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Residual excessive daytime sleepiness in patients with obstructive sleep apnea treated with positive airway pressure therapy

  • Sleep Breathing Physiology and Disorders • Original Article
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Abstract

Purpose

Patients with obstructive sleep apnea (OSA) commonly report residual excessive daytime sleepiness (EDS) despite treatment with positive airway pressure (PAP). The present study aimed to determine whether patients presenting with subjective sleepiness after treatment with PAP therapy had objective evidence of residual sleepiness.

Methods

We conducted a retrospective analysis of 29 adults with OSA on PAP therapy who underwent a standardized evaluation for EDS. Patients were evaluated with the Epworth Sleepiness Scale (ESS) and attend an in-lab polysomnogram (PSG) with PAP followed by a multiple sleep latency test (MSLT).

Results

Our cohort consisted of 23 men (79%) and 6 women (21%) with a mean age of 40.7 years. All patients were subjectively sleepy with an ESS score of > 10 and met minimal PAP usage of 4 h a night for at least 70% of nights with a residual apnea-hypopnea index (AHI) ≤ 10. On MSLT, 31% of patients had an average sleep onset latency (SOL) < 8 min, 35% had a SOL between 8 and 11 min, and 35% had SOL > 11 min.

Conclusion

After optimizing PAP therapy and sleep in patients with OSA and residual EDS, the majority were found to have objective findings of an abnormally short SOL on MSLT. This is further evidence that there is a distinct OSA phenotype that will have persistent EDS despite appropriate treatment of their sleep-disordered breathing. Objective testing to quantify the degree of sleepiness is recommended for OSA patients with residual EDS.

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References

  1. Kushida CA, Littner MR, Hirshkowitz M, Morgenthaler TI, Alessi CA, Bailey D, Boehlecke B, Brown TM, Coleman J Jr, Friedman L, Kapen S, Kapur VK, Kramer M, Lee-Chiong T, Owens J, Pancer JP, Swick TJ, Wise MS (2006) Practice parameters for the use of continuous and bilevel positive airway pressure devices to treat adult patients with sleep-related breathing disorders. SLEEP. 29(3):375–380

    Article  Google Scholar 

  2. Campos-Rodriguez F, Queipo-Corona C, Carmona-Bernal C, Jurado-Gamez B, Cordero-Guevara J, Reyes-Nuñez N, Troncoso-Acevedo F, Abad-Fernandez A, Teran-Santos J, Caballero-Rodriguez J, Martin-Romero M, Encabo-Motiño A, Sacristan-Bou L, Navarro-Esteva J, Somoza-Gonzalez M, Masa JF, Sanchez-Quiroga MA, Jara-Chinarro B, Orosa-Bertol B, Martinez-Garcia MA (2016) Continuous positive airway pressure improves quality of life in women with OSA. A randomized-controlled trial. Am J Respir Crit Care Med 194:1286–1294. https://doi.org/10.1164/rccm.201602-0265OC

    Article  PubMed  Google Scholar 

  3. Weaver TE, Maislin G, Dinges DF, Bloxham T, George CFP, Greenberg H, Kader G, Mahowald M, Younger J, Pack AI (2007) Relationship between hours of CPAP use and achieving normal levels of sleepiness and daily functioning. SLEEP. 30(6):711–719

    Article  Google Scholar 

  4. Antic NA, Catcheside P, Buchan C, Hensley M, Naughton MT, Rowland S, Williamson B, Windler S, McEvoy RD (2011) The effect of CPAP in normalizing daytime sleepiness, quality of life, and neurocognitive function in patients with moderate to severe OSA. SLEEP. 34(1):111–119

    Article  Google Scholar 

  5. Launois SH, Ramisier R, Levy P, Pepin J (2013) On treatment but still sleepy: cause and management of residual sleepiness in obstructive sleep apnea. Curr Opin Pulm Med 19:601–608

