Sleep 2013

BALTIMORE – A treatment regimen combining nasal expiratory positive airway pressure with sleeping on one’s side can help manage obstructive sleep apnea, even in patients with cardiovascular comorbidities who have failed prior therapies, according to Cleveland researchers.

In a small study of 42 adults who tried this dual therapy for 1 month, 81% achieved good to optimal control of obstructive sleep apnea (OSA) and 92% reported tolerability and compliance with the Provent expiratory positive airway pressure (EPAP) device.

"Generally, continuous positive airway pressure [CPAP] is prescribed as first-line therapy because of its proven effectiveness, however adherence remains low with CPAP, with anywhere from 46% to 83% of patients still nonadherent," said Dr. Mita Deoras of University Hospitals Case Medical Center. Because of this, physicians continue to search for alternate therapies, she said at the annual meeting of the Associated Professional Sleep Societies.

Dr. Deoras and her colleagues have recruited 42 adults with OSA from an independent sleep center starting in 2010. Twenty-five (60%) of the participants were men. The average age was 61 years and the average BMI was 30.9. The majority (76%) had known cardiovascular comorbidities, including diabetes, hypertension, hyperlipidemia, and/or coronary artery disease. Ninety percent (38) had had previous treatment for their OSA, mostly with CPAP but a few with oral appliances, uvulopalatopharyngoplasty, or some combination. Fifteen percent had mild OSA, 42.5% had moderate OSA, 37.5% had severe OSA, and 5% had primary snoring.

"This study has the ability to offer an effective therapeutic option for this very common patient population."

Researchers obtained a baseline apnea-hypopnea index (AHI) from patients’ medical records. After an initial visit, participants were told about EPAP and shown how to use it, then asked to use it for 1 month. They also were asked to sleep in positions other than their backs. After the month, if patients were compliant, they came for a validation polysomnogram in which they stayed overnight at the sleep center while wearing the EPAP device and a cannula to measure nasal flow, and were encouraged to sleep in positions other than their backs.

The majority of patients had an improvement in AHI, with a mean reduction of 22.4. No statistically significant differences in improvement were seen between genders or among varying BMI levels. Sixty percent met the study condition for optimal control of OSA, defined as an AHI less than 5, and 20% met the definition of good control of OSA, defined as an AHI of 10 or less. Patients also reported a reduction in daytime sleepiness; the average Epworth Sleepiness Scale rating declined from 9.8 at baseline to 7.6.

"While we know that nasal EPAP is FDA approved for the treatment of OSA, clinicians are still often cautious against using it in patients with severe OSA or significant comorbidities," she said. And while sleep repositioning "can be as effective as CPAP in patients with position-dependent OSA, it isn’t often recommended as a first-line therapy.... This study has the ability to offer an effective therapeutic option for this very common patient population."

Study contributors were from MetroHealth Medical Center, the Cleveland Clinic Foundation, and Northcoast Clinical Trials Sleep Center. The study was funded by University Hospitals Case Medical Center. The researchers reported having no financial conflicts.

BALTIMORE – A treatment regimen combining nasal expiratory positive airway pressure with sleeping on one’s side can help manage obstructive sleep apnea, even in patients with cardiovascular comorbidities who have failed prior therapies, according to Cleveland researchers.

In a small study of 42 adults who tried this dual therapy for 1 month, 81% achieved good to optimal control of obstructive sleep apnea (OSA) and 92% reported tolerability and compliance with the Provent expiratory positive airway pressure (EPAP) device.

"Generally, continuous positive airway pressure [CPAP] is prescribed as first-line therapy because of its proven effectiveness, however adherence remains low with CPAP, with anywhere from 46% to 83% of patients still nonadherent," said Dr. Mita Deoras of University Hospitals Case Medical Center. Because of this, physicians continue to search for alternate therapies, she said at the annual meeting of the Associated Professional Sleep Societies.

