obstructive sleep apnea (OSA)
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Etiology
- obesity (most important risk factor)[3]
- adenotonsillar hypertrophy (especially in children)
- micrognathia
- retrognathia
- macroglossia - tongue fat may contribute[67]
- vocal cord paralysis
- bulbar involvement with neuromuscular disease
- cordotomy
- poliomyelitis
- Shy-Drager syndrome
- sudden infant death syndrome
- severe altitude-related polycythemia
- Pickwickian syndrome
- hypothyroidism can worsen obstructive sleep apnea[17]
- stroke ?[22]
- asthma in adults[47] (RR=2.7)
- edentulous patients are at higher risk
Epidemiology
- 1-2% of population
- 4% of middle-aged men & 2% of middle aged women
- more common in older age
- only a small percentage of cases are diagnosed
- 10%-30% of adults suffer from OSA; ~60% have mild disease[69]
Pathology
- repetitive inspiratory occlusion of the upper airway during sleep, resulting in:
- respiratory efforts without airflow
- hypoxemia
- disrupted sleep patterns
- airway obstruction occurs at the level of the soft palate or posterior to the base of the tongue
- changes in the upper airway anatomy associated with the absence of teeth
- the tone of the genioglossus & geniohyoid muscles (abductors) decreases with the resulting pharyngeal collapse producing airway obstruction
- airway occlusion is exaggerated by a large neck circumference, increased size of the uvula & pharyngeal mucosal edema (from long-term snoring)
- protective reflexes maintain pharyngeal airway patency during wakefulness
- during sleep, protective reflexes are lost with reduced activity of the pharyngeal dilator muscle, causing collapse of the airway
- fluctuations in activity of the central pattern generator in the brain stem lead to variable output to the diaphragm & upper-airway muscles, contributing to obstructive sleep apnea[38]
- in older patients, compromised upper airway anatomy, poor pharyngeal muscle responsiveness, respiratory control instability, & low arousal threshold may all play a role[75]
- autonomic dysfunction may play a role in cognitive impairment[75]
History
Clinical manifestations
- obesity
- upper body, especially nuchal obesity
- neck circumference > 17 inches (> 40 cm)
- less likely in patient with stroke
- upper body, especially nuchal obesity
- excessive daytime sleepiness, hypersomnolence
- less likely in patient with stroke
- daytime functional impairment
- snoring, gasping &/or choking episodes during sleep
- may be reports of witnessed apneas
- may wake up gasping for breath or with palpitations
- insomnia
- personality changes
- intellectual deterioration
- morning headache (sleep apnea headache)
- daytime sleepiness[40]
- automatic behavior
- loss of libido - hypogonadotropic hypogonadism[48][81]
- night sweats
- nocturia
- erectile dysfunction
- hypertension (50%)
- dry mouth[40]
- ear, nose & throat examination
- nasal obstruction or congestion
- nasal septal deviation
- enlarged tonsils (especially in children)
- elongated soft palate (crowded pharynx)
- macroglossia
- narrow oropharynx
- erythematous, edematous oropharyngeal mucosa
- micrognathia
- patients may be asymptomatic
Laboratory
- thyroid function testing
- serum TSH, free T4
- rule out hypothyroidism
- complete blood count (CBC) may show polycythemia
- arterial blood gas for hypoxia, hypercarbia
- rule out obesity hypoventilation syndrome
- precedence over pulmonary function testing
- ambulatory oximetry not useful[81]
- elevated serum C-reactive protein is an inflammatory marker of metabolic syndrome[44]
Diagnostic procedures
- polysomnography*: gold standard
- 5 or more hypopnea or apneas/hour of sleep (apnea-hypopnea index > 5)
- recurrent arousals from sleep
- indicated vs portable sleep monitor for
- mission-critical workers
- severe cardiorespiratory disease
- possible respiratory muscle weakness
- hypoventilation while awake
- potential sleep-related hypoventilation
- chronic opioid use
- history of stroke or severe insomnia[55][59]
- portable sleep monitor (home testing)[55][59]
- uncomplicated cases with high pre-test probability
- without cormordid cardiopulmonary disease[3]
- without neuromuscular disease[3]
- when polysomnography is not available[45]
- performs comparably to polysomnography in these patients
- non-inferior to polysomnography[58]
- >= 4 hours of oximetry & flow data should be obtained[55]
- if home testing yields negative or inconclusive results, or is not technically adequate, polysomnography is indicated[55]
- uncomplicated cases with high pre-test probability
- therapeutic trial of CPAP may be diagnostic[10]
- pulmonary function testing
- overnight pulse oximetry is useful for rule-out OSA in low-risk patients[3]
- has not been validated as a screening tool for OSA[3]
- clinical tools, questionnaires, or prediction algorithms inadequate without testing (polysomnography or portable sleep monitor)[55]
- electrocardiogram:
- sinus arrhythmia seen in 90% of patients
- 2nd degree AV block
- premature ventricular contractions
- ventricular tachycardia
- component of polysomnography
- echocardiogram may show
* MKSAP19[3] & GRS11[40] differ on indications for polysomnography;
* suspicion of OSA on the basis of snoring, hypertension, obesity, low SaO2 on room air is an indication for polysomnography per GRS11[40]
Radiology
- MRI: white matter hyperintensities
- white matter is extensively affected possibly from repeated hypoxia accompanying apneic events
- alterations include axons linking major structures within the limbic system, pons, frontal, temporal & parietal cortices, & projections to & from the cerebellum
Complications
- complications of repetitive hypoxemia
- systemic hypertension: CPAP may reduce risk[27]
- pulmonary hypertension
- initially episodic
- may become sustained
- cardiac arrhythmias
- late complications, especially with obesity & chronic lung disease
- increased cardiovascular risk
- increased risk of coronary artery disease in women
- increased risk of stroke[11][78]
- increased cardiovascular mortality with severe OSA[9]
- CPAP may improve LVEF in patients with CHF
- CPAP may improve cardiovascular risk[26]
- CPAP does not lower cardiovascular risk[68]
- increased risk of sudden cardiac death[35]
- increased nocturnal hypercoagulability[34]
- other
- increased risk of motor vehicle accidents ?[19]
- postoperative pulmonary complications
- increased risk of pneumonia[39]
- insomnia worsens daytime functional impairment[40]
- hypogonadotropic hypogonadism[48]
- increased risk for depression & anxiety[65]
- cognitive impairment[40][75]
- may play a role in tau accumulation in brain[66]
- autonomic dysfunction assessed by nocturnal pulse rate variability may play a role[75]
- may cause cognitive impairment in middle age[79]
- severe OSA may result in reduced slow-wave sleep, the combination associated with increased white matter hyperintensities & possibly increased risk of cognitive impairment, dementia & stroke[82]
