Cues to starting CPAP in obstructive sleep apnoea : development and validation of the cues to CPAP Use Questionnaire (CCUQ)

Background: The reasons that a patient has to start treatment, their “Cues to Action”, are important for determining subsequent health behaviours. Cues to action are an explicit component of the Health Belief Model of CPAP acceptance adherence. At present there is no scale available to measure this construct for individuals with Obstructive Sleep Apnoea (OSA). This paper aims to develop, validate and describe responding patterns within an OSA patient sample to the Cues to CPAP Use Questionnaire (CCUQ).----- Method: Participants were 63 adult patients diagnosed with OSA who had never tried CPAP when initially recruited. The CCUQ was completed at one month after being prescribed CPAP.----- Results: Exploratory factor analysis (EFA) showed a three factor structure of the 9-item CCUQ, with “Health Cues”, “Partner Cues” and “Health Professional Cues” subscales accounting for 59.91% of the total variance. The CCUQ demonstrated modest internal consistency and split-half reliability. The questionnaire is brief and user-friendly, with readability at a 7th grade level. The most frequently endorsed cues for starting CPAP were Health Professional Cues (prompting by the sleep physician) and Health Cues such as tiredness and concern about health outcomes.----- Conclusions: This study validates a measure of an important motivational component of the Health Belief Model. Health Professional Cues and internal Health Cues were reported to be the most important prompts to commence CPAP by this patient sample.

Prevalence of risk factors for undiagnosed obstructive sleep apnoea is high in truck drivers on UK roads

Objectives To determine the prevalence of symptoms and risk factors of obstructive sleep apnoea (OSA) in truck drivers at a UK large truck stop. Methods Over a 5 day period, truck drivers completed a short questionnaire at a major UK ‘truck stop’. The questionnaire asked about OSA rist factors and symptoms, and included the Epworth Sleepiness Scale (ESS). Additionally, measurements of height, weight and collar size were taken. 148 truck drivers participated and within this random group the risk factors of OSA that were looked for were:men age over 40 y, obesity, parge neck circumference, smoking, high ESS and bed partner reporting snoring with witnessed apnoeas. Results Our sample were all men, with 82% aged over 40 y. 47% were obese (compared with 23% for UK men in general) and average neck circumference was 42 cm (compared with 38 cm for UK men in general – Martin et al 1997). 31% smoked (vs 21% for general population), and ESS averaged 2.1 points higher than expected for a healthy population (Johns et al 1997). Snoring was quite evident at 57% (compared wth 40% for men in general) and witnessed apnoeas were almost double (7%) compared with 3.8% given by Ohayon et al (1997) generally for men. Conclusion 8 key symptoms and risk factors of OSA have been found to be prevalent in a sample of truck drivers on UK roads, and to greater extent that for estimates in the general male population. Bed partners of truck drivers reporting witnessed apnoeas strongly suggests this group has a high potential for undiagnosed OSA. OSA sufferers are known to be at high risk of causing road traffi c accidents. This, together with the large size of trucks, then the potential for serious road crashes is great. Truck drivers, especially those who are obese, ought to be a high priority population for OSA screening.

Is the two hour recommended maximum driving time appropriate for both healthy older and treated obstructive sleep apnoea drivers?

Objectives The UK Department for Transport recommends taking a break from driving every 2 h. This study investigated: (i) if a 2 h drive time on a monotonous road is appropriate for OSA patients treated with CPAP, compared with healthy age matched controls, (ii) the impact of a night’s sleep restriction (with CPAP) and (iii) what happens if these patients miss one nights’ CPAP treatment. Methods About 19 healthy men aged 52–74 y (m = 66.2 y) and 19 OSA participants aged 50–75 y (m = 64.4 y) drove an interactive car simulator under monotonous motorway conditions for 2 h on two afternoons, in a counterbalanced design; (1) following a normal night’s sleep (8 h). (2) following a restricted night’s sleep (5 h), with normal CPAP use (3) following a night without CPAP treatment. (n = 11) Lane drifting incidents, indicative of falling asleep, were recorded for up to 2 h depending on competence to continue driving. Results Normal sleep: Controls drove for an average of 95.9 min (s.d. 37 min) and treated OSA drivers for 89.6 min (s.d. 29 min) without incident. 63.2% of controls and 42.1% of OSA drivers successfully completed the drive without an incident. Sleep restriction: 47.4% of controls and 26.3% OSA drivers finished without incident. Overall: controls drove for an average of 89.5 min (s.d. 39 min) and treated OSA drivers 65 min (s.d. 42 min) without incident. The effect of condition was significant [F(1.36) = 9.237, P < 0.05, eta2 = 0.204]. Stopping CPAP: 18.2% of drivers successfully completed the drive. Overall, participants drove for an average of 50.1 min (s.d. 38 min) without incident. The effect of condition was significant [F(2) = 8.8, P < 0.05, eta2 = 0.468]. Conclusion 52.6% of all drivers were able to complete a 2 hour drive under monotonous conditions after a full night’s sleep. Sleep restriction significantly affected both control and OSA drivers. We find evidence that treated OSA drivers are more impaired by sleep restriction than healthy control, as they were less able to sustain safely the 2 h drive without incidents. OSA drivers should be aware that non-compliance with CPAP can significantly impair driving performance. It may be appropriate to recommend older drivers take a break from driving every 90 min especially when undertaking a monotonous drive, as was the case here.

