Obstructive sleep apnea: Difference between revisions

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'''Obstructive sleep apnea''' is a "disorder characterized by recurrent apneas during sleep despite persistent respiratory efforts. It is due to upper airway obstruction. The respiratory pauses may induce hypercapnia or hypoxia. Cardiac arrhythmias and elevation of systemic and pulmonary arterial pressures may occur. Frequent partial arousals occur throughout sleep, resulting in relative sleep deprivation and daytime tiredness. Associated conditions include [[obesity]]; acromegaly; myxedema; micrognathia; myotonic dystrophy; adenotonsilar dystrophy; and neuromuscular diseases. (From Adams et al., Principles of Neurology, 6th ed, p395)."<ref>{{MeSH}}</ref><ref>Caples SM, Gami AS, Somers VK. Obstructive sleep apnea. Ann Intern Med. 2005 Feb 1;142(3):187-97. PMID 15684207</ref>
'''Obstructive sleep apnea''' (spelt "apnoea" in British English) is a "disorder characterized by recurrent [[apnea]]s during sleep despite persistent respiratory efforts. It is due to upper airway obstruction. The respiratory pauses may induce hypercapnia or hypoxia. Cardiac arrhythmias and elevation of systemic and pulmonary arterial pressures may occur. Frequent partial arousals occur throughout sleep, resulting in relative sleep deprivation and daytime tiredness. Associated conditions include [[obesity]]; acromegaly; myxedema; micrognathia; myotonic dystrophy; adenotonsilar dystrophy; and neuromuscular diseases. (From Adams et al., Principles of Neurology, 6th ed, p395)."<ref>{{MeSH}}</ref><ref>Caples SM, Gami AS, Somers VK. Obstructive sleep apnea. Ann Intern Med. 2005 Feb 1;142(3):187-97. PMID 15684207</ref>


==Diagnosis==
==Diagnosis==
Age, body mass index, male sex, and snoring are the best predictors of sleep apnea.<ref>Viner S, Szalai JP, Hoffstein V. Are history and physical examination a good screening test for sleep apnea? Ann Intern Med. 1991 Sep 1;115(5):356-9. PMID 1863025</ref> However, obstructive sleep apnea is difficult to diagnose based on the history and physical examinations.
Polysomnography is the best test and abnormal is a apnea–hypopnea index (AHI) of 5 or greater. The American Academy of Sleep Medicine publishes a diagnostic manual.<ref name="pmid23066376">{{cite journal| author=Berry RB, Budhiraja R, Gottlieb DJ, Gozal D, Iber C, Kapur VK et al.| title=Rules for scoring respiratory events in sleep: update of the 2007 AASM Manual for the Scoring of Sleep and Associated Events. Deliberations of the Sleep Apnea Definitions Task Force of the American Academy of Sleep Medicine. | journal=J Clin Sleep Med | year= 2012 | volume= 8 | issue= 5 | pages= 597-619 | pmid=23066376 | doi=10.5664/jcsm.2172 | pmc=PMC3459210 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23066376  }} </ref> and guidelines<ref name="pmid19960649">{{cite journal| author=Epstein LJ, Kristo D, Strollo PJ, Friedman N, Malhotra A, Patil SP et al.| title=Clinical guideline for the evaluation, management and long-term care of obstructive sleep apnea in adults. | journal=J Clin Sleep Med | year= 2009 | volume= 5 | issue= 3 | pages= 263-76 | pmid=19960649 | doi= | pmc=PMC2699173 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19960649  }} </ref>. Moderate to sever OSA is a AHI of 15 or more episodes/hour. However, this test requires a patient to attend a sleep center and is not always required to diagnose sleep apnea.<ref name="pmid17283346">{{cite journal| author=Mulgrew AT, Fox N, Ayas NT, Ryan CF| title=Diagnosis and initial management of obstructive sleep apnea without polysomnography: a randomized validation study. | journal=Ann Intern Med | year= 2007 | volume= 146 | issue= 3 | pages= 157-66 | pmid=17283346 | doi= | pmc= | url=http://www.annals.org/content/146/3/157.full Review in: Evid Based Med. 2007 Oct;12(5):148]  [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17764136 Review in: ACP J Club. 2007 Sep-Oct;147(2):45] </ref> A systematic review in 2000 concluded that the best alternative diagnostic test is not certain.<ref name="pmid10875559">{{cite journal| author=Ross SD, Sheinhait IA, Harrison KJ, Kvasz M, Connelly JE, Shea SA et al.| title=Systematic review and meta-analysis of the literature regarding the diagnosis of sleep apnea. | journal=Sleep | year= 2000 | volume= 23 | issue= 4 | pages= 519-32 | pmid=10875559 | doi= | pmc= | url= }} </ref>


A score of more than 5 on the [http://www.ssc.ca/documents/case_studies/2006/documents/sleep_BQ_e.pdf Berlin Questinnaire] has a [[sensitivity (tests)|sensitivity]] of 86%.<ref>Netzer NC, Stoohs RA, Netzer CM, Clark K, Strohl KP. Using the Berlin Questionnaire to identify patients at risk for the sleep apnea syndrome. Ann Intern Med. 1999 Oct 5;131(7):485-91. PMID 10507956</ref> [[Clinical prediction rule]]s are available to help diagnose sleep apnea.<ref>Rodsutti J, Hensley M, Thakkinstian A, D'Este C, Attia J. A clinical decision rule to prioritize polysomnography in patients with suspected sleep apnea. Sleep. 2004 Jun 15;27(4):694-9. PMID 15283004</ref>
Testing can be done at home.<ref name="pmid24218531">{{cite journal| author=El Shayeb M, Topfer LA, Stafinski T, Pawluk L, Menon D| title=Diagnostic accuracy of level 3 portable sleep tests versus level 1 polysomnography for sleep-disordered breathing: a systematic review and meta-analysis. | journal=CMAJ | year= 2014 | volume= 186 | issue= 1 | pages= E25-51 | pmid=24218531 | doi=10.1503/cmaj.130952 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24218531  }} </ref>