Dr. Deoras and her colleagues have recruited 42 adults with OSA from an independent sleep center starting in 2010. Twenty-five (60%) of the participants were men. The average age was 61 years and the average BMI was 30.9. The majority (76%) had known cardiovascular comorbidities, including diabetes, hypertension, hyperlipidemia, and/or coronary artery disease. Ninety percent (38) had had previous treatment for their OSA, mostly with CPAP but a few with oral appliances, uvulopalatopharyngoplasty, or some combination. Fifteen percent had mild OSA, 42.5% had moderate OSA, 37.5% had severe OSA, and 5% had primary snoring.

"This study has the ability to offer an effective therapeutic option for this very common patient population."

Researchers obtained a baseline apnea-hypopnea index (AHI) from patients’ medical records. After an initial visit, participants were told about EPAP and shown how to use it, then asked to use it for 1 month. They also were asked to sleep in positions other than their backs. After the month, if patients were compliant, they came for a validation polysomnogram in which they stayed overnight at the sleep center while wearing the EPAP device and a cannula to measure nasal flow, and were encouraged to sleep in positions other than their backs.

The majority of patients had an improvement in AHI, with a mean reduction of 22.4. No statistically significant differences in improvement were seen between genders or among varying BMI levels. Sixty percent met the study condition for optimal control of OSA, defined as an AHI less than 5, and 20% met the definition of good control of OSA, defined as an AHI of 10 or less. Patients also reported a reduction in daytime sleepiness; the average Epworth Sleepiness Scale rating declined from 9.8 at baseline to 7.6.

"While we know that nasal EPAP is FDA approved for the treatment of OSA, clinicians are still often cautious against using it in patients with severe OSA or significant comorbidities," she said. And while sleep repositioning "can be as effective as CPAP in patients with position-dependent OSA, it isn’t often recommended as a first-line therapy.... This study has the ability to offer an effective therapeutic option for this very common patient population."

Study contributors were from MetroHealth Medical Center, the Cleveland Clinic Foundation, and Northcoast Clinical Trials Sleep Center. The study was funded by University Hospitals Case Medical Center. The researchers reported having no financial conflicts.

BALTIMORE – A treatment regimen combining nasal expiratory positive airway pressure with sleeping on one’s side can help manage obstructive sleep apnea, even in patients with cardiovascular comorbidities who have failed prior therapies, according to Cleveland researchers.

In a small study of 42 adults who tried this dual therapy for 1 month, 81% achieved good to optimal control of obstructive sleep apnea (OSA) and 92% reported tolerability and compliance with the Provent expiratory positive airway pressure (EPAP) device.

"Generally, continuous positive airway pressure [CPAP] is prescribed as first-line therapy because of its proven effectiveness, however adherence remains low with CPAP, with anywhere from 46% to 83% of patients still nonadherent," said Dr. Mita Deoras of University Hospitals Case Medical Center. Because of this, physicians continue to search for alternate therapies, she said at the annual meeting of the Associated Professional Sleep Societies.

Dr. Deoras and her colleagues have recruited 42 adults with OSA from an independent sleep center starting in 2010. Twenty-five (60%) of the participants were men. The average age was 61 years and the average BMI was 30.9. The majority (76%) had known cardiovascular comorbidities, including diabetes, hypertension, hyperlipidemia, and/or coronary artery disease. Ninety percent (38) had had previous treatment for their OSA, mostly with CPAP but a few with oral appliances, uvulopalatopharyngoplasty, or some combination. Fifteen percent had mild OSA, 42.5% had moderate OSA, 37.5% had severe OSA, and 5% had primary snoring.

"This study has the ability to offer an effective therapeutic option for this very common patient population."

Researchers obtained a baseline apnea-hypopnea index (AHI) from patients’ medical records. After an initial visit, participants were told about EPAP and shown how to use it, then asked to use it for 1 month. They also were asked to sleep in positions other than their backs. After the month, if patients were compliant, they came for a validation polysomnogram in which they stayed overnight at the sleep center while wearing the EPAP device and a cannula to measure nasal flow, and were encouraged to sleep in positions other than their backs.