Continuous positive air pressure treatment for obstructive sleep apnoea patients : effects on sleep quality and quantity as measured by actigraphy

Objectives Actigraphy can reliably assess sleep in healthy adults and be used to estimate total sleep time in suspected obstructive sleep apnoea (OSA) patients. We compared sleep quality for Continuous Positive Air Pressure (CPAP) treated OSA patients and controls, evaluating the impact of stopping CPAP for one night. Methods 11 men, aged 51–75 years (m = 65.6 years), compliant CPAP users, treated for 1–19 years (m = 7.8 years) wore Cambridge Neurotechnology Ltd actiwatches for one night while using CPAP and for one night sleeping without CPAP. A control group of 11 healthy men, aged 63–74 years (m = 64.1 years) slept normally whilst wearing an actiwatch. Subsequent daytime sleepiness was recorded using Karolinska sleepiness scores (KSS). Results Actimetry showed no significant differences between actual sleep time, sleep efficiency, sleep disturbance index or number of wake bouts when comparing OSA participants using CPAP, with controls; there was no difference in subsequent daytime sleepiness, control KSS = 4.21, OSA KSS = 4.17. Without CPAP there was no significant difference in sleep length or sleep onset latency compared with using CPAP, but there was a significant impact on sleep quality as shown by: increased sleep disturbance index from 7.9 to 13.8 [t(10) = 3.510, P < 0.05], decreased percent of actual sleep from 92.05% to 86.15% [t(10) = 3.51, P < 0.05], decreased sleep efficiency from 86.6% to 81% [t(10) = 2.204, P < 0.05] and increased number of wake bouts from 29 to 42.5 [t(10) = 3.877, P < 0.05]. Daytime sleepiness became significantly worse increasing from KSS 4.17 to 6.27 [t(10) = )4.96, P < 0.05]. Conclusion There was no disparity in sleep quality or KSS scores between CPAP treated OSA patients and healthy controls of a similar age. Treated OSA patients obtained quality sleep with no elevated day time sleepiness. However, cessation of treatment for one night caused sleep quality to deteriorate despite a comparable sleep time; the deterioration in sleep quality could explain the increase in daytime sleepiness. OSA patients need to know that even short-term noncompliance with CPAP treatment significantly impairs sleep quality, leading to excessive sleepiness during monotonous tasks such as driving. Actigraphy successfully identified nights of non-compliance in treated OSA patients; but did not differentiate between the sleep of CPAP treated OSA patients and healthy controls.

Liking for high fat foods in patients with Obstructive Sleep Apnoea

Excess weight and obesity are factors that are strongly associated with risk for Obstructive Sleep Apnoea (OSA).Weight loss has been associated with improvements in clinical indicators of OSA severity; however, patients’ beliefs about diet change have not been investigated. This study utilized a validated behaviour change model to estimate the relationship between food liking, food intake and indices of OSA severity. Two-hundred and six OSA patients recruited from a Sleep Disorders Clinic completed standardized questionnaires of: a) fat and fibre food intake, food liking, and food knowledge and; b) attitudes and intentions towards fat reduction. OSA severity and body mass index (BMI) were objectively measured using standard clinical guidelines. The relationship between liking for high fat food and OSA severity was tested with hierarchical regression. Gender and BMI explained a significant 20% of the variance in OSA severity, Fibre Liking accounted for an additional 6% (a negative relationship), and Fat Liking accounted for a further 3.6% of variance. Although the majority of individuals (47%) were currently “active” in reducing fat intake, overall the patients’ dietary beliefs and behaviours did not correspond. The independent relationship between OSA severity and liking for high fat foods (and disliking of high fibre foods) may be consistent with a two-way interaction between sleep disruption and food choice. Whilst the majority of OSA patients were intentionally active in changing to a healthy diet, further emphasis on improving healthy eating practices and beliefs in this population is necessary.