Polysomnography is the best test and abnormal is a apnea–hypopnea index of 5 or greater. This test is not always required to diagnose sleep apnea.<ref>Mulgrew AT, Fox N, Ayas NT, Ryan CF. Diagnosis and initial management of obstructive sleep apnea without polysomnography: a randomized validation study. Ann Intern Med. 2007 Feb 6;146(3):157-66. PMID 17283346</ref>
===History and physical===
Age, body mass index, male sex, and snoring are the best predictors of sleep apnea.<ref name="pmid1863025">{{cite journal| author=Viner S, Szalai JP, Hoffstein V| title=Are history and physical examination a good screening test for sleep apnea? | journal=Ann Intern Med | year= 1991 | volume= 115 | issue= 5 | pages= 356-9 | pmid=1863025 | doi= | pmc= | url= }} </ref> Obstructive sleep apnea is difficult to diagnose based on the history and [[physical examination]]s.<ref name="pmid20143278">{{cite journal| author=Abrishami A, Khajehdehi A, Chung F| title=A systematic review of screening questionnaires for obstructive sleep apnea. | journal=Can J Anaesth | year= 2010 | volume= 57 | issue= 5 | pages= 423-38 | pmid=20143278 | url=http://www.springerlink.com/content/0384103252r31637/fulltext.html | doi=10.1007/s12630-010-9280-x }} </ref>


* A score of more than 5 on the [http://www.ssc.ca/documents/case_studies/2006/documents/sleep_BQ_e.pdf Berlin Questionnaire] has a [[sensitivity (tests)|sensitivity]] of 86% in one study.<ref>Netzer NC, Stoohs RA, Netzer CM, Clark K, Strohl KP. Using the Berlin Questionnaire to identify patients at risk for the sleep apnea syndrome. Ann Intern Med. 1999 Oct 5;131(7):485-91. PMID 10507956</ref>
* The Epworth Sleepiness Scale may help diagnose. The original cut-off was proposed to be 10. However, the optimal cut-off level may be 8<ref name="pmid18477888">{{cite journal| author=Rosenthal LD, Dolan DC| title=The Epworth sleepiness scale in the identification of obstructive sleep apnea. | journal=J Nerv Ment Dis | year= 2008 | volume= 196 | issue= 5 | pages= 429-31 | pmid=18477888 | doi=10.1097/NMD.0b013e31816ff3bf | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18477888  }} </ref> or 12 if combined with the [[body mass index|BMI]].<ref name="pmid9178919">{{cite journal| author=Pouliot Z, Peters M, Neufeld H, Kryger MH| title=Using self-reported questionnaire data to prioritize OSA patients for polysomnography. | journal=Sleep | year= 1997 | volume= 20 | issue= 3 | pages= 232-6 | pmid=9178919 | doi= | pmc= | url= }} </ref>.
* The Wisconsin Sleep Questionnaire may help diagnose.<ref name="pmid12812817">{{cite journal| author=Teculescu D, Guillemin F, Virion JM, Aubry C, Hannhart B, Michaely JP et al.| title=Reliability of the Wisconsin Sleep Questionnaire: a French contribution to international validation. | journal=J Clin Epidemiol | year= 2003 | volume= 56 | issue= 5 | pages= 436-40 | pmid=12812817 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12812817  }} </ref>
* Another [[clinical prediction rule]]s may help diagnose sleep apnea.<ref>Rodsutti J, Hensley M, Thakkinstian A, D'Este C, Attia J. A clinical decision rule to prioritize polysomnography in patients with suspected sleep apnea. Sleep. 2004 Jun 15;27(4):694-9. PMID 15283004</ref>
===Oximetry===
Oximetry, which may be performed overnight in a patient's home, is an easier alternative to formal sleep study ([[polysomnography]].
* In one study, normal overnight oximetry was very [[Sensitivity and specificity|sensitive]] and so if normal, sleep apnea was unlikely.<ref name="pmid8357109">{{cite journal| author=Sériès F, Marc I, Cormier Y, La Forge J| title=Utility of nocturnal home oximetry for case finding in patients with suspected sleep apnea hypopnea syndrome. | journal=Ann Intern Med | year= 1993 | volume= 119 | issue= 6 | pages= 449-53 | pmid=8357109 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=8357109  }} </ref> In addition, home oximetry may be equally effect in guiding prescription for automatically self-adjusting [[continuous positive airway pressure]].<ref name="pmid15486338">{{cite journal| author=Whitelaw WA, Brant RF, Flemons WW| title=Clinical usefulness of home oximetry compared with polysomnography for assessment of sleep apnea. | journal=Am J Respir Crit Care Med | year= 2005 | volume= 171 | issue= 2 | pages= 188-93 | pmid=15486338 | doi=10.1164/rccm.200310-1360OC | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15486338  }}  [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15989309 Review in: ACP J Club. 2005 Jul-Aug;143(1):21] </ref>
*Another study found that overnight oximetry, defining abnormal as 15 or more 4% desaturations/hour, was very [[Sensitivity and specificity|specific]], but not [[Sensitivity and specificity|sensitive]].<ref name="pmid8539678">{{cite journal| author=Ryan PJ, Hilton MF, Boldy DA, Evans A, Bradbury S, Sapiano S et al.| title=Validation of British Thoracic Society guidelines for the diagnosis of the sleep apnoea/hypopnoea syndrome: can polysomnography be avoided? | journal=Thorax | year= 1995 | volume= 50 | issue= 9 | pages= 972-5 | pmid=8539678 | doi= | pmc=PMC1021311 | url= }} </ref>
* Sensitivty of overnight oximetry is improved by using a 3% desaturation in oxygen.<ref name="pmid22009031">{{cite journal| author=Nigro CA, Dibur E, Rhodius E| title=Accuracy of the clinical parameters and oximetry to initiate CPAP in patients with suspected obstructive sleep apnea. | journal=Sleep Breath | year= 2012 | volume= 16 | issue= 4 | pages= 1073-9 | pmid=22009031 | doi=10.1007/s11325-011-0603-0 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22009031  }} </ref> and lowering the ODI to 5 per hour.<ref name="pmid1346422">{{cite journal| author=Douglas NJ, Thomas S, Jan MA| title=Clinical value of polysomnography. | journal=Lancet | year= 1992 | volume= 339 | issue= 8789 | pages= 347-50 | pmid=1346422 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=1346422  }} </ref>
* Oximetry may identify some patients whose outcomes are not improved by adding polysomnography.<ref name="pmid17283346"/>
==Treatment==
==Treatment==
Treatment may lower blood pressure by about 3 - 5 mm Hg.<ref>Martínez-García M, Capote F, Campos-Rodríguez F, et al. Effect of CPAP on Blood Pressure in Patients With Obstructive Sleep Apnea and Resistant Hypertension: The HIPARCO Randomized Clinical Trial. JAMA. 2013;310(22):2407-2415. {{doi|10.1001/jama.2013.281250}}.</ref><ref name="pmid23598607">{{cite journal| author=Pedrosa RP, Drager LF, de Paula LK, Amaro AC, Bortolotto LA, Lorenzi-Filho G| title=Effects of OSA Treatment on BP in Patients With Resistant Hypertension: A Randomized Trial. | journal=Chest | year= 2013 | volume= 144 | issue= 5 | pages= 1487-94 | pmid=23598607 | doi=10.1378/chest.13-0085 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23598607 }} </ref>
===Weight loss===
Weight loss of 20 kg with a liquid very low energy diet(2.3 MJ/day) for seven weeks can reduce the AHI by 23 and lead to 20% of patients becoming disease free.<ref name="pmid19959590">{{cite journal| author=Johansson K, Neovius M, Lagerros YT, Harlid R, Rössner S, Granath F et al.| title=Effect of a very low energy diet on moderate and severe obstructive sleep apnoea in obese men: a randomised controlled trial. | journal=BMJ | year= 2009 | volume= 339 | issue=  | pages= b4609 | pmid=19959590
| url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=clinical.uthscsa.edu/cite&email=badgett@uthscdsa.edu&retmode=ref&cmd=prlinks&id=19959590 | pmc=PMC2788899 | doi=10.1136/bmj.b4609 }} <!--Formatted by http://sumsearch.uthscsa.edu/cite/--></ref>
===Oral appliances===
===Oral appliances===
Regarding oral appliances, "CPAP appears to be more effective in improving sleep disordered breathing than OA. The difference in symptomatic response between these two treatments is not significant, although it is not possible to exclude an effect in favour of either therapy. Until there is more definitive evidence on the effectiveness of OA in relation to CPAP, with regard to symptoms and long-term complications, it would appear to be appropriate to recommend OA therapy to patients with mild symptomatic OSAH, and those patients who are unwilling or unable to tolerate CPAP therapy" according to the [[Cochrane Collaboration]].<ref name="pmid16437488">{{cite journal |author=Lim J, Lasserson TJ, Fleetham J, Wright J |title=Oral appliances for obstructive sleep apnoea |journal=Cochrane Database Syst Rev |volume= |issue=1 |pages=CD004435 |year=2006 |pmid=16437488 |doi=10.1002/14651858.CD004435.pub3 |url=http://dx.doi.org/10.1002/14651858.CD004435.pub3 |issn=}}</ref>
Regarding oral appliances (mandibular advancement device (MAD)), "CPAP appears to be more effective in improving sleep disordered breathing than OA. The difference in symptomatic response between these two treatments is not significant, although it is not possible to exclude an effect in favour of either therapy. Until there is more definitive evidence on the effectiveness of OA in relation to CPAP, with regard to symptoms and long-term complications, it would appear to be appropriate to recommend OA therapy to patients with mild symptomatic OSAH, and those patients who are unwilling or unable to tolerate CPAP therapy" according to the [[Cochrane Collaboration]].<ref name="pmid16437488">{{cite journal |author=Lim J, Lasserson TJ, Fleetham J, Wright J |title=Oral appliances for obstructive sleep apnoea |journal=Cochrane Database Syst Rev |volume= |issue=1 |pages=CD004435 |year=2006 |pmid=16437488 |doi=10.1002/14651858.CD004435.pub3 |url=http://dx.doi.org/10.1002/14651858.CD004435.pub3 |issn=}}</ref>
 
