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BACKGROUND: Obstructive sleep apnea (OSA) often has a significant impact on health-related quality of life (HRQoL) with social and psychological implications. For most OSA patients, a reduction in their HRQoL is due to symptoms such as poor sleep quality, excessive daytime somnolence, and fatigue with differences between gender. PURPOSE: This study explores the CPAP treatment effect on self-perceived HRQoL related to gender, somnolence, and CPAP adherence. METHODS: Out of 1082 consecutive Italian outpatients, 125 (82 M) (60.3 ± 9.6 years) completed the prospective observational study and were evaluated at the first visit (T0), and the follow-up visit (T1). Two self-reported HRQoL questionnaires were administered: six subscales Psychological General Well-Being Index (PGWBI) and 12-Item Short-Form Health Survey (SF-12). RESULTS: Scores of PGWBI and SF-12 MCS improved from T0 to T1. Patients with CPAP use >= 4 h/night showed a significant improvement in all dimensions evaluated, except for SF-12 PCS. At T1, participants with ESS > 10 improved in all scores, except SF-12 PCS. Gender comparison shows better-perceived HRQoL in males at first visit and CPAP follow-up visit. Variation of PGWBI was significantly correlated with CPAP use, ESS at T0 and T1 (p < 0.0001; r2 = 0.26). CONCLUSIONS: This study provides evidence on the effectiveness of CPAP treatment on perceived HRQoL. Participants with greater adherence to therapy, greater sleepiness, and greater improvement of daytime sleepiness with CPAP therapy, reported a higher quality of life improvement. Gender comparison shows better-perceived HRQoL in males at first visit and CPAP follow-up, despite a more considerable improvement in females.

Sleep is a physiological function that undergoes, at different stages of life, to considerable variations in neurophysiological and behavioral functions. The developmental age is a period characterized by a continuous process of physical and neuropsychological changes and synaptic remodeling processes that are the neurophysiological basis of brain plasticity, typical of this developmental phase, occurring mainly during sleep. In the description of obstructive sleep apnea (OSA) in children, two main points should be highlighted: its variability in different age groups, and its specificity compared with OSA in adults. The definition and criteria used for the diagnosis of OSA in adults are not applicable to OSA in developmental age. Although the adenotonsillar hypertrophy is the most common risk factor for pediatric OSA, obesity is becoming an increasingly prevalent risk factor, mostly in early childhood (6- 9 years) and adolescence. OSA has been shown to affect cognitive function in children and adults. However, OSA impact on cognitive function in children is more severe since acting on the plastic brain structures can change the neuro-psychic development, learning skills, and social interactions. There is a clear difference in the definition of pathology between developmental age and adulthood according to the instrumental parameters: an AHI >= 5, which represents, in the pediatric age, the cut-off for a therapeutic pathway necessary to avoid a long-term effect on the child, instead, it represents in adulthood, the lower limit value for the definition of disease. This is a narrative review concerning obstructive sleep apnea in developmental age. Conclusions: OSA is a common disorder in children and those at riskmust be identified, studied, and treated promptly because untreated OSA can be responsible for cardiovascular, metabolic, and neurocognitive morbidities and may induce, sometimes, non-reversible deficits given his insistence on a period of physical and neuro-psychic development.