The presence of executive deficits in patients with Obstructive Sleep Apnoea

Obstructive sleep apnoea (OSA) is a chronic condition in which the upper airways collapse repeatedly during sleep, completely or partially obstructing breathing. This obstruction leads to chronic intermittent hypoxia and severe sleep fragmentation, disrupting the restorative functions of sleep. Beebe and Gozal (2002)a developed a theory which hypothesises that disruption of the restorative functions of sleep lead to a chronic low level brain damage most evident in executive functions (EF). Neuropsychological testing of EF, volumetric MRI, magnetic resonance spectroscopy, event related potentials and CSF biomarkers all provide support for this theory. Little research has been done to explore the nature of the subjective complaint and it’s impact on the activities of daily living.

Trazodone increases arousal threshold in obstructive sleep apnoea.

A low arousal threshold is believed to predispose to breathing instability during sleep. The present authors hypothesised that trazodone, a nonmyorelaxant sleep-promoting agent, would increase the effort-related arousal threshold in obstructive sleep apnoea (OSA) patients. In total, nine OSA patients, mean+/-sd age 49+/-9 yrs, apnoea/hypopnoea index 52+/-32 events.h(-1), were studied on 2 nights, one with trazodone at 100 mg and one with a placebo, in a double blind randomised fashion. While receiving continuous positive airway pressure (CPAP), repeated arousals were induced: 1) by increasing inspired CO(2) and 2) by stepwise decreases in CPAP level. Respiratory effort was measured with an oesophageal balloon. End-tidal CO(2 )tension (P(ET,CO(2))) was monitored with a nasal catheter. During trazodone nights, compared with placebo nights, the arousals occurred at a higher P(ET,CO(2)) level (mean+/-sd 7.30+/-0.57 versus 6.62+/-0.64 kPa (54.9+/-4.3 versus 49.8+/-4.8 mmHg), respectively). When arousals were triggered by increasing inspired CO(2) level, the maximal oesophageal pressure swing was greater (19.4+/-4.0 versus 13.1+/-4.9 cm H(2)O) and the oesophageal pressure nadir before the arousals was lower (-5.1+/-4.7 versus -0.38+/-4.2 cm H(2)O) with trazodone. When arousals were induced by stepwise CPAP drops, the maximal oesophageal pressure swings before the arousals did not differ. Trazodone at 100 mg increased the effort-related arousal threshold in response to hypercapnia in obstructive sleep apnoea patients and allowed them to tolerate higher CO(2) levels.

Paediatric traffic accident and obstructive sleep apnoea by antrochoanal polyps: case report and literature review

Antrochoanal polyps are hyperplasias of the nasal mucosa, which have their origin in the maxillary sinus and extend through the nasal cavity and the choanae into the naso- and oropharynx. In children antrochoanal polyps represent one of the more frequent manifestations of paediatric nasal polyposis. Most studies on antrochoanal polyps in children report only on nasal obstruction, hyponasal speech and snoring, which are also encountered in the most common cause of obstructive sleep apnoea syndrome; i.e. adenoid or tonsillar hyperplasia. Only very few studies report on additional health hazards by antrochoanal polyps ranging from obstructive sleep apnoea syndrome to swallowing disorders and cachexia. We present the case of an 8 year old girl with a bicycle accident caused by excessive daytime sleepiness and obstructive sleep apnoea syndrome due to an extensive antrochoanal polyp. After a transnasal polypectomy and meatotomy type II the obstructive sleep apnoea and day time sleepiness resolved completely. Awareness of this additional health hazard is important and correct evaluation and timely diagnosis of a potential antrochoanal polyp is mandatory because minimally invasive rhinosurgery is highly curative in preventing further impending problems.