More recent [[randomized controlled trial]]s report:
* Similar findings in that oral appliances (mandibular advancement device (MAD)) are easier to tolerate, but CPAP is reduces the apnea-hypopnea index (AHI) more. Quality-of-life indicators may be better with appliance.<ref name="pmid23413266">{{cite journal| author=Phillips CL, Grunstein RR, Darendeliler MA, Mihailidou AS, Srinivasan VK, Yee BJ et al.| title=Health outcomes of continuous positive airway pressure versus oral appliance treatment for obstructive sleep apnea: a randomized controlled trial. | journal=Am J Respir Crit Care Med | year= 2013 | volume= 187 | issue= 8 | pages= 879-87 | pmid=23413266 | doi=10.1164/rccm.201212-2223OC | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23413266  }} </ref>
* MAD may not affect quality of life or daytime sleepiness, though other benefits may occur, among patients with apnea-hypopnea index (AHI) lower than 30.<ref name="pmid26030264">{{cite journal| author=Marklund M, Carlberg B, Forsgren L, Olsson T, Stenlund H, Franklin KA| title=Oral Appliance Therapy in Patients With Daytime Sleepiness and Snoring or Mild to Moderate Sleep Apnea: A Randomized Clinical Trial. | journal=JAMA Intern Med | year= 2015 | volume= 175 | issue= 8 | pages= 1278-85 | pmid=26030264 | doi=10.1001/jamainternmed.2015.2051 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26030264  }} </ref>