- testosterone deficiency & secondary hypogonadism in men[80]
- increased mortality[40]
- disease interaction(s) of obstructive sleep apnea with resistant hypertension
- disease interaction(s) of obstructive sleep apnea (OSA) with insomnia
- disease interaction(s) of obstructive sleep apnea (OSA) with urinary incontinence
- disease interaction(s) of obstructive sleep apnea (OSA) with seizures
- disease interaction(s) of obstructive sleep apnea (OSA) with erectile dysfunction (ED)
- disease interaction(s) of obstructive sleep apnea (OSA) with pneumonia
- disease interaction(s) of obstructive sleep apnea with hypertension
- disease interaction(s) of obstructive sleep apnea (OSA) with heart failure
- disease interaction(s) of obstructive sleep apnea (OSA) with obesity
Differential diagnosis
- endocrine disorders
- ear, nose & throat disorders
- narcolepsy
- severe COPD
- obesity-hypoventilation syndrome
- obesity, COPD, hypercapnia during waking hours
- may occur with obstructive sleep apnea
Management
- treat underlying/associated disorders
- weight reduction in obese patients
- may mitigate symptoms[3][21][36]
- decreases serum C-reactive protein, an inflammatory marker of metabolic symdrome
- non-surgical options should be tried prior to bariatric surgery[77]
- alcohol & sedative avoidance, especially before bedtime
- avoid medications for erectile dysfunction[17] (phosphodiesterase-5-inhibitors) <see disease interactions>
- avoid testosterone replacement therapy - may exacerbate OSA[81]
- avoid supine sleep position, sleep in lateral position
- ear, nose & throat examination to identify surgically correctable signs of upper airway obstruction
- positive airway pressure for symptomatic patients[3]
- nasal continuous positive airway pressure (CPAP or APAP)[4][36]
- heated humidification may improve compliance
- CPAP may partially reverse metabolic syndrome in patients with OSA & metabolic syndrome[25]
- may reduce blood pressure in OSA patients with resistant hypertension[37]
- even patients with mild symptoms may benefit[29]
- CPAP lowers systolic blood pressure[44]
- CPAP may improve quality of life in adults with mild OSA[69]
- improves snoring, daytime sleepiness, quality of life, & mood[54]
- CPAP may improve cognitive function given the association of OSA with exacerbation of cognitive decline[40][73]
- CPAP may or may not improve cardiovascular risk[54][57]
- CPAP may diminish mortality in obese patients with severe OSA[64]
- CPAP does not lower serum C-reactive protein[44]
- CPAP does not improve glycemic control in diabetics with OSA[70]
- compliance is an issue[3]
- review data from the CPAP device in poor responders
- auto-adjusting positive airway pressure & CPAP therapeutically equivalent for reducing apnea-hypopnea index[3]
- bilevel positive airway pressure (BiPAP) may benefit patients who fail CPAP[3]
- patients who improve with CPAP or APAP & have achieved significant weight reduction should be retested with a home sleep apnea test
- nasal continuous positive airway pressure (CPAP or APAP)[4][36]
- oral appliances[5]
- elevation of soft palate
- advancement of tongue or mandible anteriorly (mandibular advance device)[36]
- objective benefit in 50% of patients with moderate OSA
- greater patient satisfaction
- almost as effective as CPAP[24]
- often better tolerated than CPAP[33]
- CPAP & mandibular advance devices affer similar reductions in blood pressure systolic BP (-2.5 mm Hg), diastolic BP (-2.0 mm Hg)[49]
- oropharyngeal exercises may be of benefit
- compression stockings may benefit patients with peripheral edema
- pharmaceutical agents
- glucocorticoid nasal spray may benefit children[6]
- fluticasone 1 spray each nostril BID
- modafanil (Provigil) may be helpful for patients with excessive daytime sleepiness despite CPAP[7]
- acetazolamide 750 mg PO QD helpful adjunct to CPAP for short trips to altitudes of 1600-2600 meters[30]
- ramelteon improves objective but not subjective sleep onset latency in patients with OSA on CPAP
- protriptyline not consistently effective in clinical trials
- mirtazapine not consistently effective in clinical trials[40][43]
- glucocorticoid nasal spray may benefit children[6]
- supplemental oxygen is not recommended as a primary therapy for OSA[3]
- surgery[41]
- tracheostomy
- life-threatening hypoxemia
- life-threatening cardiac arrhythmia
- disabling hypersomnolence
- intolerance of or non-compliance with other therapies
- maxillomandibular advancement surgery improves apnea-hypopnea index
- uvulopalatopharyngoplasty (uvula & palate resection)
- objective improvement in 40% of patients
- no selection criteria identifies patients likely to benefit
- laser-assisted uvulopalatoplasty may reduce snoring, but does not benefit OSA
- is a recommended surgical option for treatment of OSA[3]
- combined palatal & tongue surgery[71]
- staged genioglossal & maxillo-mandibular advancement
- objective improvement in 40% of patients
- limited centers with surgical experience
- hyoid myotomy & suspension
- tonsillectomy & adenoidectomy (children)[8][28] & in adults with tonsillar hypertrophy[40]
- cryolipolysis (cool sculpting) of tongue suggested[67]
- tracheostomy
- hypoglossal nerve-stimulating device for OSA not responsive to CPAP[38]
- hypoglossal nerve stimulation improves insomnia, sleepiness, quality of life, & depressive symptoms comparable to CPAP[72]
- higher body mass index & supine sleeping position may decrease effects[86]
- transcutaneous electrical stimulation of the submental area in patients with obstructive sleep apnea & poor compliance with CPAP can improve sleep apnea severity & associated sleepiness[83]
- screening for obstructive sleep apnea
- recommended prior to non-emergency surgery (see STOP-BANG)
- insufficient evidence to recommend for or against routine screening (USPSTF)[56]
Notes
- non-specialists can manage obstructive sleep apnea[60]
- blistering report from AHRQ
- studies are highly inconsistent in definition of breathing measures during sleep studies & of obstructive sleep apnea itself[76]
- insufficient evidence exists to assess the validity of change in apnea-hypopnea index as a surrogate or intermediate measure for long-term health outcomes[76]
- randomized controlled trials do not provide evidence that CPAP affects long-term, clinically important outcomes[76]
More general terms
More specific terms
Additional terms
- apnea-hypopnea index
- polysomnography (PSG)
- screening for obstructive sleep apnea
- sleep-related hypoventilation syndrome
- STOP BANG (STOP Questionnaire)
References
- ↑ Manual of Medical Therapeutics, 28th ed, Ewald & McKenzie (eds), Little, Brown & Co, Boston, 1995, pg 257-58
- ↑ Saunders Manual of Medical Practice, Rakel (ed), WB Saunders, Philadelphia, 1996, pg 1087-90
- ↑ 3.00 3.01 3.02 3.03 3.04 3.05 3.06 3.07 3.08 3.09 3.10 3.11 3.12 3.13 3.14 Medical Knowledge Self Assessment Program (MKSAP) 11, 14, 15, 16, 17, 18, 19. American College of Physicians, Philadelphia 1998, 2006, 2009, 2012, 2015, 2018, 2022.