    Article  CAS  Google Scholar 

  6. Laranjeira CM, Barbosa ERF, Rabahi MF (2018) Is subjective sleep evaluation a good predictor for obstructive sleep apnea? Clinics (Sao Paulo) 73:e355

    Article  Google Scholar 

  7. Johns MW (2000) Sensitivity and specificity of the multiple sleep latency test (MSLT), the maintenance of wakefulness test and the Epworth sleepiness scale: failure of the MSLT as a gold standard. J Sleep Res 9(1):5–11

    Article  CAS  Google Scholar 

  8. Garbarino S, Scoditti E, Lanteri P, Conte L, Magnavita N, Toraldo DM (2018) Obstructive sleep apnea with or without excessive daytime sleepiness: clinical and experimental data-driven phenotyping. Front Neurol 9:505. https://doi.org/10.3389/fneur.2018.00505

    Article  PubMed  PubMed Central  Google Scholar 

  9. Nam H, Lim J, Kim J et al (2016) Sleep perception in obstructive sleep apnea: a study using polysomnography and the multiple sleep latency test. J Clin Neurol 12(2):230–235

    Article  Google Scholar 

  10. Li Y, Vgontzas AN, Fernandez-Mendoza J, Kritikou I, Basta M, Pejovic S, Gaines J, Bixler E (2017) Objective, but not subjective, sleepiness is associated with inflammation in sleep apnea. SLEEP. 40(2)

  11. Littner MR, Kushida C, Wise M, Davila DG, Morgenthaler T, Lee-Chiong T et al (2005) Practice parameters for clinical use of the multiple sleep latency test and the maintenance of wakefulness test. SLEEP. 28(1):113–121

    Article  Google Scholar 

  12. Sunwoo BY, Jackson N, Maislin G, Gurubhagavatula I, George C, Pack AI (2012) Reliability of a single objective measure in assessing sleepiness. SLEEP. 35(1):149–158

    Article  Google Scholar 

  13. American Academy of Sleep Medicine (2014) International classification of sleep disorders, 3rd edn. American Academy of Sleep Medicine, Darien, IL

    Google Scholar 

  14. Berry RB, Brooks R, Gamaldo CE, Hardling SM, Marcus CL, Vaughn BV (2012) The AASM manual for the scoring of sleep and associated events. Rules, terminology and technical specifications. American Academy of Sleep Medicine, Illinois

    Google Scholar 

  15. O'donoghue FJ, Briellmann RS, Rochford PD et al (2005) Cerebral structural changes in severe obstructive sleep apnea. Am J Respir Crit Care Med 171(10):1185–1190

    Article  Google Scholar 

  16. Robbins J, Redline S, Ervin A, Walsleben JA, Ding J, Nieto FJ (2005) Associations of sleep-disordered breathing and cerebral changes on MRI. J Clin Sleep Med 1(2):159–165

    Article  Google Scholar 

  17. Vernet C, Redolfi S, Attali V, Konofal E, Brion A, Frija-Orvoen E, Pottier M, Similowski T, Arnulf I (2011) Residual sleepiness in obstructive sleep apnoea: phenotype and related symptoms. Eur Respir J 38(1):98–105

    Article  CAS  Google Scholar 

  18. Philip P, Stoohs R, Guilleminault C (1994) Sleep fragmentation in normals: a model for sleepiness associated with upper airway resistance syndrome. Sleep. 17(3):242–247

    CAS  PubMed  Google Scholar 

  19. Calero G, Farre R, Ballester E, Hernandez L, Daniel N, Montserrat canal JM (2006) Physiological consequences of prolonged periods of flow limitation in patients with sleep apnea hypopnea syndrome. Respir Med 100(5):813–817

    Article  Google Scholar 

  20. Mansour KF, Rowley JA, Meshenish AA, Shkoukani MA, Badr MS (2002) A mathematical model to detect inspiratory flow limitation during sleep. J Appl Physiol 93(3):1084–1092

