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Oxygen saturation as a predictor of inflammation in obstructive sleep apnea


Obstructive sleep apnea (OSA) is a chronic sleep disorder, and its prevalence is increasing worldwide. This disorder has been consistently associated with several comorbidities. Although it is clear that obstructive sleep apnea severity is associated with inflammation, the trigger for this phenomenon continues to puzzle scientists. Here, we investigated the relationship between obstructive sleep apnea severity and immune parameters.


In this cross-sectional epidemiological research, we analyzed the immune profile of 461 adults according to OSA severity (mild, moderate, and severe) and oxygen saturation.


The hallmark of OSA severity — the apnea–hypopnea index (AHI) — weakly correlated with an inflammatory profile. However, individuals who experienced lower oxygen saturation were more likely to exhibit higher total leukocyte and neutrophil counts, a higher neutrophil–lymphocyte ratio (NLR), and an increased concentration of C-reactive protein.


Our findings indicated that oxygen saturation is a predictor of inflammation during OSA and should be considered crucial in disease diagnostic and treatment strategies.

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  1. Benjafield AV et al (2019) Estimation of the global prevalence and burden of obstructive sleep apnoea: a literature-based analysis. Lancet Respir Med 7(8):687–698

    Article  PubMed  PubMed Central  Google Scholar 

  2. Gottlieb DJ, Punjabi NM (2020) Diagnosis and management of obstructive sleep apnea: a review. JAMA 323(14):1389–1400

    Article  PubMed  Google Scholar 

  3. Kheirandish-Gozal L, Gozal D (2019) Obstructive sleep apnea and inflammation: proof of concept based on two illustrative cytokines. Int J Mol Sci 20(3)

  4. Besedovsky L, Lange T, Haack M (2019) The sleep-immune crosstalk in health and disease. Physiol Rev 99(3):1325–1380

    Article  PubMed  PubMed Central  Google Scholar 

  5. Santos-Silva R et al (2009) Sao Paulo Epidemiologic sleep study: rationale, design, sampling, and procedures. Sleep Med 10(6):679–685

    Article  PubMed  Google Scholar 

  6. Berry R et al (2013) The AASM manual for the scoring of sleep and associated events: rules, terminology and technical specifications. 2.0.2 ed. Darien, IL: American Academy of Sleep Medicine

  7. Fulop T et al (2017) Immunosenescence and inflamm-aging as two sides of the same coin: Friends or Foes? Front Immunol 8:1960

    Article  PubMed  Google Scholar 

  8. Van der Touw T, Andronicos NM, Smart N (2019) Is C-reactive protein elevated in obstructive sleep apnea? a systematic review and meta-analysis. Biomarkers 24(5):429–435

    Article  PubMed  Google Scholar 

  9. Li K et al (2017) Is C-reactive protein a marker of obstructive sleep apnea?: a meta-analysis. Medicine (Baltimore). 96(19):e6850

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  10. Forget P et al (2017) What is the normal value of the neutrophil-to-lymphocyte ratio? BMC Res Notes 10(1):12

    Article  PubMed  PubMed Central  Google Scholar 

  11. Geovanini GR et al (2018) Association between obstructive sleep apnea and cardiovascular risk factors: variation by age, sex, and race. The Multi-Ethnic Study of Atherosclerosis. Ann Am Thorac Soc 15(8):970–977

    Article  PubMed  PubMed Central  Google Scholar 

  12. Silvestre-Roig C et al (2020) Neutrophils as regulators of cardiovascular inflammation. Nat Rev Cardiol 17(6):327–340

    Article  PubMed  Google Scholar 

  13. Cummins EP et al (2016) The role of HIF in immunity and inflammation. Mol Aspects Med 47–48:24–34

    Article  PubMed  Google Scholar 

  14. Garvey JF, Taylor CT, McNicholas WT (2009) Cardiovascular disease in obstructive sleep apnoea syndrome: the role of intermittent hypoxia and inflammation. Eur Respir J 33(5):1195–1205

    Article  CAS  PubMed  Google Scholar 

  15. Schaffer K, Taylor CT (2015) The impact of hypoxia on bacterial infection. FEBS J 282(12):2260–2266

    Article  CAS  PubMed  Google Scholar 

  16. Schulz R et al (2000) Enhanced release of superoxide from polymorphonuclear neutrophils in obstructive sleep apnea. Impact of continuous positive airway pressure therapy. Am J Respir Crit Care Med 162(2 Pt 1):566–70