Medical Knowledge Self Assessment Program (MKSAP) 19 Board Basics. An Enhancement to MKSAP19. American College of Physicians, Philadelphia 2022 - ↑ 4.0 4.1 Journal Watch 21(13):107, 2001 Barbe F et al Treatment with continuous positive airway pressure is not effective in patients with sleep apnea but no daytime sleepiness. a randomized, controlled trial. Ann Intern Med 134:1015, 2001 PMID: https://www.ncbi.nlm.nih.gov/pubmed/11388814
Pack AI & Maislin G Who should get treated for sleep apnea? Ann Intern Med 134:1065, 2001 PMID: https://www.ncbi.nlm.nih.gov/pubmed/11388820 - ↑ 5.0 5.1 Journal Watch 21(13):108, 2001 Mehta A et al A randomized, controlled study of a mandibular advancement splint for obstructive sleep apnea. J Respir Crit Car Med 163:1457, 2001 PMID: https://www.ncbi.nlm.nih.gov/pubmed/11371418
- ↑ 6.0 6.1 Journal Watch 21(14):117, 2001 Brouillete RT et al Efficacy of fluticasone nasal spray for pediatric obstructive sleep apnea. J Pediatr 138:838, 2001 PMID: https://www.ncbi.nlm.nih.gov/pubmed/11391326 Marcus CL, Nasal steroids as treatment for obstructive sleep apnea: Don't throw away the scalpel yet. J Pediatr 138:795, 2001 PMID: https://www.ncbi.nlm.nih.gov/pubmed/11391318
- ↑ 7.0 7.1 Journal Watch 22(2):17, 2002 Pack AI et al Modafinil as adjunct therapy for daytime sleepiness in obstructive sleep apnea. Am J Respir Crit Care Med 164:1675, 2001 PMID: https://www.ncbi.nlm.nih.gov/pubmed/11719309
- ↑ 8.0 8.1 Journal Watch 24(15):122, 2004 Goldstein NA, Pugazhendhi V, Rao SM, Weedon J, Campbell TF, Goldman AC, Post JC, Rao M. Clinical assessment of pediatric obstructive sleep apnea. Pediatrics. 2004 Jul;114(1):33-43. PMID: https://www.ncbi.nlm.nih.gov/pubmed/15231905
Chervin RD, Ruzicka DL, Giordani BJ, Weatherly RA, Dillon JE, Hodges EK, Marcus CL, Guire KE. Sleep-disordered breathing, behavior, and cognition in children before and after adenotonsillectomy. Pediatrics. 2006 Apr;117(4):e769-78. PMID: https://www.ncbi.nlm.nih.gov/pubmed/16585288
Marcus CL et al A Randomized Trial of Adenotonsillectomy for Childhood Sleep Apnea. N Engl J Med. May 21, 2013 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/23616163 <Internet> http://www.nejm.org/doi/full/10.1056/NEJMoa1215881
Brouillette RT Let's CHAT about Adenotonsillectomy N Engl J Med. May 21, 2013 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/23692171 <Internet> http://www.nejm.org/doi/full/10.1056/NEJMe1305492 - ↑ 9.0 9.1 Journal Watch 25(10):79, 2005 Marin JM, Carrizo SJ, Vicente E, Agusti AG. Long-term cardiovascular outcomes in men with obstructive sleep apnoea-hypopnoea with or without treatment with continuous positive airway pressure: an observational study. Lancet. 2005 Mar 16;365(9464):1046-53. PMID: https://www.ncbi.nlm.nih.gov/pubmed/15781100
- ↑ 10.0 10.1 Senn O, Brack T, Russi EW, Bloch KE. A continuous positive airway pressure trial as a novel approach to the diagnosis of the obstructive sleep apnea syndrome. Chest. 2006 Jan;129(1):67-75. PMID: https://www.ncbi.nlm.nih.gov/pubmed/16424414
Collop NA. Blue light special on CPAP, aisle 11. Chest. 2006 Jan;129(1):6-7. No abstract available. PMID: https://www.ncbi.nlm.nih.gov/pubmed/16424404 - ↑ 11.0 11.1 Arzt M et al, Association of sleep-disordered breathing and the occurrence of stroke. Am J Respir Crit Care Med 2005, 172:1447 PMID: https://www.ncbi.nlm.nih.gov/pubmed/16141444
- ↑ Kushida CA, Morgenthaler TI, Littner MR, Alessi CA, Bailey D, Coleman J Jr, Friedman L, Hirshkowitz M, Kapen S, Kramer M, Lee-Chiong T, Owens J, Pancer JP; American Academy of Sleep. Practice parameters for the treatment of snoring and Obstructive Sleep Apnea with oral appliances: an update for 2005. Sleep. 2006 Feb 1;29(2):240-3. <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/16494092 <Internet> http://www.aasmnet.org/PDF/PracParam_OralAppliance05.pdf
- ↑ Institute for Clinical Systems Improvement (ICSI) Diagnosis and treatment of obstructive sleep apnea http://www.icsi.org/knowledge/browse_bydate.asp?catID=29
NINDS Sleep Apnea Information Page https://www.ninds.nih.gov/Disorders/All-Disorders/Sleep-Apnea-Information-Page
What Is Sleep Apnea? http://www.nhlbi.nih.gov/health/dci/Diseases/SleepApnea/SleepApnea_WhatIs.html - ↑ The American Academy of Sleep Medicine (AASM): Practice parameters for the use of continuous and bilevel positive airway pressure devices to treat adult patients with sleep- related breathing disorders Guideline withdrawn (Dec 2011)
- ↑ [No authors listed] Practice guidelines for the perioperative management of patients with obstructive sleep apnea: a report by the american society of anesthesiologists task force on perioperative management of patients with obstructive sleep apnea. Anesthesiology. 2006 May;104(5):1081-93. No abstract available. <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/16645462 <Internet> http://www.anesthesiology.org/pt/re/anes/fulltext.00000542-200605000-00026.htm
- ↑ Yoshinaga K et al, The effects of continuous positive airway pressure on myocardial energetics in patients with heart failure and obstructive sleep apnea. J Am Coll Cardiol 2007, 49:450 PMID: https://www.ncbi.nlm.nih.gov/pubmed/17258090