The majority of patients had an improvement in AHI, with a mean reduction of 22.4. No statistically significant differences in improvement were seen between genders or among varying BMI levels. Sixty percent met the study condition for optimal control of OSA, defined as an AHI less than 5, and 20% met the definition of good control of OSA, defined as an AHI of 10 or less. Patients also reported a reduction in daytime sleepiness; the average Epworth Sleepiness Scale rating declined from 9.8 at baseline to 7.6.

"While we know that nasal EPAP is FDA approved for the treatment of OSA, clinicians are still often cautious against using it in patients with severe OSA or significant comorbidities," she said. And while sleep repositioning "can be as effective as CPAP in patients with position-dependent OSA, it isn’t often recommended as a first-line therapy.... This study has the ability to offer an effective therapeutic option for this very common patient population."

Study contributors were from MetroHealth Medical Center, the Cleveland Clinic Foundation, and Northcoast Clinical Trials Sleep Center. The study was funded by University Hospitals Case Medical Center. The researchers reported having no financial conflicts.

BALTIMORE – A single session of cognitive-behavioral therapy for insomnia, given in a large group format, may effectively improve sleep conditions for many healthy adults, California researchers have found.

Nearly 90% of 363 insomnia patients who attended the session reported improvements in their sleep patterns, of whom nearly a third said their insomnia had resolved, said Dr. Dennis Hwang, director of the Sleep Disorders Center at Kaiser Permanente Fontana (Calif.) Medical Center. He reported results of a retrospective analysis from his center at the annual meeting of the Associated Professional Sleep Societies.

To offer cognitive-behavioral therapy (CBT) efficiently, Dr. Hwang and his colleagues created a 2.5-hour CBT session, taught by a physician assistant (PA) to groups of 20 patients at a time. The first 2 hours of the class discuss proper sleep hygiene, sleep beliefs, relaxation techniques, and sleep restriction, and offer patients a chance to create an individual plan of action and sleep diary. The next 15 minutes of the class, taught by a PA or pharmacist, goes over basic insomnia medication education, including how to wean off insomnia medications, and the last 15-minute section of the class, taught by a PA or physical therapist, demonstrates optimal sleep positions.

"We teach patients how to sleep better by positioning pillows in certain areas and really try to get them into a neutral spine position," Dr. Hwang said. Many patients report that doing that alone helps their insomnia, he said.

Individual telephone follow-up calls are scheduled between the PA and the participants as needed, until there is an improvement in sleep patterns or the patient declines further participation.

Dr. Hwang’s group reviewed responses from patients participating between December 2010 and December 2011. There were 230 women and 133 men with an average age of 56 years. Among them, 117 had obstructive sleep apnea, 20 had restless legs syndrome, and 20 were night-shift workers; 134 took medications for insomnia and 102 took medications for depression or anxiety.

After completing the program, 321 (88%) patients said they had at least some improvement in their insomnia, and 110 (30%) said their insomnia had resolved. Twenty-five patients said they had no improvement.

Statistically significant improvements were seen in the following sleep parameters before and after the program: sleep latency (57 vs. 26 minutes); awakenings (3 vs. 1.4); and total sleep time (5 hours vs. 6.5 hours). The patients taking sleep medications decreased their use from 6.1 to 3.9 nights/week). And there was a decrease in primary care office visits in the year following the program, compared with the year before the program, from 4.3 to 3.5, an adjusted average of 1 full visit.

Most patients completed the program within 2.5 months, needing only one follow-up telephone call, Dr. Hwang said, indicating that "the class itself is effective even without follow-up." He cautioned that he could not find a good control group to match to those in the CBT program and that the office had a 30%-40% no-show rate for sessions.

An online program and weekly/biweekly interactive voice response questionnaire have been added to the therapy program since the study was completed, he said, allowing providers to single out those in need of additional follow-up.

The study was funded by his Kaiser Permanente.