    Article  Google Scholar 

  21. Kapur VK, Baldwin CM, Resnick HE, Gottlieb DJ, Nieto FJ (2005) Sleepiness in patients with moderate to severe sleep-disordered breathing. Sleep. 28(4):472–477

    Article  Google Scholar 

  22. Li Y, Vgontzas AN, Fernandex-Mendoza J et al (2017) Objective, but not subjective, sleepiness is associated with inflammation in sleep apnea. Sleep. 40(2):1–6

    Article  Google Scholar 

  23. He K, Kapur V (2017) Sleep-disordered breathing and excessive daytime sleepiness. Sleep Med Clin 12:369–382

    Article  Google Scholar 

  24. Gottlieb DJ, Ellenbogen JM, Bianchi MT, Czeisler CA (2018) Sleep deficiency and motor vehicle crash risk in the general population: a prospective cohort study. BMC Med 16(1):44

    Article  Google Scholar 

  25. Korkmaz S, Bilecenoglu NT, Aksu M, Yoldas TK (2018) Cyclic alternating pattern in obstructive sleep apnea patients with versus without excessive sleepiness. Sleep Disord 2018:8713409–8713407. https://doi.org/10.1155/2018/8713409. eCollection 2018

    Article  PubMed  PubMed Central  Google Scholar 

  26. Maugeri A, Medina-Inojosa JR, Kunzova S, Agodi A, Barchitta M, Sochor O, Lopez-Jimenez F, Geda Y, Vinciguerra M (2018) Sleep duration and excessive daytime sleepiness are associated with obesity independent of diet and physical activity. Nutrients. 10(9):pii: E1219. https://doi.org/10.3390/nu10091219

    Article  CAS  Google Scholar 

  27. Fu Y, Xu H, Xia Y et al (2017) Excessive daytime sleepiness and metabolic syndrome in men with obstructive sleep apnea: a large cross-sectional study. Oncotarget. 8(45):79693–79702

    Article  Google Scholar 

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Authors and Affiliations

  1. Department of Sleep Medicine, San Antonio Military Medical Center, 1100 Wilford Hall Loop, Lackland AFB, San Antonio, TX, 78236, USA

    Shannon N. Foster, Shana L. Hansen, Nicholas J. Scalzitti & Vincent Mysliwiec

  2. Operations Research Department, Naval Postgraduate School, Monterey, CA, 93943, USA

    Panagiotis Matsangas

  3. University of Texas Health Science Center at San Antonio, 7550 I-10 West, San Antonio, TX, 78229, USA

    Brian A. Moore

  4. University of Texas at San Antonio, One UTSA Circle, San Antonio, TX, 78249, USA

    Brian A. Moore

Authors
  1. Shannon N. Foster
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  2. Shana L. Hansen
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  3. Nicholas J. Scalzitti
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  4. Panagiotis Matsangas
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  5. Brian A. Moore
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  6. Vincent Mysliwiec
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Corresponding author

Correspondence to Shannon N. Foster.

Ethics declarations

All procedures performed in this study as it pertains to the utilization of personally identifiable information (involving human participants) were in accordance with the ethical standards of the San Antonio Military Health Systems Institutional Review Board and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards.

Conflict of interest

The authors declare that they have not conflict of interest.

Disclaimer

All work was performed at the Wilford Hall Ambulatory Surgical Center, JBSA Lackland, TX 78236. The opinions and assertions in this manuscript are those of the authors and do not represent those of the Department of the Air Force, Department of the Army, Department of Defense, or the U.S. government.

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Foster, S.N., Hansen, S.L., Scalzitti, N.J. et al. Residual excessive daytime sleepiness in patients with obstructive sleep apnea treated with positive airway pressure therapy. Sleep Breath 24, 143–150 (2020). https://doi.org/10.1007/s11325-019-01830-6

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  • DOI: https://doi.org/10.1007/s11325-019-01830-6

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