Background and purpose There are several primary causes for excessive daytime sleepiness (EDS) and sleep disorders in patients with epilepsy. Up to now, studies in the literature report conflicting data in terms of both prevalence and aetiology. The aim of our study was therefore to evaluate the prevalence of EDS and some sleep disorders in a population of patients with epilepsy treated with no more than two antiepileptic drugs (AEDs). We also investigated the role of the depression of mood as a variable that can negatively affect EDS. Methods We prospectively and consecutively recruited 99 patients with a diagnosis of epilepsy, sleep disorders and EDS, belonging to the Centre for Epilepsy of the Department of Experimental Biomedicine and Clinical Neurosciences of the University of Palermo. 61.6% of patients recruited were suffering from focal epilepsy, and 38.3% from generalized epilepsy. 68.6% were undertaking monotherapy and 27.2% were drug resistant. Patients were matched for sex and age (+/- 5 years) with 96 non epileptic controls recruited from high school students, college students, relatives and friends of the medical team that conducted the study. EDS was found in 11.1% of patients with epilepsy. Clinical evaluation of sleep disorders was performed using validated questionnaires to investigate excessive daytime sleepiness (EDS), insomnia, Restless Legs Syndrome (RLS) and Obstructive Sleep Apnoea Syndrome (OSAS). In a second phase of the study, 43 of the investigated patients and 34 controls - after giving their consent - underwent a polysomnographic examination by "Compumedics Somte". Results Our study shows a statistically significant difference between cases and controls with regard to the prevalence of RLS (p = 0.022) and severity of OSAS with an increased risk in moderate-severe forms of epilepsy (odd ratio [OR] 2.5) most significantly associated with male gender (p = 0.04) and focal epilepsy (OR 3.8) with PSG seizures (0.02). Moreover, a statistically significant difference was demonstrated about mood disorders (p = 0.001) among patients with epilepsy and non epileptic controls. Sleepiness in patients with epilepsy seems to be particularly related to both the depression of mood (p = 0.01) and the presence of OSAS (p = 0.03), as well as to a higher mean age (p = 0.006) and a longer duration of illness (p = 0.04). Conclusions Our results confirm that drowsiness trouble frequently complained by patients with epilepsy, is particularly related not only to the presence of OSAS but also to the depression of mood.

Background: Obstructive sleep apnea (OSA) is associated with nocturnal intermittent hypoxia, which may be responsible for increased circulating levels of vascular endothelial growth factor (VEGF) and inflammatory mediators, such as metalloproteinases (MMPs), and which contributes to the pathogenesis of systemic hypertension. Why some OSA patients remain normotensive is poorly understood. Relaxin-2, a pregnancy hormone, may sometimes circulate in men and could increase in hypoxic conditions. It exerts a vasodilatory activity and can modulate the release of molecules, such as MMPs and VEGF. Objectives: The objective of this study was to explore if circulating relaxin-2 in male OSA subjects may be related to OSA severity, to circulating levels of MMPs, of their inhibitors (tissue inhibitors of metalloproteinases; TIMPs), and of VEGF, and if it may protect from hypertension. Patients andMethods: Fifty untreated male subjects with suspected OSA were recruited. After nocturnal polysomnography, a morning venous blood sample was withdrawn. Then, 24-hour ambulatory blood pressure (BP) monitoring was performed. Results: The respiratory disturbance index in the sample was 30.4 [interquartile range (IQR) 15.6-55.2]. Relaxin-2 was detectable in 20 subjects. These subjects did not differ in OSA severity or diurnal and nocturnal BP from subjects with undetectable relaxin-2, but they showed lower TIMP-1 (126.8 ± 29.1 vs. 156.9 ± 41.7 pg/ml, respectively; p = 0.007) and a marginally higher MMP-9/TIMP-1 molar ratio [0.58 (IQR 0.23-1.35) vs. 0.25 (IQR 0.15-0.56); p = 0.052]. Conclusions: Relaxin-2 in male subjects was not related to OSA severity, but it was associated with lower TIMP-1. As it was often undetectable, even when BP values were normal, it is unlikely that it plays a role as a major factor protecting from hypertension in OSA.