===Continuous positive airway pressure (CPAP)===
===Continuous positive airway pressure (CPAP)===
Regarding [[continuous positive airway pressure]] (CPAP), "CPAP is effective in reducing symptoms of sleepiness and improving quality of life measures in people with moderate and severe obstructive sleep apnoea (OSA). It is more effective than oral appliances in reducing respiratory disturbances in these people but subjective outcomes are more equivocal. Certain people tend to prefer oral appliances to CPAP where both are effective"<ref name="pmid17054251">{{cite journal |author=Chai CL, Pathinathan A, Smith B |title=Continuous positive airway pressure delivery interfaces for obstructive sleep apnoea |journal=Cochrane Database Syst Rev |volume= |issue=4 |pages=CD005308 |year=2006 |pmid=17054251 |doi=10.1002/14651858.CD005308.pub2 |url=http://dx.doi.org/10.1002/14651858.CD005308.pub2 |issn=}}</ref>
Several trials have studied [[continuous positive airway pressure]]:
* Patients with Epworth Sleepiness Scale score >10 has a reduction in daytime symptoms.<ref name="pmid22837377">{{cite journal| author=Weaver TE, Mancini C, Maislin G, Cater J, Staley B, Landis JR et al.| title=Continuous Positive Airway Pressure Treatment of Sleepy Patients with Milder Obstructive Sleep Apnea: Results of the CPAP Apnea Trial North American Program (CATNAP) Randomized Clinical Trial. | journal=Am J Respir Crit Care Med | year= 2012 | volume= 186 | issue= 7 | pages= 677-83 | pmid=22837377 | doi=10.1164/rccm.201202-0200OC | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22837377  }} </ref>
* Patients with Epworth Sleepiness Scale score <10 had no reduction in cardiovascular events.<ref name="pmid22618923">{{cite journal| author=Barbé F, Durán-Cantolla J, Sánchez-de-la-Torre M, Martínez-Alonso M, Carmona C, Barceló A et al.| title=Effect of continuous positive airway pressure on the incidence of hypertension and cardiovascular events in nonsleepy patients with obstructive sleep apnea: a randomized controlled trial. | journal=JAMA | year= 2012 | volume= 307 | issue= 20 | pages= 2161-8 | pmid=22618923 | doi=10.1001/jama.2012.4366 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22618923  }} </ref>


"The optimum form of CPAP delivery interface remains unclear... nasal pillows or the Oracle oral mask may be useful alternatives when a patient is unable to tolerate conventional nasal masks" according to the [[Cochrane Collaboration]].<ref name="pmid17054251">{{cite journal |author=Chai CL, Pathinathan A, Smith B |title=Continuous positive airway pressure delivery interfaces for obstructive sleep apnoea |journal=Cochrane Database Syst Rev |volume= |issue=4 |pages=CD005308 |year=2006 |pmid=17054251 |doi=10.1002/14651858.CD005308.pub2 |url=http://dx.doi.org/10.1002/14651858.CD005308.pub2 |issn=}}</ref>
A [[randomized controlled trial]] of patients with central sleep apnea concluded "CPAP attenuated central sleep apnea, improved nocturnal oxygenation, increased the ejection fraction, lowered [[norepinephrine]] levels, and increased the distance walked in six minutes, it did not affect survival."<ref name="pmid16282177">{{cite journal |author=Bradley TD, Logan AG, Kimoff RJ, ''et al'' |title=Continuous positive airway pressure for central sleep apnea and heart failure |journal=N. Engl. J. Med. |volume=353 |issue=19 |pages=2025–33 |year=2005 |month=November |pmid=16282177 |doi=10.1056/NEJMoa051001 |url=http://content.nejm.org/cgi/pmidlookup?view=short&pmid=16282177&promo=ONFLNS19 |issn=}}</ref>.
 
Regarding research prior to these trials, the [[Cochrane Collaboration]] concluded "CPAP is effective in reducing symptoms of sleepiness and improving quality of life measures in people with moderate and severe obstructive sleep apnoea (OSA). It is more effective than oral appliances in reducing respiratory disturbances in these people but subjective outcomes are more equivocal. Certain people tend to prefer oral appliances to CPAP where both are effective"<ref name="pmid17054251">{{cite journal |author=Chai CL, Pathinathan A, Smith B |title=Continuous positive airway pressure delivery interfaces for obstructive sleep apnoea |journal=Cochrane Database Syst Rev |volume= |issue=4 |pages=CD005308 |year=2006 |pmid=17054251 |doi=10.1002/14651858.CD005308.pub2 |url=http://dx.doi.org/10.1002/14651858.CD005308.pub2 |issn=}}</ref>
 
[[Continuous positive airway pressure]] can be automatically self-adjusting.<ref  name="pmid15486338" /><ref name="pmid11902424">{{cite journal| author=Littner M, Hirshkowitz M, Davila D, Anderson WM, Kushida CA, Woodson BT et al.| title=Practice parameters for the use of auto-titrating continuous positive airway pressure devices for titrating pressures and treating adult patients with obstructive sleep apnea syndrome. An American Academy of Sleep Medicine report. | journal=Sleep | year= 2002 | volume= 25 | issue= 2 | pages= 143-7 | pmid=11902424 | doi= | pmc= | url= }} </ref>
 
Bi-level positive airway pressure (BiPAP) is often more tolerable, as it decreases the pressure when the patient exhales, reducing respiratory effort.<ref name="pmid19821310">{{cite journal| author=Smith I, Lasserson TJ| title=Pressure modification for improving usage of continuous positive airway pressure machines in adults with obstructive sleep apnoea. | journal=Cochrane Database Syst Rev | year= 2009 | volume=  | issue= 4 | pages= CD003531 | pmid=19821310
| url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=clinical.uthscsa.edu/cite&email=badgett@uthscdsa.edu&retmode=ref&cmd=prlinks&id=19821310 | doi=10.1002/14651858.CD003531.pub3 }}</ref> For both CPAP and BiPAP, there are a wide range of masks, nasal catheters called "nasal pillows", and it may take several devices and expert fitting to find the right appliance for individual patient."The optimum form of CPAP delivery interface remains unclear... nasal pillows or the Oracle oral mask may be useful alternatives when a patient is unable to tolerate conventional nasal masks" according to the [[Cochrane Collaboration]].<ref name="pmid17054251" /> A heated humidifier in the compressed air path also helps compliance by preventing drying of the nasal mucosa.
 