BALTIMORE – A single session of cognitive-behavioral therapy for insomnia, given in a large group format, may effectively improve sleep conditions for many healthy adults, California researchers have found.

Nearly 90% of 363 insomnia patients who attended the session reported improvements in their sleep patterns, of whom nearly a third said their insomnia had resolved, said Dr. Dennis Hwang, director of the Sleep Disorders Center at Kaiser Permanente Fontana (Calif.) Medical Center. He reported results of a retrospective analysis from his center at the annual meeting of the Associated Professional Sleep Societies.

To offer cognitive-behavioral therapy (CBT) efficiently, Dr. Hwang and his colleagues created a 2.5-hour CBT session, taught by a physician assistant (PA) to groups of 20 patients at a time. The first 2 hours of the class discuss proper sleep hygiene, sleep beliefs, relaxation techniques, and sleep restriction, and offer patients a chance to create an individual plan of action and sleep diary. The next 15 minutes of the class, taught by a PA or pharmacist, goes over basic insomnia medication education, including how to wean off insomnia medications, and the last 15-minute section of the class, taught by a PA or physical therapist, demonstrates optimal sleep positions.

"We teach patients how to sleep better by positioning pillows in certain areas and really try to get them into a neutral spine position," Dr. Hwang said. Many patients report that doing that alone helps their insomnia, he said.

Individual telephone follow-up calls are scheduled between the PA and the participants as needed, until there is an improvement in sleep patterns or the patient declines further participation.

Dr. Hwang’s group reviewed responses from patients participating between December 2010 and December 2011. There were 230 women and 133 men with an average age of 56 years. Among them, 117 had obstructive sleep apnea, 20 had restless legs syndrome, and 20 were night-shift workers; 134 took medications for insomnia and 102 took medications for depression or anxiety.

After completing the program, 321 (88%) patients said they had at least some improvement in their insomnia, and 110 (30%) said their insomnia had resolved. Twenty-five patients said they had no improvement.

Statistically significant improvements were seen in the following sleep parameters before and after the program: sleep latency (57 vs. 26 minutes); awakenings (3 vs. 1.4); and total sleep time (5 hours vs. 6.5 hours). The patients taking sleep medications decreased their use from 6.1 to 3.9 nights/week). And there was a decrease in primary care office visits in the year following the program, compared with the year before the program, from 4.3 to 3.5, an adjusted average of 1 full visit.

Most patients completed the program within 2.5 months, needing only one follow-up telephone call, Dr. Hwang said, indicating that "the class itself is effective even without follow-up." He cautioned that he could not find a good control group to match to those in the CBT program and that the office had a 30%-40% no-show rate for sessions.

An online program and weekly/biweekly interactive voice response questionnaire have been added to the therapy program since the study was completed, he said, allowing providers to single out those in need of additional follow-up.

The study was funded by his Kaiser Permanente.

BALTIMORE – A single session of cognitive-behavioral therapy for insomnia, given in a large group format, may effectively improve sleep conditions for many healthy adults, California researchers have found.

Nearly 90% of 363 insomnia patients who attended the session reported improvements in their sleep patterns, of whom nearly a third said their insomnia had resolved, said Dr. Dennis Hwang, director of the Sleep Disorders Center at Kaiser Permanente Fontana (Calif.) Medical Center. He reported results of a retrospective analysis from his center at the annual meeting of the Associated Professional Sleep Societies.

To offer cognitive-behavioral therapy (CBT) efficiently, Dr. Hwang and his colleagues created a 2.5-hour CBT session, taught by a physician assistant (PA) to groups of 20 patients at a time. The first 2 hours of the class discuss proper sleep hygiene, sleep beliefs, relaxation techniques, and sleep restriction, and offer patients a chance to create an individual plan of action and sleep diary. The next 15 minutes of the class, taught by a PA or pharmacist, goes over basic insomnia medication education, including how to wean off insomnia medications, and the last 15-minute section of the class, taught by a PA or physical therapist, demonstrates optimal sleep positions.