Objective: To determine whether the use of a gel pillow with side cutouts designed to accommodate a continuous positive airway pressure (CPAP) mask and reduce head temperature improves the efficacy of and adherence to auto-CPAP therapy. Methods: Twenty-three consecutive CPAP-naïve patients with obstructive sleep apnea were enrolled in the study. Patients were given an auto-CPAP machine with an appropriate CPAP mask and were instructed to use CPAP for 15 nights. They were instructed to sleep with their own pillow (the control pillow) from nights 1 to 5 and with either a foam pillow or a gel pillow, both of which had side cutouts, for 5 consecutive nights each, in random order. After night 15, auto-CPAP machine data were downloaded and patients rated their satisfaction with each pillow on a visual analog scale. Results: Twenty-two patients completed the protocol. The pressures administered, residual apnea-hypopnea index, air leaks, and mean duration of CPAP use did not differ among the periods during which each pillow was used. Patients were significantly more satisfied with the gel pillow than with the control pillow and the foam pillow (p = 0.022 and p = 0.004, respectively), their level of satisfaction with the gel pillow correlating significantly with excessive daytime sleepiness (r2 = 0.19; p = 0.0443). Conclusions: Among obstructive sleep apnea patients treated with nasal CPAP, the use of a gel pillow with side cutouts appears to have no impact on treatment effectiveness. Nevertheless, such patients seem to prefer a gel pillow over other types of pillows. RESUMO Objetivo: Determinar se o uso de um travesseiro de gel com recortes laterais para acomodar a máscara de continuous positive airway pressure (CPAP, pressão positiva contínua nas vias aéreas) e diminuir a temperatura em torno da cabeça melhora a eficácia do tratamento com auto-CPAP e a adesão dos pacientes ao tratamento. Métodos: Foram incluídos no estudo 23 pacientes consecutivos com apneia obstrutiva do sono que nunca haviam recebido tratamento com CPAP. Os pacientes receberam um aparelho de auto-CPAP com uma máscara apropriada e foram instruídos a usar CPAP durante 15 noites. Foram também instruídos a dormir com seu próprio travesseiro (o travesseiro controle) nas 5 primeiras noites e com um travesseiro de espuma ou um travesseiro de gel, ambos com recortes laterais, durante 5 noites consecutivas cada, em ordem aleatória. Depois da 15ª noite, os dados registrados nos aparelhos de auto-CPAP foram baixados e os pacientes determinaram seu grau de satisfação com cada travesseiro por meio de uma escala visual analógica. Resultados: Vinte e dois pacientes completaram o protocolo. Não houve diferenças entre os períodos durante os quais cada travesseiro foi usado quanto às pressões administradas, índice de apneia-hipopneia residual, vazamentos de ar e média de duração da CPAP. Os pacientes ficaram significativamente mais satisfeitos com o travesseiro de gel do que com o travesseiro controle e o travesseiro de espuma (p = 0,022 e p = 0,004, respectivamente), com correlação entre o grau de satisfação com o travesseiro de gel e a sonolência diurna excessiva (r2 = 0,19; p = 0,0443). Conclusões: Em pacientes com apneia obstrutiva do sono tratados com CPAP nasal, o uso de um travesseiro de gel com recortes laterais aparentemente não tem nenhum impacto na eficácia do tratamento. No entanto, esses pacientes aparentemente preferem um travesseiro de gel a outros tipos de travesseiros.

Background Perceived Health Related Quality of Life (HRQoL) is impaired in obstructive sleep apnea (OSA). This study examines changes in HRQoL aspects occurring immediately after CPAP titration. Furthermore, we analyzed variations in each gender and in patients undergoing home or laboratory-based CPAP titration pathways. Methods Twohundredfive outpatients (151 M) (56.7 ± 10.3 years) were evaluated, before first visit and nocturnal diagnostic examination (T0), and the morning after CPAP titration (T1). Two self-reported HRQoL questionnaires were administered: Psychological General Well-Being Index (PGWBI), composed by six subscales, and 12-Item Short-Form Health Survey (SF-12), including Physical (PCS) and Mental Component Summaries (MCS). CPAP titration was performed using auto-adjusting CPAP units at patients’ home or in the sleep laboratory. Results PGWBI scores at T1 improved compared to T0 (p