Chareonthaitawee P and Somers V Continuous positive airway pressure and increased ejection fraction in heart failure and obstructive sleep apnea: Is there a metabolic cost or benefit? J Am Coll Cardiol 2007, 49:459 PMID: https://www.ncbi.nlm.nih.gov/pubmed/17258091 - ↑ 17.0 17.1 17.2 Prescriber's Letter 15(10): 2008 COMMENTARY: Medications that Can Exacerbate Sleep Apnea GUIDELINES: Sleep Apnea and Cardiovascular Disease
Somers VK et al, American Heart Association Council for High Blood Pressure Research Professional Education Committee, Council on Clinical Cardiology; American Heart Association Stroke Council; American Heart Association Council on Cardiovascular Nursing; American College of Cardiology Foundation. Sleep apnea and cardiovascular disease: an American Heart Association/American College Of Cardiology Foundation Scientific Statement from the American Heart Association Council for High Blood Pressure Research Professional Education Committee, Council on Clinical Cardiology, Stroke Council, and Council On Cardiovascular Nursing. In collaboration with the National Heart, Lung, and Blood Institute National Center on Sleep Disorders Research (National Institutes of Health). Circulation. 2008 Sep 2;118(10):1080-111. Epub 2008 Aug 25. PMID: https://www.ncbi.nlm.nih.gov/pubmed/18725495
Somers VK et al Sleep apnea and cardiovascular disease: an American Heart Association/American College of Cardiology Foundation Scientific Statement from the American Heart Association Council for High Blood Pressure Research Professional Education Committee, Council on Clinical Cardiology, Stroke Council, and Council on Cardiovascular Nursing. J Am Coll Cardiol. 2008 Aug 19;52(8):686-717 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/18702977 <Internet> http://content.onlinejacc.org/cgi/reprint/52/8/686 GUIDELINES: Diagnosis and Treatment of Sleep Apnea 2008 Update (Canadian) http://www.lung.ca/cts-sct/pdf/1000_THO_SleepApnea_v10.pdf GUIDELINES: Diagnosis and Treatment of Sleep Disordered Breathing in Adults
Fleetham J et al; CTS Sleep Disordered Breathing Committee. Canadian Thoracic Society guidelines: diagnosis and treatment of sleep disordered breathing in adults. Can Respir J. 2006 Oct;13(7):387-92. <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/17036094 <Internet> http://www.lung.ca/pdf/Sleep-Exec-Summary.pdf Detail-Document#: http://prescribersletter.com/(5bhgn1a4ni4cyp2tvybwfh55)/pl/ArticleDD.aspx?li=1&st=1&cs=&s=PRL&pt=3&fpt=25&dd=241007&pb=PRL (subscription needed) http://www.prescribersletter.com - ↑ Macey PM et al. Brain structural changes in obstructive sleep apnea. Sleep 2008 Jul 1; 31:967. PMID: https://www.ncbi.nlm.nih.gov/pubmed/18652092
- ↑ 19.0 19.1 Vakulin A et al, Effects of Alcohol and Sleep Restriction on Simulated Driving Performance in Untreated Patients With Obstructive Sleep Apnea Annals of Internal Medicine 2009 151:447 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/19805768 <Internet> http://www.annals.org/cgi/content/abstract/151/7/447
- ↑ Epstein LJ et al, Clinical Guideline for the Evaluation, Management and Long-term Care of Obstructive Sleep Apnea in Adults Journal of Clinical Sleep Medicine 2009, 5(3):263 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/19960649 <Internet> http://www.aasmnet.org/Resources/ClinicalGuidelines/OSA_Adults.pdf
- ↑ 21.0 21.1 Johansson K et al Effect of a very low energy diet on moderate and severe obstructive sleep apnoea in obese men: A randomised controlled trial. BMJ 2009 Dec 3; 339:b4609 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/19959590 <Internet> http://dx.doi.org/10.1136/bmj.b4609
- ↑ 22.0 22.1 Arzt M et al. Dissociation of obstructive sleep apnea from hypersomnolence and obesity in patients with stroke. Stroke 2010 Mar; 41:e129. PMID: https://www.ncbi.nlm.nih.gov/pubmed/20075361
- ↑ Redolfi S et al. Attenuation of obstructive sleep apnea by compression stockings in subjects with venous insufficiency. Am J Respir Crit Care Med 2011 Nov 1; 184:1062. PMID: https://www.ncbi.nlm.nih.gov/pubmed/21836140
- ↑ 24.0 24.1 Holley AB et al. Efficacy of an adjustable oral appliance and comparison with continuous positive airway pressure for the treatment of obstructive sleep apnea syndrome. Chest 2011 Dec; 140:1511 PMID: https://www.ncbi.nlm.nih.gov/pubmed/21636666
- ↑ 25.0 25.1 Sharma SK et al. CPAP for the metabolic syndrome in patients with obstructive sleep apnea. N Engl J Med 2011 Dec 15; 365:2277 PMID: https://www.ncbi.nlm.nih.gov/pubmed/22168642
- ↑ 26.0 26.1 Campos-Rodriguez F et al. Cardiovascular mortality in women with obstructive sleep apnea with or without continuous positive airway pressure treatment: A cohort study. Ann Intern Med 2012 Jan 17; 156:115. PMID: https://www.ncbi.nlm.nih.gov/pubmed/22250142
- ↑ 27.0 27.1 Marin JM et al Association Between Treated and Untreated Obstructive Sleep Apnea and Risk of Hypertension JAMA. 2012;307(20):2169-2176 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/22618924 <Internet> http://jama.jamanetwork.com/article.aspx?articleID=1167315
Barbe F et al 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. 2012;307(20):2161-2168 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/22618923 <Internet> http://jama.jamanetwork.com/article.aspx?articleid=1167316