[[Eszopiclone]], a [[sedative]], used nightly for 14 nights may provide sustained increase in patient compliance<ref name="pmid19920270">{{cite journal| author=Lettieri CJ, Shah AA, Holley AB, Kelly WF, Chang AS, Roop SA et al.| title=Effects of a short course of eszopiclone on continuous positive airway pressure adherence: a randomized trial. | journal=Ann Intern Med | year= 2009 | volume= 151 | issue= 10 | pages= 696-702 | pmid=19920270
| url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=clinical.uthscsa.edu/cite&email=badgett@uthscdsa.edu&retmode=ref&cmd=prlinks&id=19920270 | doi=10.1059/0003-4819-151-10-200911170-00006 }}</ref>


===Medications===
===Medications===
Regarding medications, "there is insufficient evidence to recommend the use of drug therapy in the treatment of OSA" according to the [[Cochrane Collaboration]].<ref name="pmid16625567">{{cite journal |author=Smith I, Lasserson TJ, Wright J |title=Drug therapy for obstructive sleep apnoea in adults |journal=Cochrane Database Syst Rev |volume= |issue=2 |pages=CD003002 |year=2006 |pmid=16625567 |doi=10.1002/14651858.CD003002.pub2 |url=http://dx.doi.org/10.1002/14651858.CD003002.pub2 |issn=}}</ref>
Regarding medications, "there is insufficient evidence to recommend the use of drug therapy in the treatment of OSA" according to the [[Cochrane Collaboration]].<ref name="pmid16625567">{{cite journal |author=Smith I, Lasserson TJ, Wright J |title=Drug therapy for obstructive sleep apnoea in adults |journal=Cochrane Database Syst Rev |volume= |issue=2 |pages=CD003002 |year=2006 |pmid=16625567 |doi=10.1002/14651858.CD003002.pub2 |url=http://dx.doi.org/10.1002/14651858.CD003002.pub2 |issn=}}</ref>
===Oropharyngeal exercises===
Oropharyngeal exercises my help.<ref name="pmid19234106">{{cite journal |author=Guimarães KC, Drager LF, Genta PR, Marcondes BF, Lorenzi-Filho G |title=Effects of oropharyngeal exercises on patients with moderate obstructive sleep apnea syndrome |journal=Am. J. Respir. Crit. Care Med. |volume=179 |issue=10 |pages=962–6 |year=2009 |month=May |pmid=19234106 |doi=10.1164/rccm.200806-981OC |url=http://ajrccm.atsjournals.org/cgi/pmidlookup?view=long&pmid=19234106 |issn=}}</ref>


===Surgery===
===Surgery===
Regarding surgery, studies "do not provide evidence to support the use of surgery in sleep apnoea/hypopnoea syndrome, as overall significant benefit has not been demonstrated" according to the [[Cochrane Collaboration]].<ref name="pmid16235277">{{cite journal |author=Sundaram S, Bridgman SA, Lim J, Lasserson TJ |title=Surgery for obstructive sleep apnoea |journal=Cochrane Database Syst Rev |volume= |issue=4 |pages=CD001004 |year=2005 |pmid=16235277 |doi=10.1002/14651858.CD001004.pub2 |url=http://dx.doi.org/10.1002/14651858.CD001004.pub2 |issn=}}</ref>
Regarding surgery, studies "do not provide evidence to support the use of surgery in sleep apnoea/hypopnoea syndrome, as overall significant benefit has not been demonstrated" according to the [[Cochrane Collaboration]].<ref name="pmid16235277">{{cite journal |author=Sundaram S, Bridgman SA, Lim J, Lasserson TJ |title=Surgery for obstructive sleep apnoea |journal=Cochrane Database Syst Rev |volume= |issue=4 |pages=CD001004 |year=2005 |pmid=16235277 |doi=10.1002/14651858.CD001004.pub2 |url=http://dx.doi.org/10.1002/14651858.CD001004.pub2 |issn=}}</ref>
===Compression stockings===
A small [[randomized controlled trial]] reported that [[compression stocking]]s reduced the number of apneas and hypopnea, perhaps by "prevention of fluid accumulation in the legs during the day, and its nocturnal displacement into the neck at night."<ref  name="pmid21836140">{{cite journal| author=Redolfi S, Arnulf I,  Pottier M, Lajou J, Koskas I, Bradley TD et al.| title=Attenuation of  Obstructive Sleep Apnea by Compression Stockings in Subjects With Venous  Insufficiency. | journal=Am J Respir Crit Care Med | year= 2011 |  volume=  | issue=  | pages=  | pmid=21836140 |  doi=10.1164/rccm.201102-0350OC | pmc= |  url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21836140  }} </ref>
==Prognosis==
An AHI over 20 is associated with death.<ref>
Gami AS, Olson EJ, Shen WK, Wright RS, Ballman KV, Hodge DO, et al. Obstructive Sleep Apnea and the Risk of Sudden Cardiac Death: A Longitudinal Study of 10,701 Adults. Journal of the American College of Cardiology. Available from: http://www.sciencedirect.com/science/article/pii/S0735109713022511
</ref>


==References==
==References==
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</small>[[Category:Suggestion Bot Tag]]

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Obstructive sleep apnea (spelt "apnoea" in British English) is a "disorder characterized by recurrent apneas during sleep despite persistent respiratory efforts. It is due to upper airway obstruction. The respiratory pauses may induce hypercapnia or hypoxia. Cardiac arrhythmias and elevation of systemic and pulmonary arterial pressures may occur. Frequent partial arousals occur throughout sleep, resulting in relative sleep deprivation and daytime tiredness. Associated conditions include obesity; acromegaly; myxedema; micrognathia; myotonic dystrophy; adenotonsilar dystrophy; and neuromuscular diseases. (From Adams et al., Principles of Neurology, 6th ed, p395)."[1][2]