Background Perceived Health Related Quality of Life (HRQoL) is impaired in obstructive sleep apnea (OSA). To our knowledge, no study has analyzed the effect of OSA diagnosis communication on HRQoL. We evaluated self-perceived HRQoL in patients afferent to our sleep center, in order to examine the effect of the diagnosis disclosure on their HRQoL. Methods Two hundred ninety-seven consecutive outpatients (227 M) (mean age 54.1 ± 11.6 yrs, range 23–80 yrs) were evaluated, before first clinical visit and nocturnal diagnostic examination (Time A), and after diagnosis disclosure (Time B), with two self-reported questionnaires for HRQoL assessment: Psychological General Well-Being Index (PGWBI), consisting of anxiety, depressed mood, positive well-being, self-control, general health, vitality subscales, and 12-Item Short-Form Health Survey (SF-12), comprising Physical (PCS) and Mental Component Summaries (MCS). Results Comparison of mean HRQoL scores at Time A with reference values, showed worse scores. Mean PGWBI Total and subscales scores improved at Time B. Similar improvement was observed for SF-12 MCS (p = 0.0148), but nor for SF-12 PCS. At Time B, Anxiety, Depression and Well-being PGWBI subscales became similar to reference values, while the scores in the other PGWBI subscales and SF-12 remained worse. Comparison between males and females showed higher HRQoL values for males at both times. Score changes were independent from age, gender, BMI, AHI, TSat90 and excessive daytime sleepiness. Conclusions Diagnosis communication improves patients’ HRQoL, regardless of the severity. Changes in HRQoL after diagnosis disclosure may be due to patients’ motivation for medical check and diagnostic expectations.

Background Obstructive sleep apnea (OSA) is a high prevalence sleep disorder characterized by upper airway obstruction during sleep, nocturnal intermittent hypoxemia, poor sleep quality, risk for cardiovascular and metabolic diseases. The adherence to CPAP is the key for an effective management of these patients. The aim of the study was to assess the adherence to CPAP therapy with and without early reinforcing interventions, consisting of motivational reinforcement and technical support in the first month of therapy. Methods Forty patients with OSA undergoing counseling and a one year follow-up on a quarterly basis were included in the study. Twenty subjects (intervention group) underwent reinforcing interventions with telephone interviews in the first month of therapy, and twenty (control group) remained without reinforcing interventions. The two populations were homogeneous for age, severity of illness and BMI. Results During the first month, intervention group patients showed a higher number of nights with a device use ≥4 hours. Average treatment adherence in the first month (days of therapy with at least 4 hours per night on the total number of days from device delivery) was 77.5% in the intervention group and 55.7% in the control group (p = 0.022). At one year the differences between the two groups were not significant. Conclusions Our findings suggest that it is important that adequate time and effort is spent to ensure patient comfort at the time of CPAP therapy start to optimize acceptance and adherence to treatment, and suggest that it is necessary to maintain reinforcing interventions over time.

A 20% increase in REM sleep duration has been proposed as a threshold to identify REM rebound in patients with obstructive sleep apnea (OSA) who start continuous positive airway pressure (CPAP) treatment. We describe the case of one patient with OSA who showed an unexpectedly high degree of REM rebound during titration of CPAP. A 34-year-old man was diagnosed with OSA. He remained untreated for many years, during which he developed systemic hypertension, depression, and severe daytime somnolence. When he was reevaluated sixteen years later, his Epworth sleepiness score was 18, and his OSA had greatly worsened (apnea/hypopnea index: 47, lowest nocturnal saturation: 57%). He underwent a successful CPAP titration during nocturnal polysomnography. Electroencephalographic analysis of the sleep recording revealed a huge amount of REM sleep, accounting for 72% of the total sleep time. When asked, the patient referred that he had suddenly interrupted paroxetine assumption three days before the polysomnography. The very large REM rebound observed in this patient could be due to additional effects of initiation of CPAP therapy and suspension of antidepressive treatment. This case does not report any dangerous consequence, but sudden antidepressive withdrawal could be dangerous for patients with OSA who develop hypoventilation during REM sleep with CPAP application.