Kapur VK and Weaver EM Filling in the Pieces of the Sleep Apnea-Hypertension Puzzle JAMA. 2012;307(20):2197-2198 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/22618928 <Internet> http://jama.jamanetwork.com/article.aspx?articleid=1167316 - ↑ 28.0 28.1 Marcus CL et al Diagnosis and Management of Childhood Obstructive Sleep Apnea Syndrome Pediatrics, August 27, 2012 http://pediatrics.aappublications.org/content/early/2012/08/22/peds.2012-1671.full.pdf+html (corresponding NGC guideline withdrawn Nov 2017)
- ↑ 29.0 29.1 Weaver TE et al. 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 2012 Oct 1; 186:677 PMID: https://www.ncbi.nlm.nih.gov/pubmed/22837377
- ↑ 30.0 30.1 Latshang TD Effect of Acetazolamide and AutoCPAP Therapy on Breathing Disturbances Among Patients With Obstructive Sleep Apnea Syndrome Who Travel to Altitude. A Randomized Controlled Trial. JAMA. 2012;308(22):2390-2398 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/23232895 <Internet> http://jama.jamanetwork.com/article.aspx?articleid=1484516
- ↑ Vasu TS, Doghramji K, Cavallazzi R et al Obstructive sleep apnea syndrome and postoperative complications: clinical use of the STOP-BANG questionnaire. Arch Otolaryngol Head Neck Surg. 2010 Oct;136(10):1020-4 PMID: https://www.ncbi.nlm.nih.gov/pubmed/20956751
- ↑ Chai-Coetzer CL et al. Primary care vs specialist sleep center management of obstructive sleep apnea and daytime sleepiness and quality of life: A randomized trial. JAMA 2013 Mar 13; 309:997. PMID: https://www.ncbi.nlm.nih.gov/pubmed/23483174
- ↑ 33.0 33.1 Phillips CL et al. 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 2013 Apr 15; 187:879 PMID: https://www.ncbi.nlm.nih.gov/pubmed/23413266
- ↑ 34.0 34.1 Shah BR et al Use of Stress Testing and Diagnostic Catheterization after Coronary Stenting: Association of Site-level Patterns with Patient Characteristics and Outcomes in 247,052 Medicare Beneficiaries. J Am Coll Cardiol. Published online June 5, 2013. <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/23727207 <Internet> http://content.onlinejacc.org/Onlinefirst.aspx
- ↑ 35.0 35.1 Gami AS et al. Obstructive sleep apnea and the risk of sudden cardiac death: A longitudinal study of 10,701 adults. J Am Coll Cardiol 2013 Jun 12 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/23770166 <Internet> http://www.sciencedirect.com/science/article/pii/S0735109713022511
- ↑ 36.0 36.1 36.2 36.3 Qaseem A et al Management of Obstructive Sleep Apnea in Adults: A Clinical Practice Guideline From the American College of Physicians. Ann Intern Med. Published online 24 September 2013 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/24061345 <Internet> http://annals.org/article.aspx?articleid=1740756
- ↑ 37.0 37.1 Martinez-Garcia MA 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 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/24327037 <Internet> http://jama.jamanetwork.com/article.aspx?articleid=1788459
- ↑ 38.0 38.1 38.2 Strollo PJ et al Upper-Airway Stimulation for Obstructive Sleep Apnea. N Engl J Med 2014; 370:139-149January 9, 2014 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/24401051 <Internet> http://www.nejm.org/doi/full/10.1056/NEJMoa1308659
Malhotra A Hypoglossal-Nerve Stimulation for Obstructive Sleep Apnea. N Engl J Med 2014; 370:170-171January 9, 2014 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/24401056 <Internet> http://www.nejm.org/doi/full/10.1056/NEJMe1314084 - ↑ 39.0 39.1 Yi-Fong Su V, Liu CJ, Wang HK et al Sleep apnea and risk of pneumonia: a nationwide population- based study. CMAJ March 3, 2014 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/24591276 <Internet> http://www.cmaj.ca/content/early/2014/03/03/cmaj.131547
- ↑ 40.00 40.01 40.02 40.03 40.04 40.05 40.06 40.07 40.08 40.09 40.10 Geriatric Review Syllabus, 8th edition (GRS8) Durso SC and Sullivan GN (eds) American Geriatrics Society, 2013
Geriatric Review Syllabus, 11th edition (GRS11) Harper GM, Lyons WL, Potter JF (eds) American Geriatrics Society, 2022 - ↑ 41.0 41.1 Aurora RN, Casey KR, Kristo D et al Practice parameters for the surgical modifications of the upper airway for obstructive sleep apnea in adults. Sleep. 2010 Oct;33(10):1408-13. Review. PMID: https://www.ncbi.nlm.nih.gov/pubmed/21061864 (corresponding NGC guideline withdrawn Nov 2015)
- ↑ Kushida CA, Chediak A, Berry RB et al Clinical guidelines for the manual titration of positive airway pressure in patients with obstructive sleep apnea. J Clin Sleep Med. 2008 Apr 15;4(2):157-71. PMID: https://www.ncbi.nlm.nih.gov/pubmed/18468315
- ↑ 43.0 43.1 Marshall NS, Yee BJ, Desai AV et al Two randomized placebo-controlled trials to evaluate the efficacy and tolerability of mirtazapine for the treatment of obstructive sleep apnea. Sleep. 2008 Jun;31(6):824-31. PMID: https://www.ncbi.nlm.nih.gov/pubmed/18548827
- ↑ 44.0 44.1 44.2 44.3 Sofair A and Chavey WE CPAP Addresses Some, But Not All, Cardiovascular Risks from Sleep Apnea Physician's First Watch, June 13 2014 David G. Fairchild, MD, MPH, Editor-in-Chief Massachusetts Medical Society http://www.jwatch.org