Diagnosis

Polysomnography is the best test and abnormal is a apnea–hypopnea index (AHI) of 5 or greater. The American Academy of Sleep Medicine publishes a diagnostic manual.[3] and guidelines[4]. Moderate to sever OSA is a AHI of 15 or more episodes/hour. However, this test requires a patient to attend a sleep center and is not always required to diagnose sleep apnea.[5] A systematic review in 2000 concluded that the best alternative diagnostic test is not certain.[6]

Testing can be done at home.[7]

History and physical

Age, body mass index, male sex, and snoring are the best predictors of sleep apnea.[8] Obstructive sleep apnea is difficult to diagnose based on the history and physical examinations.[9]

  • A score of more than 5 on the Berlin Questionnaire has a sensitivity of 86% in one study.[10]
  • The Epworth Sleepiness Scale may help diagnose. The original cut-off was proposed to be 10. However, the optimal cut-off level may be 8[11] or 12 if combined with the BMI.[12].
  • The Wisconsin Sleep Questionnaire may help diagnose.[13]
  • Another clinical prediction rules may help diagnose sleep apnea.[14]

Oximetry

Oximetry, which may be performed overnight in a patient's home, is an easier alternative to formal sleep study (polysomnography.

  • In one study, normal overnight oximetry was very sensitive and so if normal, sleep apnea was unlikely.[15] In addition, home oximetry may be equally effect in guiding prescription for automatically self-adjusting continuous positive airway pressure.[16]
  • Another study found that overnight oximetry, defining abnormal as 15 or more 4% desaturations/hour, was very specific, but not sensitive.[17]
  • Sensitivty of overnight oximetry is improved by using a 3% desaturation in oxygen.[18] and lowering the ODI to 5 per hour.[19]
  • Oximetry may identify some patients whose outcomes are not improved by adding polysomnography.[5]

Treatment

Treatment may lower blood pressure by about 3 - 5 mm Hg.[20][21]

Weight loss

Weight loss of 20 kg with a liquid very low energy diet(2.3 MJ/day) for seven weeks can reduce the AHI by 23 and lead to 20% of patients becoming disease free.[22]

Oral appliances

Regarding oral appliances (mandibular advancement device (MAD)), "CPAP appears to be more effective in improving sleep disordered breathing than OA. The difference in symptomatic response between these two treatments is not significant, although it is not possible to exclude an effect in favour of either therapy. Until there is more definitive evidence on the effectiveness of OA in relation to CPAP, with regard to symptoms and long-term complications, it would appear to be appropriate to recommend OA therapy to patients with mild symptomatic OSAH, and those patients who are unwilling or unable to tolerate CPAP therapy" according to the Cochrane Collaboration.[23]

More recent randomized controlled trials report:

  • Similar findings in that oral appliances (mandibular advancement device (MAD)) are easier to tolerate, but CPAP is reduces the apnea-hypopnea index (AHI) more. Quality-of-life indicators may be better with appliance.[24]
  • MAD may not affect quality of life or daytime sleepiness, though other benefits may occur, among patients with apnea-hypopnea index (AHI) lower than 30.[25]

Continuous positive airway pressure (CPAP)

Several trials have studied continuous positive airway pressure:

  • Patients with Epworth Sleepiness Scale score >10 has a reduction in daytime symptoms.[26]
  • Patients with Epworth Sleepiness Scale score <10 had no reduction in cardiovascular events.[27]

A randomized controlled trial of patients with central sleep apnea concluded "CPAP attenuated central sleep apnea, improved nocturnal oxygenation, increased the ejection fraction, lowered norepinephrine levels, and increased the distance walked in six minutes, it did not affect survival."[28].

Regarding research prior to these trials, the Cochrane Collaboration concluded "CPAP is effective in reducing symptoms of sleepiness and improving quality of life measures in people with moderate and severe obstructive sleep apnoea (OSA). It is more effective than oral appliances in reducing respiratory disturbances in these people but subjective outcomes are more equivocal. Certain people tend to prefer oral appliances to CPAP where both are effective"[29]

Continuous positive airway pressure can be automatically self-adjusting.[16][30]

Bi-level positive airway pressure (BiPAP) is often more tolerable, as it decreases the pressure when the patient exhales, reducing respiratory effort.[31] For both CPAP and BiPAP, there are a wide range of masks, nasal catheters called "nasal pillows", and it may take several devices and expert fitting to find the right appliance for individual patient."The optimum form of CPAP delivery interface remains unclear... nasal pillows or the Oracle oral mask may be useful alternatives when a patient is unable to tolerate conventional nasal masks" according to the Cochrane Collaboration.[29] A heated humidifier in the compressed air path also helps compliance by preventing drying of the nasal mucosa.

Eszopiclone, a sedative, used nightly for 14 nights may provide sustained increase in patient compliance[32]

Medications

Regarding medications, "there is insufficient evidence to recommend the use of drug therapy in the treatment of OSA" according to the Cochrane Collaboration.[33]

Oropharyngeal exercises

Oropharyngeal exercises my help.[34]

Surgery

Regarding surgery, studies "do not provide evidence to support the use of surgery in sleep apnoea/hypopnoea syndrome, as overall significant benefit has not been demonstrated" according to the Cochrane Collaboration.[35]

Compression stockings

A small randomized controlled trial reported that compression stockings reduced the number of apneas and hypopnea, perhaps by "prevention of fluid accumulation in the legs during the day, and its nocturnal displacement into the neck at night."[36]

Prognosis

An AHI over 20 is associated with death.[37]