OBJECTIVES: To investigate the usefulness of measuring upper airway collapsibility with a negative expiratory pressure application as a screening test for severe obstructive sleep apnea (OSA). INTRODUCTION: OSA is a risk factor for cardiovascular disease, and it may have serious consequences. Its recognition may have important implications during the perioperative period. Increased upper airway collapsibility is one of the main determinants of OSA, and its evaluation could be useful for identifying this condition. METHODS: Severe OSA and normal subjects (24 in each group) were matched by body mass index and referred to our sleep laboratory. The subjects were enrolled in an overnight sleep study, and a diurnal negative expiratory pressure test was performed. Flow drop (DV) and expiratory volume were measured in the first 0.2 s (V02) of the negative expiratory pressure test. RESULTS: DV (%) and V02 (%) values were statistically different between normal and OSA subjects. OSA patients showed a greater decrease in flow than normal subjects. In addition, severely OSA patients exhaled during the first 0.2 s of the negative expiratory pressure application was an average of only 11.2% of the inspired volume compared to 34.2% for the normal subjects. Analysis of the receiver operating characteristics showed that V02 (%) and DV (%) could accurately identify severe OSA in subjects with sensitivities of 95.8% and 91.7%, respectively, and specificities of 95.8% and 91.7%, respectively. CONCLUSIONS: V02 (%) and DV (%) are highly accurate parameters for detecting severe OSA. The pharyngeal collapsibility measurement, which uses negative expiratory pressure during wakefulness, is predictive of collapsibility during sleep.

OBJECTIVE: Obstructive sleep apnea is characterized by increased upper airway collapsibility during sleep. The present study investigated the use of the negative expiratory pressure test as a method to rule out obstructive sleep apnea. METHODS: Flow limitation was evaluated in 155 subjects. All subjects underwent a diurnal negative expiratory pressure test and a nocturnal sleep study. The severity of sleep apnea was determined based on the apneahypopnea index. Flow limitation was assessed by computing the exhaled volume at 0.2, 0.5, and 1.0 s (V0.2, V0.5, and V1.0, respectively) during the application of a negative expiratory pressure and expressed as a percentage of the previous exhaled volume. Receiver-operating characteristic curves were constructed to identify the optimal threshold volume at 0.2, 0.5, and 1.0 s for obstructive sleep apnea detection. RESULTS: Mean expiratory volumes at 0.2 and 0.5 s were statistically higher (p

Introduction Sleep-disordered breathing adversely affects daytime alertness and cognition. Obstructive sleep apnea (OSA) patients have several typical symptoms including habitual snoring, excessive daytime sleepiness, fatigue, lack of concentration, memory impairment, and at times psychological disturbances. We evaluated different aspects in the health related quality of life (HRQoL) in subjects referred to our sleep laboratory for their first examination for suspicion of OSA. Methods One hundred ninety-eight consecutive outpatients (152 M) (mean age 52.7 ± 12.8 years, range 18–82 years; mean BMI 31.0 ± 6.5 kg/m2, range 17.3-57.8 kg/m2) were evaluated with two self-reported questionnaires for HRQoL assessment: Psychological General Well-Being Index (PGWBI), that asses anxiety, depressed mood, positive well-being, self-control, general health, vitality, and 12-Item Short-Form Health Survey (SF-12), consisting assesses of Physical and Mental Component Summaries (PCS and MCS). Epworth Sleepiness Scale (ESS) was used to assess daytime sleepiness before nocturnal diagnostic examination. Results Subjects showed variable HRQoL scores. HRQoL was worse in women than men and it decreased with age. No relation was found with AHI severity (range 0–129 n/h). BMI and TSat90 (range 0–87.9%) affected physical health perception (SF-12 PCS). Furthermore TSat90 influenced PGWBI Vitality subscale. Subjects with ESS > 10 showed a worse HRQoL profile (p