Gottlieb DJ et al CPAP versus Oxygen in Obstructive Sleep Apnea. N Engl J Med 2014; 370:2276-2285 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/24918372 <Internet> http://www.nejm.org/doi/full/10.1056/NEJMoa1306766
Chirinos JA et al CPAP, Weight Loss, or Both for Obstructive Sleep Apnea. N Engl J Med 2014; 370:2265-2275 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/24918371 <Internet> http://www.nejm.org/doi/full/10.1056/NEJMoa1306187
Basner RC Cardiovascular Morbidity and Obstructive Sleep Apnea. N Engl J Med 2014; 370:2339-2341 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/24918377 <Internet> http://www.nejm.org/doi/full/10.1056/NEJMe1404501 - ↑ 45.0 45.1 Qaseem A et al Diagnosis of Obstructive Sleep Apnea in Adults: A Clinical Practice Guideline From the American College of Physicians. Ann Intern Med. 2014;161(3):210-220 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/25089864 <Internet> http://annals.org/article.aspx?articleid=1892620
- ↑ 46.0 46.1 Moser M, Setaro JF. Clinical practice. Resistant or difficult-to-control hypertension. N Engl J Med 2006 Jul 28; 355:385. PMID: https://www.ncbi.nlm.nih.gov/pubmed/16870917
Myat A et al. Resistant hypertension. BMJ 2012 Nov 22; 345:e7473. PMID: https://www.ncbi.nlm.nih.gov/pubmed/23169802 - ↑ 47.0 47.1 Teodorescu M et al Association Between Asthma and Risk of Developing Obstructive Sleep Apnea. JAMA. 2015;313(2):156-164 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/25585327 <Internet> http://jama.jamanetwork.com/article.aspx?articleid=2089354
- ↑ 48.0 48.1 48.2 Attal P, Chanson P. Endocrine aspects of obstructive sleep apnea. J Clin Endocrinol Metab. 2010 Feb;95(2):483-95. Review. PMID: https://www.ncbi.nlm.nih.gov/pubmed/20061419
- ↑ 49.0 49.1 Bratton DJ et al CPAP vs Mandibular Advancement Devices and Blood Pressure in Patients With Obstructive Sleep ApneaA Systematic Review and Meta-analysis. JAMA. 2015;314(21):2280-2293 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/26624827 <Internet> http://jama.jamanetwork.com/article.aspx?articleid=2473494
- ↑ Zaghi S et al. Maxillomandibular advancement for treatment of obstructive sleep apnea: A meta-analysis. JAMA Otolaryngol Head Neck Surg 2015 Nov 25 PMID: https://www.ncbi.nlm.nih.gov/pubmed/26606321
- ↑ Caples SM, Rowley JA, Prinsell JR et al Surgical modifications of the upper airway for obstructive sleep apnea in adults: a systematic review and meta-analysis. Sleep. 2010 Oct;33(10):1396-407. Review. PMID: https://www.ncbi.nlm.nih.gov/pubmed/21061863 Free PMC Article
- ↑ Jordan AS, McSharry DG, Malhotra A. Adult obstructive sleep apnoea. Lancet. 2014 Feb 22;383(9918):736-47. Review. PMID: https://www.ncbi.nlm.nih.gov/pubmed/23910433 Free PMC Article
- ↑ American Society of Anesthesiologists Task Force on Perioperative Management of patients with obstructive sleep apnea. Practice guidelines for the perioperative management of patients with obstructive sleep apnea: an updated report by the American Society of Anesthesiologists Task Force on Perioperative Management of patients with obstructive sleep apnea. Anesthesiology. 2014 Feb;120(2):268-86 PMID: https://www.ncbi.nlm.nih.gov/pubmed/24346178
- ↑ 54.0 54.1 54.2 Peker Y, Glantz H, Eulenburg C et al. Effect of positive airway pressure on cardiovascular outcomes in coronary artery disease patients with nonsleepy obstructive sleep apnea: The RICCADSA randomized controlled trial. Am J Respir Crit Care Med 2016 Sep 1; 194:613. <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/26914592 <Internet> http://www.atsjournals.org/doi/10.1164/rccm.201601-0088OC#.V9LDA7WEtRk
Parthasarathy S. The positive and negative about positive airway pressure therapy. Am J Respir Crit Care Med 2016 Sep 1; 194:535 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/27585380 <Internet> http://www.atsjournals.org/doi/10.1164/rccm.201603-0484ED#.V9LDKLWEtRk - ↑ 55.0 55.1 55.2 55.3 55.4 55.5 Kapur VK, Auckley DH, Chowdhuri S et al Clinical Practice Guideline for Diagnostic Testing for Adult Obstructive Sleep Apnea: An American Academy of Sleep Medicine Clinical Practice Guideline. J Clin Sleep Med. 13(3):479-504 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/28162150 <Internet> http://www.aasmnet.org/jcsm/ViewAbstract.aspx?pid=30972
- ↑ 56.0 56.1 U.S. Preventive Services Task Force (USPSTF) Clinical Summary, Obstructive Sleep Apnea in Adults: Screening. https://www.uspreventiveservicestaskforce.org/Page/Document/ClinicalSummaryFinal/obstructive-sleep-apnea-in-adults-screening
- ↑ 57.0 57.1 Yu J, Zhou Z, McEvoy RD et al. Association of positive airway pressure with cardiovascular events and death in adults with sleep apnea: A systematic review and meta-analysis. JAMA 2017 Jul 11; 318:156. PMID: https://www.ncbi.nlm.nih.gov/pubmed/28697252
Gottlieb DJ. Does obstructive sleep apnea treatment reduce cardiovascular risk? It is far too soon to say. JAMA 2017 Jul 11; 318:128. PMID: https://www.ncbi.nlm.nih.gov/pubmed/28697240 - ↑ 58.0 58.1 58.2 Corral J, Sanchez-Quiroga MA, Carmona-Bernal C et al. Conventional polysomnography is not necessary for the management of most patients with suspected obstructive sleep apnea: Noninferiority, randomized controlled trial. Am J Respir Crit Care Med 2017 Nov 1; 196:1181-1190. PMID: https://www.ncbi.nlm.nih.gov/pubmed/28636405
