs. 20.3%; criterion 2: 64.3% vs. 32.5%), while NREM-p OSA had lower response rate than REM-p and SI (REM-p vs. NREM-p vs. SI: criterion 1: 43.9% vs. 9.7% vs. 34.2%; criterion 2: 54.5% vs. 41.9% vs. 53.3%). Despite the more reduction in AHI, desaturaiotn, and arousal in responders, there was no differences in change of ESS, EDS, sleep pattern, depression, SF 36 domain, and BP between responders and non-responders which remained unchanged after stratified with sleep stage and position phenotypes.

Conclusion

Non-positional and NREM-predominant OSA had lower responses rate to MAD treatment. There were no differences in non-breathing outcomes between responders and nonresponders regardless of sleep stage and positional phenotype.

Support (if any)

The work was supported by grants from the National Science and Technology Council, Taiwan (NSTC 111-2314-B-002-293); Ministry of Science and Technology, Taiwan (MOST 109-2314-B-002-252); National Taiwan University Hospital (NTUH 107-19, 111-X0033, 111-S0298)
0474 Observing the Changes of Tongue and Airway Configurations in Responders of Mandibular Advancement Device Using Ultrasound Imaging
Authors: Chen Yunn-Jy , Chang Ke-Vin , Chao Pei-Yu , Chen Argon
Published: May 2023

Introduction

Mandibular advancement device (MAD) is designed to pull the mandible and the tongue forward anteriorly to increase the cross-sectional airway dimension and thus possibly reduce airway obstructions during sleep. The effectiveness of a MAD may be affected by the pre-treatment OSA severity, BMI, and degree of changes in pharyngeal dimensions resulting from the device in situ. In this study, 3D submental ultrasound imaging is applied to evaluate the difference in the tongue and airway configurations between the responders and non-responders of the MAD treatment.

Methods

In this retrospective study, 31 subjects (25 males, median age/BMI/baseline AHI of 56/24.5/25.3) diagnosed with sleep apnea and underwent tongue-backing-MAD (t-MAD) treatment were consented from the Department of dentistry of National Taiwan University Hospital between April and December 2022 (IRB 202108078RIPD). Changes in the severity of OSA were assessed with polysomnographic studies. Success of t-MAD treatment was defined by an AHI of less than 10 events/hour and at least 50% decrease in AHI from baseline. There were no significant differences in age, BMI, gender and baseline AHI between responders (17) and non-responders (14). While awake and lying in supine position, the tongue and airway configurations at retropalatal and retroglossal regions without and with t-MAD in situ were assessed with standardized 3D submental ultrasound imaging (AmCAD BioMed Corp., Taiwan). Statistical comparisons were performed using t-tests, chi-square tests and nonparametric Mann-Whitney tests.

Results

The anteroposterior location of the tongue-airway interface at retroglossal region, relative to the superior-inferior location of the soft-palate-airway interface, was found significantly reduced in responders when t-MAD is in situ (p = 0.0078). 13 responders (76.5%) and 9 non-responders (64.3%) were observed with airway width increase in the retroglossal region with t-MAD in situ. However, the difference in airway width changes between responders and non-responders was not statistically significant possibly due to the limited sample size.

Conclusion

With the real-time visualization and quantitative characterization of the tongue and airway configurations, the 3D submental ultrasound with standardized imaging protocol is able to differentiate the responders from non-responders of the t-MAD treatment and could be a potential tool for treatment response evaluation.

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0475 Optimal Thresholds for Split-Night Polysomnography with Transitions in Laboratory Hypopnea Scoring Criteria
Authors: Plante David , Hamm Brian , Rumble Meredith
Published: May 2023

Introduction

Performance of split-night polysomnography, the application and titration of positive airway pressure (PAP) therapy after an initial diagnostic interval, is a common practice in clinical sleep medicine. There is no currently recommended apnea-hypopnea index (AHI) threshold at which PAP should be applied during polysomnography. Differences in American Academy of Sleep Medicine (AASM) and Centers for Medicare and Medicaid Services (CMS) hypopnea scoring criteria and limitations on real-time hypopnea classification complicates identification of an optimal split-night threshold. Of particular concern is that patients may be “split” under AASM hypopnea rules but have insufficiently severe sleep disordered breathing under CMS rules to be diagnosed or treated appropriately. This study aimed to clarify optimal AHI thresholds for split night polysomnography in the context of a laboratory-wide transition from CMS to AASM hypopnea scoring criteria.