References

  1. ↑ Anonymous (2024), Obstructive sleep apnea (English). Medical Subject Headings. U.S. National Library of Medicine.
  2. ↑ Caples SM, Gami AS, Somers VK. Obstructive sleep apnea. Ann Intern Med. 2005 Feb 1;142(3):187-97. PMID 15684207
  3. ↑ Berry RB, Budhiraja R, Gottlieb DJ, Gozal D, Iber C, Kapur VK et al. (2012). "Rules for scoring respiratory events in sleep: update of the 2007 AASM Manual for the Scoring of Sleep and Associated Events. Deliberations of the Sleep Apnea Definitions Task Force of the American Academy of Sleep Medicine.". J Clin Sleep Med 8 (5): 597-619. DOI:10.5664/jcsm.2172. PMID 23066376. PMC PMC3459210. Research Blogging.
  4. ↑ Epstein LJ, Kristo D, Strollo PJ, Friedman N, Malhotra A, Patil SP et al. (2009). "Clinical guideline for the evaluation, management and long-term care of obstructive sleep apnea in adults.". J Clin Sleep Med 5 (3): 263-76. PMID 19960649. PMC PMC2699173. [e]
  5. ↑ 5.0 5.1 {{cite journal| author=Mulgrew AT, Fox N, Ayas NT, Ryan CF| title=Diagnosis and initial management of obstructive sleep apnea without polysomnography: a randomized validation study. | journal=Ann Intern Med | year= 2007 | volume= 146 | issue= 3 | pages= 157-66 | pmid=17283346 | doi= | pmc= | url=http://www.annals.org/content/146/3/157.full Review in: Evid Based Med. 2007 Oct;12(5):148] Review in: ACP J Club. 2007 Sep-Oct;147(2):45
  6. ↑ Ross SD, Sheinhait IA, Harrison KJ, Kvasz M, Connelly JE, Shea SA et al. (2000). "Systematic review and meta-analysis of the literature regarding the diagnosis of sleep apnea.". Sleep 23 (4): 519-32. PMID 10875559. [e]
  7. ↑ El Shayeb M, Topfer LA, Stafinski T, Pawluk L, Menon D (2014). "Diagnostic accuracy of level 3 portable sleep tests versus level 1 polysomnography for sleep-disordered breathing: a systematic review and meta-analysis.". CMAJ 186 (1): E25-51. DOI:10.1503/cmaj.130952. PMID 24218531. Research Blogging.
  8. ↑ Viner S, Szalai JP, Hoffstein V (1991). "Are history and physical examination a good screening test for sleep apnea?". Ann Intern Med 115 (5): 356-9. PMID 1863025. [e]
  9. ↑ Abrishami A, Khajehdehi A, Chung F (2010). "A systematic review of screening questionnaires for obstructive sleep apnea.". Can J Anaesth 57 (5): 423-38. DOI:10.1007/s12630-010-9280-x. PMID 20143278. Research Blogging.
  10. ↑ Netzer NC, Stoohs RA, Netzer CM, Clark K, Strohl KP. Using the Berlin Questionnaire to identify patients at risk for the sleep apnea syndrome. Ann Intern Med. 1999 Oct 5;131(7):485-91. PMID 10507956
  11. ↑ Rosenthal LD, Dolan DC (2008). "The Epworth sleepiness scale in the identification of obstructive sleep apnea.". J Nerv Ment Dis 196 (5): 429-31. DOI:10.1097/NMD.0b013e31816ff3bf. PMID 18477888. Research Blogging.
  12. ↑ Pouliot Z, Peters M, Neufeld H, Kryger MH (1997). "Using self-reported questionnaire data to prioritize OSA patients for polysomnography.". Sleep 20 (3): 232-6. PMID 9178919. [e]
  13. ↑ Teculescu D, Guillemin F, Virion JM, Aubry C, Hannhart B, Michaely JP et al. (2003). "Reliability of the Wisconsin Sleep Questionnaire: a French contribution to international validation.". J Clin Epidemiol 56 (5): 436-40. PMID 12812817. [e]
  14. ↑ Rodsutti J, Hensley M, Thakkinstian A, D'Este C, Attia J. A clinical decision rule to prioritize polysomnography in patients with suspected sleep apnea. Sleep. 2004 Jun 15;27(4):694-9. PMID 15283004
  15. ↑ Sériès F, Marc I, Cormier Y, La Forge J (1993). "Utility of nocturnal home oximetry for case finding in patients with suspected sleep apnea hypopnea syndrome.". Ann Intern Med 119 (6): 449-53. PMID 8357109. [e]
  16. ↑ 16.0 16.1 Whitelaw WA, Brant RF, Flemons WW (2005). "Clinical usefulness of home oximetry compared with polysomnography for assessment of sleep apnea.". Am J Respir Crit Care Med 171 (2): 188-93. DOI:10.1164/rccm.200310-1360OC. PMID 15486338. Research Blogging. Review in: ACP J Club. 2005 Jul-Aug;143(1):21
  17. ↑ Ryan PJ, Hilton MF, Boldy DA, Evans A, Bradbury S, Sapiano S et al. (1995). "Validation of British Thoracic Society guidelines for the diagnosis of the sleep apnoea/hypopnoea syndrome: can polysomnography be avoided?". Thorax 50 (9): 972-5. PMID 8539678. PMC PMC1021311. [e]
  18. ↑ Nigro CA, Dibur E, Rhodius E (2012). "Accuracy of the clinical parameters and oximetry to initiate CPAP in patients with suspected obstructive sleep apnea.". Sleep Breath 16 (4): 1073-9. DOI:10.1007/s11325-011-0603-0. PMID 22009031. Research Blogging.
  19. ↑ Douglas NJ, Thomas S, Jan MA (1992). "Clinical value of polysomnography.". Lancet 339 (8789): 347-50. PMID 1346422. [e]
  20. ↑ Martínez-García M, Capote F, Campos-Rodríguez F, et al. Effect of CPAP on Blood Pressure in Patients With Obstructive Sleep Apnea and Resistant Hypertension: The HIPARCO Randomized Clinical Trial. JAMA. 2013;310(22):2407-2415. DOI:10.1001/jama.2013.281250.