Chai-Coetzer CL, McEvoy RD. The debate should now be over: Simplified cardiorespiratory sleep tests are a reliable, cost-saving option for diagnosing obstructive sleep apnea. Am J Respir Crit Care Med. 2017 Nov 1;196(9):1096-1098 PMID: https://www.ncbi.nlm.nih.gov/pubmed/28661700 - ↑ 59.0 59.1 59.2 Mokhlesi B, Cifu AS Diagnostic Testing for Obstructive Sleep Apnea in Adults. JAMA. 2017;318(20):2035-2036 PMID: https://www.ncbi.nlm.nih.gov/pubmed/29183053 https://jamanetwork.com/journals/jama/fullarticle/2664436
- ↑ 60.0 60.1 Kunisaki KM, Greer N, Khalil W et al Provider Types and Outcomes in Obstructive Sleep Apnea Case Finding and Treatment: A Systematic Review. Ann Intern Med. 2018. Jan 30. <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/29379962 <Internet> http://annals.org/aim/article-abstract/2671030/provider-types-outcomes-obstructive-sleep-apnea-case-finding-treatment-systematic
- ↑ Gagnon K, Baril AA, Gagnon JF et al Cognitive impairment in obstructive sleep apnea. Pathol Biol (Paris). 2014 Oct;62(5):233-40. Review. PMID: https://www.ncbi.nlm.nih.gov/pubmed/25070768
- ↑ Balachandran JS, Patel SR. In the clinic. Obstructive sleep apnea. Ann Intern Med. 2014 Nov 4;161(9):ITC1-15; Review. PMID: https://www.ncbi.nlm.nih.gov/pubmed/25364899
- ↑ Veasey SC, Rosen IM Obstructive Sleep Apnea in Adults. N Engl J Med 2019; 380:1442-1449. April 11. PMID: https://www.ncbi.nlm.nih.gov/pubmed/30970189 https://www.nejm.org/doi/full/10.1056/NEJMcp1816152
- ↑ 64.0 64.1 Lisan Q, Van Sloten T, Marques Vidal P et al Association of Positive Airway Pressure Prescription With Mortality in Patients With Obesity and Severe Obstructive Sleep Apnea. The Sleep Heart Health Study. JAMA Otolaryngol Head Neck Surg. Published online April 11, 2019. PMID: https://www.ncbi.nlm.nih.gov/pubmed/30973594 https://jamanetwork.com/journals/jamaotolaryngology/fullarticle/2730379
Kushida CA. Positive Airway Pressure and Survival in Patients With Obstructive Sleep Apnea. JAMA Otolaryngol Head Neck Surg. Published online April 11, 2019. PMID: https://www.ncbi.nlm.nih.gov/pubmed/30973600 https://jamanetwork.com/journals/jamaotolaryngology/fullarticle/2730377 - ↑ 65.0 65.1 Kim JY, Ko I, Kim DK. Association of Obstructive Sleep Apnea With the Risk of Affective Disorders. JAMA Otolaryngol Head Neck Surg. September 12, 2019. PMID: https://www.ncbi.nlm.nih.gov/pubmed/31513273 https://jamanetwork.com/journals/jamaotolaryngology/article-abstract/2749521
- ↑ 66.0 66.1 Brooks M Sleep Apnea Tied to Higher Levels of Alzheimer Protein. Medscape - Mar 05, 2019. https://www.medscape.com/viewarticle/909889
- ↑ 67.0 67.1 67.2 Wang SH, Keenan BT, Wiemken A et al Effect of Weight Loss on Upper Airway Anatomy and the Apnea Hypopnea Index: The Importance of Tongue Fat. Am J Resp Crit Care Med, January 10, 2020 PMID: https://www.ncbi.nlm.nih.gov/pubmed/31918559 https://www.atsjournals.org/doi/abs/10.1164/rccm.201903-0692OC
- ↑ 68.0 68.1 Sanchez-de-la-Torre M, Sanchez-de-la-Torre A, Bertran S et al. Effect of obstructive sleep apnoea and its treatment with continuous positive airway pressure on the prevalence of cardiovascular events in patients with acute coronary syndrome (ISAACC study): A randomised controlled trial. Lancet Respir Med 2020 Apr; 8:359-367 PMID: https://www.ncbi.nlm.nih.gov/pubmed/31839558 https://www.thelancet.com/pdfs/journals/lanres/PIIS2213-2600(19)30271-1.pdf
- ↑ 69.0 69.1 69.2 Soloway B CPAP Might Improve Symptoms in Mild Obstructive Sleep Apnea. NEJM Journal Watch. April 21, 2020 Massachusetts Medical Society (subscription needed) http://www.jwatch.org
Wimms AJ et al. Continuous positive airway pressure versus standard care for the treatment of people with mild obstructive sleep apnoea (MERGE): A multicentre, randomised controlled trial. Lancet Respir Med 2020 Apr; 8:349. PMID: https://www.ncbi.nlm.nih.gov/pubmed/31806413 https://www.thelancet.com/pdfs/journals/lanres/PIIS2213-2600(19)30402-3.pdf
McNicholas WT. Active management of mild obstructive sleep apnoea: The evidence grows. Lancet Respir Med 2020 Apr; 8:322 PMID: https://www.ncbi.nlm.nih.gov/pubmed/31806412 https://www.thelancet.com/pdfs/journals/lanres/PIIS2213-2600(19)30447-3.pdf - ↑ 70.0 70.1 Loffler KA et al. Continuous positive airway pressure treatment, glycemia, and diabetes risk in obstructive sleep apnea and comorbid cardiovascular disease. Diabetes Care 2020 Aug; 43:1859. https://care.diabetesjournals.org/content/43/8/1859
- ↑ 71.0 71.1 MacKay S, Carney AS, Catcheside PG et al Effect of Multilevel Upper Airway Surgery vs Medical Management on the Apnea-Hypopnea Index and Patient-Reported Daytime Sleepiness Among Patients With Moderate or Severe Obstructive Sleep Apnea. The SAMS Randomized Clinical Trial. JAMA. Published online September 4, 2020. PMID: https://www.ncbi.nlm.nih.gov/pubmed/32886102 https://jamanetwork.com/journals/jama/fullarticle/2770361
Mansukhani MP, Olson EJ, Caples SM. Upper Airway Surgery for Obstructive Sleep Apnea. JAMA. Published online September 4, 2020. PMID: https://www.ncbi.nlm.nih.gov/pubmed/32886089 https://jamanetwork.com/journals/jama/fullarticle/2770360 - ↑ 72.0 72.1 Pascoe M, Wang L, Aylor J et al Association of Hypoglossal Nerve Stimulation With Improvements in Long-term, Patient-Reported Outcomes and Comparison With Positive Airway Pressure for Patients With Obstructive Sleep Apnea. JAMA Otolaryngol Head Neck Surg. Published online November 11, 2021. PMID: https://www.ncbi.nlm.nih.gov/pubmed/34762105 https://jamanetwork.com/journals/jamaotolaryngology/fullarticle/2785872
