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Obstructive sleep apnea: General characteristics in hypertensive patients, positional sensitivity, and upper airway sensory neuropathy
Linköping University, Department of Clinical and Experimental Medicine, Division of Neuroscience. Linköping University, Faculty of Health Sciences. Östergötlands Läns Landsting, Anaesthetics, Operations and Specialty Surgery Center, Department of Clinical Neurophysiology.
2012 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Introduction: Obstructive sleep apnea (OSA) is a highly prevalent disorder, especially in populations with cardiovascular disease. Unfortunately most cases with OSA remain undiagnosed. The ability to identify OSA is important for both the individual and the society, as it is a treatable risk factor for cardiovascular disease and also associated with impaired quality of life. This could be particularly important in populations with cardiovascular disease where the most beneficiary treatment effects could be expected. However, the diagnostic process in OSA may be affected by positional dependency (a majority of OSA patients have more breathing interruptions in supine sleep compared to other sleeping positions). Based on the assumption that individuals have different proportions of supine and non-supine sleep on different nights, positional dependency may be a potential confounder in both diagnosis, classification of OSA severity and evaluation of treatment efficacy. Another aspect of OSA is that the pathogenesis is not fully understood. Data indicate that OSA might be a progressive disease, and many patients report years of snoring before witnessed apneas and symptoms occur. One hypothesis on the pathogenesis of OSA is that long-standing, snoring-induced vibrations cause neurogenic lesions in upper airway tissues, progressively damaging the reflex circuits responsible for keeping the upper airway open during sleep.

Aims: To describe the occurrence of undiagnosed OSA and to identify determinants of moderate/severe OSA in patients with hypertension (study I). To describe the prevalence of position dependent OSA (POSA) and its relation to OSA severity classification (study II). To compare two methods for quantitative testing of cold sensory function (as a sign of neuropathy) in the upper airway with special focus on test-retest repeatability (study III). To evaluate signs of upper airway sensory neuropathy, by cold sensory testing, in non-snorers, snorers, and snoring OSA subjects with special reference to AHI and duration of snoring history (study IV).

Methods: In study I 411 consecutive patients with hypertension from four primary care health centers in Sweden were evaluated for OSA as measured by the apnea hypopnea index (AHI) through polygraphic (PG) recordings. Different predictors for moderate/severe OSA were evaluated. In study II the PG recordings of 265 subjects were specially assessed for POSA and the relation between severity classification based on POSA and traditional OSA severity classification. In study III 40 non-snoring subjects were tested for cold detection thresholds at the soft palate and the lip at two separate occasions with two different methods (MLE/MLI). Bland-Altman analysis was used to compare test-retest repeatability. In study IV cold sensory testing of the soft palate and lip was used to evaluate signs of upper airway sensory neuropathy in both non-snorers; snorers, and subjects with OSA (groups were formed based on AHI and snoring history, n=90).

Results and Conclusions: Undiagnosed OSA is common in Swedish primary care patients with hypertension, and male gender, BMI>30 kg/m2, and a clinical history of snoring and witnessed apneas are predictors of moderate/severe OSA. POSA is common both in subjects that by traditional classification had OSA as well as those without OSA. The severity of OSA, if based on total AHI, could be dependent on supine time in a substantial amount of subjects. Cold sensory testing is easily performed in the oropharynx, with acceptable test–retest repeatability. MLI is considerably faster to perform and have a slightly better repeatability than MLE. Therefore MLI should be the used method for cold thermal testing at the soft palate. Both self-reported snoring years and OSA severity are correlated to the degree of cold sensory impairment in the upper airway. Our results strengthen the hypothesis that snoring vibrations may cause a neuropathy in the upper airway, which may contribute to the progression and development of OSA.