    Article  CAS  PubMed  Google Scholar 

  17. Lefebvre B et al (2008) Leukotriene B4: early mediator of atherosclerosis in obstructive sleep apnoea? Eur Respir J 32(1):113–120

    Article  CAS  PubMed  Google Scholar 

  18. Dyugovskaya L et al (2008) Delayed neutrophil apoptosis in patients with sleep apnea. Am J Respir Crit Care Med 177(5):544–554

    Article  CAS  PubMed  Google Scholar 

  19. Wu L et al (2019) Tumor-associated neutrophils in cancer: going pro. Cancers (Basel) 11(4)

  20. Woo SJ et al (2011) Elevated systemic neutrophil count in diabetic retinopathy and diabetes: a hospital-based cross-sectional study of 30,793 Korean subjects. Invest Ophthalmol Vis Sci 52(10):7697–7703

    Article  PubMed  Google Scholar 

  21. Hatanaka E et al (2006) Neutrophils and monocytes as potentially important sources of proinflammatory cytokines in diabetes. Clin Exp Immunol 146(3):443–447

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  22. Ray A, Kolls JK (2017) Neutrophilic inflammation in asthma and association with disease severity. Trends Immunol 38(12):942–954

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  23. Salvemini D, Cuzzocrea S (2002) Superoxide, superoxide dismutase and ischemic injury. Curr Opin Investig Drugs 3(6):886–895

    CAS  PubMed  Google Scholar 

  24. Pialoux V et al (2009) Effects of exposure to intermittent hypoxia on oxidative stress and acute hypoxic ventilatory response in humans. Am J Respir Crit Care Med 180(10):1002–1009

    Article  CAS  PubMed  Google Scholar 

  25. Almeida GP et al (2017) The role of acute intermittent hypoxia in neutrophil-generated superoxide, sympathovagal balance, and vascular function in healthy subjects. Front Physiol 8:4

    Article  PubMed  PubMed Central  Google Scholar 

  26. Kinnula VL, Crapo JD (2003) Superoxide dismutases in the lung and human lung diseases. Am J Respir Crit Care Med 167(12):1600–1619

    Article  PubMed  Google Scholar 

  27. Rha MS et al (2020) Association between the neutrophil-to-lymphocyte ratio and obstructive sleep apnea: a meta-analysis. Sci Rep 10(1):10862

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  28. Liu Y et al (2020) Neutrophil-to-lymphocyte ratio as an independent risk factor for mortality in hospitalized patients with COVID-19. J Infect 81(1):e6–e12

    Article  PubMed  PubMed Central  Google Scholar 

  29. Jeong HJ et al (2005) Hypoxia-induced IL-6 production is associated with activation of MAP kinase, HIF-1, and NF-kappaB on HEI-OC1 cells. Hear Res 207(1–2):59–67

    Article  CAS  PubMed  Google Scholar 

  30. Chowdhury S et al (2020) Muscle-derived interleukin 6 increases exercise capacity by signaling in osteoblasts. J Clin Invest 130(6):2888–2902

    Article  CAS  PubMed  PubMed Central  Google Scholar 

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We would like to thank AFIP and Instituto do Sono for allowing access to EPISONO data.


This work was supported by Associação Fundo de Incentivo à Pesquisa (AFIP); Fundação de Amparo à Pesquisa do Estado de São Paulo (FAPESP); and Conselho Nacional de Desenvolvimento Científico e Técnológico (CNPq).

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Design of the analysis was performed by Edgar Ruz Fernandes and Daniela Santoro Rosa; Data was analyzed by Edgar Ruz Fernandes and Gabriel Natan Pires; Manuscript writing was done by Edgar Ruz Fernandes; The access to EPISONO database was provided by Sergio Tufik and Monica Levy Andersen; all authors edited and corrected the paper.

All authors have seen and approved the manuscript submission.

Corresponding author

Correspondence to Daniela Santoro Rosa.

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The procedures were conducted in accordance with the ethical standards and thereby approved by The Ethics Committee of Federal University of São Paulo (EPISONO study number 610514/14).

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The authors declare no competing interest.

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Fernandes, E.R., Pires, G.N., Andersen, M.L. et al. Oxygen saturation as a predictor of inflammation in obstructive sleep apnea. Sleep Breath 26, 1613–1620 (2022).

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