- ↑ 73.0 73.1 Gosselin N, Baril AA, Osorio RS et al. Obstructive sleep apnea and the risk of cognitive decline in older adults. Am J Respir Crit Care Med. 2019;199(2):142-148 PMID: https://www.ncbi.nlm.nih.gov/pubmed/30113864 PMCID: PMC6943882 Free PMC article https://www.atsjournals.org/doi/10.1164/rccm.201801-0204PP
- ↑ Braley TJ, Dunietz GL, Chervin RD et al. Recognition and diagnosis of obstructive sleep apnea in older Americans. J Am Geriatr Soc. 2018;66(7):1296-1302 PMID: https://www.ncbi.nlm.nih.gov/pubmed/29744855 PMCID: PMC6097901 Free PMC article https://agsjournals.onlinelibrary.wiley.com/doi/10.1111/jgs.15372
- ↑ 75.0 75.1 75.2 75.3 75.4 Sabil A, Blanchard M, Annweiler C et al Overnight pulse rate variability and risk of major neurocognitive disorder in older patients with obstructive sleep apnea. J Am Ger Soc. 2022. Nov;70(11):3127-3137. Online: June 20 https://agsjournals.onlinelibrary.wiley.com/doi/10.1111/jgs.17933
Miner B, Zinchuk A. Obstructive sleep apnea pathophysiology: A key to understanding obstructive sleep apnea's impact on older adults. J Am Ger Soc. 2022, Sept 22 PMID: https://www.ncbi.nlm.nih.gov/pubmed/36128735 https://agsjournals.onlinelibrary.wiley.com/doi/full/10.1111/jgs.18026 - ↑ 76.0 76.1 76.2 76.3 Balk EM, Adam GP, Cao W et al Long-Term Health Outcomes in Obstructive Sleep Apnea: A Systematic Review of Comparative Studies Evaluating Positive Airway Pressure and the Validity of Breathing Measures as Surrogate Outcomes. AHRQ: Technology Assessment Program. Dec 1, 2022 https://www.ahrq.gov/sites/default/files/wysiwyg/research/findings/ta/sleep-apnea/sleep-apnea-report.pdf
Appendix A. Methods https://www.ahrq.gov/sites/default/files/wysiwyg/research/findings/ta/sleep-apnea/sleep-apnea-appendix.pdf - ↑ 77.0 77.1 Ramar K, Dort LC, Katz SG et al Clinical Practice Guideline for the Treatment of Obstructive Sleep Apnea and Snoring with Oral Appliance Therapy: An Update for 2015. J Clin Sleep Med 2015;11(7):773-827 PMID: https://www.ncbi.nlm.nih.gov/pubmed/26094920 PMCID: PMC4481062 Free PMC article
- ↑ 78.0 78.1 Whitlock Burton K Disordered Sleep Tied to a Marked Increase in Stroke Risk. Medscape. April 10, 2023 https://www.medscape.com/viewarticle/990611
Mc Carthy CE, Yusuf S, Judge S et al Sleep Patterns and the Risk of Acute Stroke: Results from the INTERSTROKE International Case-Control Study. Neurology. 2023. April 5 PMID: https://www.ncbi.nlm.nih.gov/pubmed/37019662 https://n.neurology.org/content/early/2023/04/05/WNL.0000000000207249 - ↑ 79.0 79.1 Gnoni V, Mesquita M, O'Regan D et al Distinct cognitive changes in male patients with obstructive sleep apnoea without co-morbidities. Front. Sleep, 06 April 2023 https://www.frontiersin.org/articles/10.3389/frsle.2023.1097946/full
- ↑ 80.0 80.1 Kim SD, Cho KS Obstructive Sleep Apnea and Testosterone Deficiency. World J Mens Health. 2019 Jan;37(1):12-18. PMID: https://www.ncbi.nlm.nih.gov/pubmed/29774669 PMCID: PMC6305865 Free PMC article
- ↑ 81.0 81.1 81.2 81.3 NEJM Knowledge+ Endocrinology
- ↑ 82.0 82.1 Carvalho DZ, McCarter SJ, St Louis EK et al Association of Polysomnographic Sleep Parameters With Neuroimaging Biomarkers of Cerebrovascular Disease in Older Adults With Sleep Apnea. Neurology. 2023 Jul 11;101(2):e125-e136. PMID: https://www.ncbi.nlm.nih.gov/pubmed/37164654 https://n.neurology.org/content/101/2/e125
- ↑ 83.0 83.1 Short E Noninvasive Nerve Stimulator May Ease Sleep Apnea. Intervention recipients saw apnea, oxygen desaturation, sleepiness scores improve. MedPage Today August 4, 2023 https://www.medpagetoday.com/pulmonology/sleepdisorders/105775
Ratneswaran D, Cheng M, Nasser E et al Domiciliary transcutaneous electrical stimulation in patients with obstructive sleep apnoea and limited adherence to continuous positive airway pressure therapy: a single-centre, open-label, randomised, controlled phase III trial. eClinical Medicine. ugust 03, 2023 https://www.thelancet.com/journals/eclinm/article/PIIS2589-5370(23)00289-4/fulltext - ↑ 84.0 84.1 Chung F, Memtsoudis SG, Ramachandran SK, et al. Society of Anesthesia and Sleep Medicine guidelines on preoperative screening and assessment of adult patients with obstructive sleep apnea. Anesth Analg. 2016;123:452-73. P MID: 27442772
- ↑ Kent D, Stanley J, Aurora RN et al Referral of adults with obstructive sleep apnea for surgical consultation: an American Academy of Sleep Medicine clinical practice guideline. J Clin Sleep Med. 2021 Dec 1;17(12):2499-2505. doi:http://dx.doi.org/ 10.5664/jcsm.9592. PMID: https://www.ncbi.nlm.nih.gov/pubmed/34351848 PMCID: PMC8726361 Free PMC article.
- ↑ 86.0 86.1 Patel RM, Wang HZ, Jamro EL et al Response to Hypoglossal Nerve Stimulation Changes With Body Mass Index and Supine Sleep. JAMA Otolaryngol Head Neck Surg. 2024. April 4. PMID: https://www.ncbi.nlm.nih.gov/pubmed/38573632 https://jamanetwork.com/journals/jamaotolaryngology/fullarticle/2817168