Place, publisher, year, edition, pages
Linköping: Linköping University Electronic Press, 2012. , 94 p.
Series
Linköping University Medical Dissertations, ISSN 0345-0082 ; 1341
National Category
Medical and Health Sciences
Identifiers
URN: urn:nbn:se:liu:diva-85021ISBN: 978-91-7519-760-9 (print)OAI: oai:DiVA.org:liu-85021DiVA: diva2:563605
Public defence
2012-12-07, Flemingsalen, Campus US, Linköpings universitet, Linköping, 09:00 (Swedish)
Opponent
Supervisors
Available from: 2012-10-30 Created: 2012-10-30 Last updated: 2014-06-13Bibliographically approved
List of papers
1. Factors associated with undiagnosed obstructive sleep apnoea in hypertensive primary care patients
Open this publication in new window or tab >>Factors associated with undiagnosed obstructive sleep apnoea in hypertensive primary care patients
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2012 (English)In: Scandinavian Journal of Primary Health Care, ISSN 0281-3432, E-ISSN 1502-7724, Vol. 30, no 2, 107-113 p.Article in journal (Refereed) Published
Abstract [en]

Objective. In hypertensive primary care patients below 65 years of age, (i) to describe the occurrence of undiagnosed obstructive sleep apnoea (OSA), and (ii) to identify the determinants of moderate/severe OSA. Design. Cross-sectional. Setting. Four primary care health centres in Sweden. Patients. 411 consecutive patients (52% women), mean age 57.9 years (SD 5.9 years), with diagnosed and treated hypertension (BP andgt; 140/90). Main outcome measures. Occurrence of OSA as measured by the apnoea hypopnoea index (AHI). Results. Mild (AHI 5-14.9/h) and moderate/severe (AHI andgt; 15/h) OSA were seen among 29% and 30% of the patients, respectively. Comparing those without OSA with those with mild or moderate/severe OSA, no differences were found in blood pressure, pharmacological treatment (anti-hypertensive, anti-depressive, and hypnotics), sleep, insomnia symptoms, daytime sleepiness, or depressive symptoms. Obesity (BMI andgt; 30 kg/m(2)) was seen in 30% and 68% of the patients with mild and moderate/severe OSA, respectively. Male gender, BMI andgt; 30 kg/m(2), snoring, witnessed apnoeas, and sleep duration andgt; 8 hours were determinants of obstructive sleep apnoea. Conclusion. Previously undiagnosed OSA is common among patients with hypertension in primary care. Obesity, snoring, witnessed apnoeas, long sleep duration, and male gender were the best predictors of OSA, even in the absence of daytime sleepiness and depressive symptoms.

Place, publisher, year, edition, pages
Informa Healthcare, 2012
Keyword
Depression, hypertension, obstructive sleep apnoea, sleep, sleep disordered breathing, snoring
National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-78805 (URN)10.3109/02813432.2012.675563 (DOI)000304602800009 ()
Note

Funding Agencies|Swedish Heart Lung Foundation|20090547|

Available from: 2012-06-21 Created: 2012-06-21 Last updated: 2017-12-07
2. Positional sensitivity as a confounder in diagnosis of severity of obstructive sleep apnea
Open this publication in new window or tab >>Positional sensitivity as a confounder in diagnosis of severity of obstructive sleep apnea
2013 (English)In: Sleep and Breathing, ISSN 1520-9512, E-ISSN 1522-1709, Vol. 17, no 1, 173-179 p.Article in journal (Refereed) Published
Abstract [en]

Purpose: The apnea–hypopnea index (AHI) is used to grade obstructive sleep apnea (OSA) into mild, moderate, and severe forms. Obstructive events are most common in the supine position. The amount of supine sleep thus influences total AHI. Our aim was to determine the prevalence of position-dependent OSA (POSA) and its relation to OSA severity classification as recommended by the American Academy of Sleep Medicine (AASM).

Methods: Two hundred sixty-five subjects were recruited from primary care hypertension clinics. Whole-night respiratory recordings were performed to determine the AHI in the supine and non-supine positions, respectively. POSA was defined as supine AHI twice the non-supine AHI with supine AHI ≥5.

Results: Fifty-three percent had POSA, 22% had non-position-dependent OSA, and 25% had normal respiration. By AASM classification, 81 subjects did not have OSA, but 42% of them had some degree of obstruction when supine, and 5 subjects would have been classified as moderate–severe if they had only slept supine. Conversely, of the 53 classified as mild OSA, 30% would have changed to a more severe classification if they had exclusively slept supine.