Recommendations for the management of patients with obstructive sleep apnoea and hypertension

This article is aimed at addressing the current state-of-the-art in epidemiology, pathophysiology, diagnostic procedures and treatment options for appropriate management of obstructive sleep apnoea (OSA) in cardiovascular (in particular hypertensive) patients, as well as for the management of cardiovascular diseases (in particular arterial hypertension) in OSA patients. The present document is the result of work performed by a panel of experts participating in the European Union COST (Cooperation in Scientific and Technological research) Action B26 on OSA, with the endorsement of the European Respiratory Society and the European Society of Hypertension. In particular, these recommendations are aimed at reminding cardiovascular experts to consider the occurrence of sleep-related breathing disorders in patients with high blood pressure. They are also aimed at reminding respiration experts to consider the occurrence of hypertension in patients with respiratory problems at night.

Sleepiness and performance is disproportionate in patients with non-organic hypersomnia in comparison to patients with narcolepsy and mild to moderate obstructive sleep apnoea.

BACKGROUND/AIMS Clinical differentiation between organic hypersomnia and non-organic hypersomnia (NOH) is challenging. We aimed to determine the diagnostic value of sleepiness and performance tests in patients with excessive daytime sleepiness (EDS) of organic and non-organic origin. METHODS We conducted a retrospective comparison of the multiple sleep latency test (MSLT), pupillography, and the Steer Clear performance test in three patient groups complaining of EDS: 19 patients with NOH, 23 patients with narcolepsy (NAR), and 46 patients with mild to moderate obstructive sleep apnoea syndrome (OSAS). RESULTS As required by the inclusion criteria, all patients had Epworth Sleepiness Scale (ESS) scores >10. The mean sleep latency in the MSLT indicated mild objective sleepiness in NOH (8.1 ± 4.0 min) and OSAS (7.2 ± 4.1 min), but more severe sleepiness in NAR (2.5 ± 2.0 min). The difference between NAR and the other two groups was significant; the difference between NOH and OSAS was not. In the Steer Clear performance test, NOH patients performed worst (error rate = 10.4%) followed by NAR (8.0%) and OSAS patients (5.9%; p = 0.008). The difference between OSAS and the other two groups was significant, but not between NOH and NAR. The pupillary unrest index was found to be highest in NAR (11.5) followed by NOH (9.2) and OSAS (7.4; n.s.). CONCLUSION A high error rate in the Steer Clear performance test along with mild sleepiness in an objective sleepiness test (MSLT) in a patient with subjective sleepiness (ESS) is suggestive of NOH. This disproportionately high error rate in NOH may be caused by factors unrelated to sleep pressure, such as anergia, reduced attention and motivation affecting performance, but not conventional sleepiness measurements.

Frequency of insomnia report in patients with obstructive sleep apnoea hypopnea syndrome (OSAHS)

Background and purpose: Insomnia and Obstructive Sleep Apnoea Hypopnea Syndrome (OSAHS) are the two most common sleep disorders, and both have significant associated health costs. Despite this, relatively little is known about the prevalence or impact of insomnia in those with OSAHS, although a recent study suggested there may be substantial comorbidity between these disorders [Chest 120 (2001) 1923-9]. The primary aim of this study was to further explore the prevalence of insomnia in OSAHS. A secondary aim was to assess the effect of factors that may impact on both conditions, including mood and sleep-beliefs. Patients and methods: Consecutive patients referred to an accredited Sleep Investigations Unit (n = 105) completed a brief standardized battery of validated questionnaires assessing sleep-related variables and mood. Results: Results showed a high rate of prevalence of clinical insomnia in this OSAHS population, and a strong positive correlation between OSAHS and insomnia symptom severity. Further, OSAHS patients with comorbid insomnia had increased levels of depression, anxiety and stress compared to patients with OSAHS-only, and both patient groups reported similar and significant levels of dysfunctional beliefs about sleep. Findings in relation to habitual sleep, assessed using subjective (diary) and objective criteria (polysomnogram), were mixed but generally showed greater sleep disturbance among those with OSAHS-insomnia compared to those with OSAHS-only. Conclusions: Overall these findings suggest that comorbidity of insomnia in OSAHS patients may lead to increased OSAHS severity and that patients with both conditions may experience more symptoms relating to depression, anxiety and stress. These findings underscore the need for insomnia assessment and management services, even in clinics that primarily service patients with OSAHS. (C) 2004 Elsevier B.V. All rights reserved.