"We teach patients how to sleep better by positioning pillows in certain areas and really try to get them into a neutral spine position," Dr. Hwang said. Many patients report that doing that alone helps their insomnia, he said.

Individual telephone follow-up calls are scheduled between the PA and the participants as needed, until there is an improvement in sleep patterns or the patient declines further participation.

Dr. Hwang’s group reviewed responses from patients participating between December 2010 and December 2011. There were 230 women and 133 men with an average age of 56 years. Among them, 117 had obstructive sleep apnea, 20 had restless legs syndrome, and 20 were night-shift workers; 134 took medications for insomnia and 102 took medications for depression or anxiety.

After completing the program, 321 (88%) patients said they had at least some improvement in their insomnia, and 110 (30%) said their insomnia had resolved. Twenty-five patients said they had no improvement.

Statistically significant improvements were seen in the following sleep parameters before and after the program: sleep latency (57 vs. 26 minutes); awakenings (3 vs. 1.4); and total sleep time (5 hours vs. 6.5 hours). The patients taking sleep medications decreased their use from 6.1 to 3.9 nights/week). And there was a decrease in primary care office visits in the year following the program, compared with the year before the program, from 4.3 to 3.5, an adjusted average of 1 full visit.

Most patients completed the program within 2.5 months, needing only one follow-up telephone call, Dr. Hwang said, indicating that "the class itself is effective even without follow-up." He cautioned that he could not find a good control group to match to those in the CBT program and that the office had a 30%-40% no-show rate for sessions.

An online program and weekly/biweekly interactive voice response questionnaire have been added to the therapy program since the study was completed, he said, allowing providers to single out those in need of additional follow-up.

The study was funded by his Kaiser Permanente.

BALTIMORE – Resistant hypertension was significantly more prevalent in adults with severe obstructive sleep apnea than in those with moderate OSA, despite the use of multiple antihypertensive medications, based on data from a randomized, controlled trial.

"Strategies to treat sleep apnea in this subgroup should be strongly considered, as improvements in blood pressure could potentially lead to improvements in cardiovascular morbidity and mortality," said Dr. Harneet Walia of the Cleveland Clinic, reporting results of her study at the annual meeting of the Associated Professional Sleep Societies.

Dr. Walia and her colleagues reviewed baseline data from 318 individuals at four sites participating in the HeartBEAT (Heart Biomarker Evaluation in Apnea Treatment) study. The trial randomized patients to receive an educational program about healthy lifestyle and sleep schedules, or the educational program plus either nighttime continuous positive airway pressure or nighttime supplemental oxygen. All patients underwent blood pressure monitoring and completed sleep studies with type III portable monitors.

Of the 318 participants, 73 were taking at least three prescribed antihypertensive medications, including a diuretic. Among these 73 patients, resistant hypertension was noted in 58% of those with severe obstructive sleep apnea and 28% of those with moderate OSA. The adjusted odds ratio for resistant blood pressure in severe OSA was 3.3.

Individuals with blood pressure greater than 170/110 mm Hg were excluded from the study, "so we may have underestimated the effects of sleep apnea," Dr. Walia said.

The average age of the patients was 65 years, approximately 70% were men, and the average apnea-hypopnea index (AHI) was 27. Resistant blood pressure was defined as failure to reach a target below 140/90 mmHg (or 130/80 mmHg for patients with diabetes or chronic kidney disease), despite the use of medication. Approximately half of patients with resistant hypertension met the criteria for severe OSA (AHI of 30 or higher).

"Rigorous trials are needed to assess the effects of sleep apnea treatment on blood pressure control in individuals on intensive antihypertensive regimens," Dr. Walia noted.

The study was funded by the National Heart, Lung, and Blood Institute. Dr. Walia said she had no relevant financial disclosures.

BALTIMORE – Resistant hypertension was significantly more prevalent in adults with severe obstructive sleep apnea than in those with moderate OSA, despite the use of multiple antihypertensive medications, based on data from a randomized, controlled trial.