Conclusions: POSA was common both in subjects that by AASM classification had OSA as well as those without. The severity of OSA, as defined by AASM, could be dependent on supine time in a substantial amount of subjects

National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-85020 (URN)10.1007/s11325-012-0666-6 (DOI)000315167200031 ()
Available from: 2012-10-30 Created: 2012-10-30 Last updated: 2017-12-07Bibliographically approved
3. How should sensory function in the oropharynx be tested? Cold thermal testing; a comparison of the methods of levels and limits
Open this publication in new window or tab >>How should sensory function in the oropharynx be tested? Cold thermal testing; a comparison of the methods of levels and limits
2010 (English)In: Clinical Neurophysiology, ISSN 1388-2457, E-ISSN 1872-8952, Vol. 121, no 11, 1886-1889 p.Article in journal (Refereed) Published
Abstract [en]

Objective: Several studies indicate an upper airway peripheral neuropathy in obstructive sleep apnea syndrome (OSAS). The sensation of cold, as measured by cold detection thresholds (CDT), in the oropharynx has been shown to be compromised in patients with sleep apnea and, to a lesser extent, habitual snoring. To reveal whether this neuropathy is part of the pathogenetic process of OSAS, longitudinal studies of snorers are needed. The objective of the present study was to establish the test-retest repeatability for the two most commonly used thermal testing methods: the reaction time exclusive method of levels (MLE) and the method of limits (MLI). Methods: Forty non-snoring subjects were tested at the soft palate and the lip at two separate occasions (mean interval 45 days) using a Medoc TSA - 2001 equipment with an intra-oral thermode. Results: With MLE mean CDTs were lower for both the lip and soft palate than with MLI. However, MLI showed a better test-retest repeatability (r = 2.2 vs. 2.6) for the soft palate. Conclusions: MLI should be used in longitudinal studies. The performance of this method is also faster. Significance: We have established a quick, safe and reliable method suitable for longitudinal studies of peripheral neuropathy in sleep apnea pathogenesis.

Place, publisher, year, edition, pages
Elsevier Science B.V., Amsterdam., 2010
Keyword
Cold thermal testing, Oropharynx, Method of levels, Method of limits, Quantitative sensory testing, Obstructive sleep apnea
National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-60510 (URN)10.1016/j.clinph.2010.05.002 (DOI)000282158200013 ()
Available from: 2010-10-15 Created: 2010-10-15 Last updated: 2012-10-30
4. Soft Palate Sensory Neuropathy in the Pathogenesis of Obstructive Sleep Apnea
Open this publication in new window or tab >>Soft Palate Sensory Neuropathy in the Pathogenesis of Obstructive Sleep Apnea
2011 (English)In: The Laryngoscope, ISSN 0023-852X, E-ISSN 1531-4995, Vol. 121, no 2, 451-456 p.Article in journal (Refereed) Published
Abstract [en]

Objectives/Hypothesis: In general, obstructive sleep apnea (USA) seems to be a progressive disorder whose pathogenesis is not fully understood. One hypothesis is that long-standing snoring vibrations cause a local neuropathy in the upper airway, which predisposes to obstructive events during sleep. The aim of this study was to investigate sensory function in the upper airway in a cohort of subjects comprising nonsnorers, snorers, and untreated subjects with USA, and to correlate data to apnea-hypopnea index (AHI) and duration of snoring. Study Design: Cross-sectional cohort study. Methods: Subjects were recruited from primary care hypertension clinics. Whole-night respiratory recordings were performed to determine presence and degree of USA. Three groups were formed based on AHI and snoring history: 1) nonsnorers (n = 25); 2) snorers, AHI andlt; 10 (n = 32); 3) USA subjects, AHI andgt;= 10 (n = 33). Quantitative cold sensory testing of the soft palate and lip was used to assess neuropathy. Results: There were no significant differences concerning lip sensory function between groups. Nonsnorers showed significantly lower thresholds for cold (i.e., better sensitivity) in the soft palate compared to both other groups (P andlt; .01). Snorers had lower thresholds than USA subjects (P andlt; .05). There were significant correlations (P andlt; .01) between decreased sensory function and AHI (r(s) = .41) and to duration of snoring (r(s) = .47). Conclusions: The degree of sensory neuropathy in the upper airway correlates with degree of obstructive sleep disorder. Our results strengthen the hypothesis that snoring vibrations may cause a neuropathy in the upper airway, which contributes to the progression and development of USA.

Place, publisher, year, edition, pages
Laryngoscope, 2011
Keyword
Obstructive sleep apnea, snoring, cold thermal testing, soft palate, method of limits, quantitative sensory testing
National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-66865 (URN)10.1002/lary.21371 (DOI)000287006400040 ()
Available from: 2011-03-22 Created: 2011-03-21 Last updated: 2017-12-11

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