  21. ↑ Pedrosa RP, Drager LF, de Paula LK, Amaro AC, Bortolotto LA, Lorenzi-Filho G (2013). "Effects of OSA Treatment on BP in Patients With Resistant Hypertension: A Randomized Trial.". Chest 144 (5): 1487-94. DOI:10.1378/chest.13-0085. PMID 23598607. Research Blogging.
  22. ↑ Johansson K, Neovius M, Lagerros YT, Harlid R, Rössner S, Granath F et al. (2009). "Effect of a very low energy diet on moderate and severe obstructive sleep apnoea in obese men: a randomised controlled trial.". BMJ 339: b4609. DOI:10.1136/bmj.b4609. PMID 19959590. PMC PMC2788899. Research Blogging.
  23. ↑ Lim J, Lasserson TJ, Fleetham J, Wright J (2006). "Oral appliances for obstructive sleep apnoea". Cochrane Database Syst Rev (1): CD004435. DOI:10.1002/14651858.CD004435.pub3. PMID 16437488. Research Blogging.
  24. ↑ Phillips CL, Grunstein RR, Darendeliler MA, Mihailidou AS, Srinivasan VK, Yee BJ et al. (2013). "Health outcomes of continuous positive airway pressure versus oral appliance treatment for obstructive sleep apnea: a randomized controlled trial.". Am J Respir Crit Care Med 187 (8): 879-87. DOI:10.1164/rccm.201212-2223OC. PMID 23413266. Research Blogging.
  25. ↑ Marklund M, Carlberg B, Forsgren L, Olsson T, Stenlund H, Franklin KA (2015). "Oral Appliance Therapy in Patients With Daytime Sleepiness and Snoring or Mild to Moderate Sleep Apnea: A Randomized Clinical Trial.". JAMA Intern Med 175 (8): 1278-85. DOI:10.1001/jamainternmed.2015.2051. PMID 26030264. Research Blogging.
  26. ↑ Weaver TE, Mancini C, Maislin G, Cater J, Staley B, Landis JR et al. (2012). "Continuous Positive Airway Pressure Treatment of Sleepy Patients with Milder Obstructive Sleep Apnea: Results of the CPAP Apnea Trial North American Program (CATNAP) Randomized Clinical Trial.". Am J Respir Crit Care Med 186 (7): 677-83. DOI:10.1164/rccm.201202-0200OC. PMID 22837377. Research Blogging.
  27. ↑ Barbé F, Durán-Cantolla J, Sánchez-de-la-Torre M, Martínez-Alonso M, Carmona C, Barceló A et al. (2012). "Effect of continuous positive airway pressure on the incidence of hypertension and cardiovascular events in nonsleepy patients with obstructive sleep apnea: a randomized controlled trial.". JAMA 307 (20): 2161-8. DOI:10.1001/jama.2012.4366. PMID 22618923. Research Blogging.
  28. ↑ Bradley TD, Logan AG, Kimoff RJ, et al (November 2005). "Continuous positive airway pressure for central sleep apnea and heart failure". N. Engl. J. Med. 353 (19): 2025–33. DOI:10.1056/NEJMoa051001. PMID 16282177. Research Blogging.
  29. ↑ 29.0 29.1 Chai CL, Pathinathan A, Smith B (2006). "Continuous positive airway pressure delivery interfaces for obstructive sleep apnoea". Cochrane Database Syst Rev (4): CD005308. DOI:10.1002/14651858.CD005308.pub2. PMID 17054251. Research Blogging.
  30. ↑ Littner M, Hirshkowitz M, Davila D, Anderson WM, Kushida CA, Woodson BT et al. (2002). "Practice parameters for the use of auto-titrating continuous positive airway pressure devices for titrating pressures and treating adult patients with obstructive sleep apnea syndrome. An American Academy of Sleep Medicine report.". Sleep 25 (2): 143-7. PMID 11902424. [e]
  31. ↑ Smith I, Lasserson TJ (2009). "Pressure modification for improving usage of continuous positive airway pressure machines in adults with obstructive sleep apnoea.". Cochrane Database Syst Rev (4): CD003531. DOI:10.1002/14651858.CD003531.pub3. PMID 19821310. Research Blogging.
  32. ↑ Lettieri CJ, Shah AA, Holley AB, Kelly WF, Chang AS, Roop SA et al. (2009). "Effects of a short course of eszopiclone on continuous positive airway pressure adherence: a randomized trial.". Ann Intern Med 151 (10): 696-702. DOI:10.1059/0003-4819-151-10-200911170-00006. PMID 19920270. Research Blogging.
  33. ↑ Smith I, Lasserson TJ, Wright J (2006). "Drug therapy for obstructive sleep apnoea in adults". Cochrane Database Syst Rev (2): CD003002. DOI:10.1002/14651858.CD003002.pub2. PMID 16625567. Research Blogging.
  34. ↑ Guimarães KC, Drager LF, Genta PR, Marcondes BF, Lorenzi-Filho G (May 2009). "Effects of oropharyngeal exercises on patients with moderate obstructive sleep apnea syndrome". Am. J. Respir. Crit. Care Med. 179 (10): 962–6. DOI:10.1164/rccm.200806-981OC. PMID 19234106. Research Blogging.
  35. ↑ Sundaram S, Bridgman SA, Lim J, Lasserson TJ (2005). "Surgery for obstructive sleep apnoea". Cochrane Database Syst Rev (4): CD001004. DOI:10.1002/14651858.CD001004.pub2. PMID 16235277. Research Blogging.
  36. ↑ Redolfi S, Arnulf I, Pottier M, Lajou J, Koskas I, Bradley TD et al. (2011). "Attenuation of Obstructive Sleep Apnea by Compression Stockings in Subjects With Venous Insufficiency.". Am J Respir Crit Care Med. DOI:10.1164/rccm.201102-0350OC. PMID 21836140. Research Blogging.
  37. ↑ Gami AS, Olson EJ, Shen WK, Wright RS, Ballman KV, Hodge DO, et al. Obstructive Sleep Apnea and the Risk of Sudden Cardiac Death: A Longitudinal Study of 10,701 Adults. Journal of the American College of Cardiology. Available from: http://www.sciencedirect.com/science/article/pii/S0735109713022511

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