Methods

Effective October 1, 2021, our laboratory transitioned solely to scoring AASM-defined hypopneas, with additional post hoc identification of CMS hypopneas for reporting purposes. With this change, the split-night threshold was changed from 15 to 30/hr. All diagnostic polysomnograms (without PAP therapy) performed on adult patients through October 31, 2022, were retrospectively analyzed to clarify the effect of changing hypopnea scoring criteria in this context.

Results

634 diagnostic polysomnograms were analyzed. An AHI threshold of 15/hr (using AASM hypopnea criteria) in the first two hours of sleep with at least 3 hours of time remaining for PAP titration would have resulted in 96 additional patients receiving treatment with PAP therapy. Among these, only one (1.04%) had CMS AHI below 5/hr. Sixty-eight of these patients had CMS AHI 5-15/hr during the first two hours of sleep. Among these, only eight patients did not have an additional comorbidity or symptom profile under CMS guidelines making them eligible for PAP therapy, however, none had CMS AHI >15/hr when the full night of sleep was analyzed.

Conclusion

Our study suggests there is little need to raise the split-night threshold when transitioning from CMS to AASM hypopnea criteria, and doing so substantially reduces the number of patients treated with PAP therapy in the sleep laboratory.

Support (if any)

None
0479 Prevalence, Clinical Features, and Impact of Low Respiratory Arousal Threshold on Patients with Hypoglossal Nerve Stimulation
Authors: Shah Sachin , Manchanda Shalini , Stahl Stephanie , Hasnain Fahad , Patel Jaimin , Dabboussi Tarek , Parker Noah
Published: May 2023

Introduction

This study aims to explore the prevalence and clinical features associated with low respiratory arousal threshold (ArTH) amongst patients with hypoglossal nerve stimulation (HNS) for the treatment of obstructive sleep apnea (OSA) and the possible effects it has on HNS adherence and device usage between time of activation and 1-year post-activation.

Methods

Following institutional review board approval, consecutive patients who underwent HNS system implantation were retrospectively studied, including clinical characteristics, diagnostic polysomnography (PSG) or homes sleep apnea test (HSAT) and HNS post-implant data. Inclusion criteria were patients with ≥1 year of HNS usage who had also completed a post-implant HNS PSG titration study.

Results

Forty-five patients met inclusion criteria. Low ArTH was present in 44.4% of patients and compared to those with high ArTH, low ArTH had a higher prevalence of restless leg syndrome (RLS) (45% vs 12%, p< 0.05) and depression (60% vs 28%, p< 0.05). Low ArTH exhibited a trend toward shorter diagnostic total sleep time (TST) (295.0 vs 373.3 minutes, 0.05 < p < 0.1). Bivalent logistic regression indicated the odds of having low ArTH is 8.6 times greater in patients with RLS (OR 8.6, CI 1.1 – 68.6, p< 0.05). Across all time points, low ArTH resulted in lower mean percentage of HNS nights used (92% vs 86%, p< 0.001) and a lower HNS amplitude (2.41 V vs 1.96 V, p< 0.001) and demonstrated a trend towards lower percentage of nights used ≥4 hours (72.9% vs 66.1%, 0.05 < p < 0.1). 1-year post activation, low ArTH patients continued to show lower percentage of HNS nights used (89.8% vs 75.6%, p< 0.01) and a lower HNS amplitude (2.3 V vs 1.9 V, p< 0.01).

Conclusion

Low ArTH was highly prevalent amongst patients with OSA treated with HNS and was more frequently associated in patients with RLS. Patients with a low ArTH demonstrated significantly lower percentage of nights used and lower amplitudes, indicating the importance this particular phenotype may play in patient compliance with HNS. These findings could help better select candidates who will tolerate HNS therapy and develop targeted therapies to improve long-term adherence.

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0480 Psychoactive Substance Use and Sleep Characteristics Among Individuals with Untreated Obstructive Sleep Apnea
Authors: Walker Alexander , Baldassarri Stephen , Chu Jen-hwa , Deng Annan , Xu Zhichao , Blohowiak Reagan , Byrne Sean , Kushida Clete , Yaggi H , Zinchuk Andrey
Published: May 2023

Introduction

Obstructive sleep apnea (OSA) is characterized by recurrent airway obstruction causing intermittent hypoxia, arousal from sleep, and autonomic instability, and is associated with a variety of long-term health sequala. The fragmented sleep resulting from these respiratory events leads to disruption in normal sleep architecture and progression to deeper stages of sleep, a potential mediator for some of the functional and neurocognitive impairments seen in this population. Similarly, psychoactive substance use (i.e., nicotine, alcohol, and caffeine) impacts sleep architecture in healthy individuals, but their effects in those with OSA have not been well described. We aimed to describe the association between psychoactive substance use and sleep characteristics and daytime symptoms in individuals with untreated OSA.