"Strategies to treat sleep apnea in this subgroup should be strongly considered, as improvements in blood pressure could potentially lead to improvements in cardiovascular morbidity and mortality," said Dr. Harneet Walia of the Cleveland Clinic, reporting results of her study at the annual meeting of the Associated Professional Sleep Societies.

Dr. Walia and her colleagues reviewed baseline data from 318 individuals at four sites participating in the HeartBEAT (Heart Biomarker Evaluation in Apnea Treatment) study. The trial randomized patients to receive an educational program about healthy lifestyle and sleep schedules, or the educational program plus either nighttime continuous positive airway pressure or nighttime supplemental oxygen. All patients underwent blood pressure monitoring and completed sleep studies with type III portable monitors.

Of the 318 participants, 73 were taking at least three prescribed antihypertensive medications, including a diuretic. Among these 73 patients, resistant hypertension was noted in 58% of those with severe obstructive sleep apnea and 28% of those with moderate OSA. The adjusted odds ratio for resistant blood pressure in severe OSA was 3.3.

Individuals with blood pressure greater than 170/110 mm Hg were excluded from the study, "so we may have underestimated the effects of sleep apnea," Dr. Walia said.

The average age of the patients was 65 years, approximately 70% were men, and the average apnea-hypopnea index (AHI) was 27. Resistant blood pressure was defined as failure to reach a target below 140/90 mmHg (or 130/80 mmHg for patients with diabetes or chronic kidney disease), despite the use of medication. Approximately half of patients with resistant hypertension met the criteria for severe OSA (AHI of 30 or higher).

"Rigorous trials are needed to assess the effects of sleep apnea treatment on blood pressure control in individuals on intensive antihypertensive regimens," Dr. Walia noted.

The study was funded by the National Heart, Lung, and Blood Institute. Dr. Walia said she had no relevant financial disclosures.

BALTIMORE – Resistant hypertension was significantly more prevalent in adults with severe obstructive sleep apnea than in those with moderate OSA, despite the use of multiple antihypertensive medications, based on data from a randomized, controlled trial.

"Strategies to treat sleep apnea in this subgroup should be strongly considered, as improvements in blood pressure could potentially lead to improvements in cardiovascular morbidity and mortality," said Dr. Harneet Walia of the Cleveland Clinic, reporting results of her study at the annual meeting of the Associated Professional Sleep Societies.

Dr. Walia and her colleagues reviewed baseline data from 318 individuals at four sites participating in the HeartBEAT (Heart Biomarker Evaluation in Apnea Treatment) study. The trial randomized patients to receive an educational program about healthy lifestyle and sleep schedules, or the educational program plus either nighttime continuous positive airway pressure or nighttime supplemental oxygen. All patients underwent blood pressure monitoring and completed sleep studies with type III portable monitors.

Of the 318 participants, 73 were taking at least three prescribed antihypertensive medications, including a diuretic. Among these 73 patients, resistant hypertension was noted in 58% of those with severe obstructive sleep apnea and 28% of those with moderate OSA. The adjusted odds ratio for resistant blood pressure in severe OSA was 3.3.

Individuals with blood pressure greater than 170/110 mm Hg were excluded from the study, "so we may have underestimated the effects of sleep apnea," Dr. Walia said.

The average age of the patients was 65 years, approximately 70% were men, and the average apnea-hypopnea index (AHI) was 27. Resistant blood pressure was defined as failure to reach a target below 140/90 mmHg (or 130/80 mmHg for patients with diabetes or chronic kidney disease), despite the use of medication. Approximately half of patients with resistant hypertension met the criteria for severe OSA (AHI of 30 or higher).

"Rigorous trials are needed to assess the effects of sleep apnea treatment on blood pressure control in individuals on intensive antihypertensive regimens," Dr. Walia noted.

The study was funded by the National Heart, Lung, and Blood Institute. Dr. Walia said she had no relevant financial disclosures.