Methods

We performed a secondary, cross-sectional analysis of The Apnea Positive Pressure Long-term Efficacy Study (APPLES). Exposures included current smoking, alcohol, and caffeine use in individuals with untreated OSA. Outcome domains included subjective and objective sleep characteristics, daytime symptoms, and co-morbid conditions. Linear or logistic regression assessed the association between substance use and each domain (e.g., self-reported sleep duration, total polysomnographic sleep time, sleepiness, and anxiety).

Results

Of the 919 individuals with untreated OSA, 116 (12.6%) were current cigarette smokers, 585 (63.7%) were moderate or heavy alcohol users, and 769 (83.7%) were moderate or heavy caffeine users. Current smokers exhibited lower sleep duration (0.3 hours) and longer sleep latency (5 minutes) compared with non-smokers (all p-values< 0.05). REM sleep increased in those with moderate and heavy alcohol use (2.5 and 5% of total sleep time respectively), and moderate caffeine use (2%, all p-values < 0.05)). The combined smoker plus caffeine group exhibited shorter sleep duration (0.4 hours) and higher risk for chronic pain [Odds Ratio (95%CI) = 4.83 (1.57, 14.9). .

Conclusion

Both psychoactive substances and untreated OSA impact normal sleep architecture, their cumulative effect may have clinical implications in this subgroup. Stimulating or sedating substances may be used in OSA patients to mitigate daytime and nighttime symptoms respectively. Further investigation into the effects substances have on this population may present opportunities to better understand disease mechanisms and increase the effectiveness of treatment in OSA

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0483 Stakeholder Engagement Studios to Explore the Journey to Diagnosis of OSA Informed by Primary Care Providers and Patients
Authors: Watach Alexa , Sawyer Amy , Rosen Ilene , Simonsen Samantha , Pack Allan , Magalang Ulysses
Published: May 2023

Introduction

Barriers to obstructive sleep apnea (OSA) diagnosis include operational misalignments and miscommunications among patients, providers, industry, insurers, and the healthcare system. To explore this, we engaged stakeholders to examine determinants of OSA diagnosis in primary care to optimize trial planning.

Methods

We conducted two, separate, virtual, 1-hour stakeholder engagement studio sessions with Penn Medicine Primary Care Providers (n=6) and patients referred for OSA diagnostics within prior year (n=3). Facilitation guides were used to elicit barriers/facilitators to reaching diagnosis. Sessions were facilitated by a sleep physician and advanced practice sleep nurse with two note-takers in attendance. Rapid matrix analysis approach identified consistent themes within diagnosis barrier and facilitator categories. Themes were categorized by Safety Engineering Initiative for Patient Safety (SEIPS) work system domains: people (P), environment (E), tools (T), and tasks (T), PETT.

Results

Fourteen facilitators (2P, 3E, 3T, 6T) and 15 barriers (2P, 4E, 3T, 6T) were identified for “getting to OSA diagnosis.” Provider-level barriers include: hesitancy to provide anticipatory guidance to patients due to ambiguous workflows after referral, excessive referral order options, no access to templated patient instructions or quality education resources, confusing order panels and use of electronic health record (EHR) workarounds, and fragmented communication. Patient-level barriers include: timeliness of communication and care, sleep health unawareness, low technology literacy for EHR messaging, financial considerations, and insufficient follow-up from healthcare team. Provider facilitators include: classic OSA presentation, diagnosis decision aids, patient education resources, easy to find results in EHR, and low threshold to order referral due to knowledge about sleep. Patient facilitators include: trusted primary care relationship, choice of visit type (telehealth vs. in-person) and communication mode (phone call vs. text vs. EHR portal), active outreach/engagement by healthcare team, and access to educational materials.

Conclusion

Repeated studios, including stakeholders from varied sites, will further refine determinants with more saturation and validity. Engaging with stakeholders is supporting the design of a contextually relevant, end-user valued study to address undiagnosed OSA. Given the estimated high prevalence of undiagnosed OSA and the multiple stakeholders that contribute to the diagnostic process and experience, research-driven solutions will be impactful and better optimized with multi-level partnered research.

Support (if any)

K12HS026372