Sleep Medicine

Obstructive sleep apnea: Epidemiology

Punjabi NM, Caffo BS, Goodwin JL, et al. Sleep-disordered breathing and mortality: a prospective cohort study. PLoS Med 2009;6(8):e10000132. Epub 2009 Aug 18. This analysis from the Sleep Heart Health Study is noteworthy for being the largest prospective cohort study to date to find increased adjusted all-cause mortality in patients with severe sleep-disordered breathing (AHI > 30 events/hr) with a hazard ratio 1.46 (C.I. 1.14 – 1.86). The subset of men aged 40 to 70 years had especially elevated risk (HR 2.09, C.I. 1.31 – 3.33).

PMID: 19688045

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Obstructive Sleep Apnea : Diagnosis

Iber C, O'Brien C, Schluter J, et al. Single night studies in obstructive sleep apnea. Sleep 1991;14:383-5. Contrary to the accompanying editorial, this study first documented the effectiveness of split-night studies for the evaluation of OSA and helped establish split-night studies as the standard of care.

PMID: 1759089.

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; 196:1181-90. This 6-month study of 430 patients with moderate to high suspicion for OSA found use of home sleep study for diagnosis was noninferior to use of laboratory polysomnography and was less expensive. All patients diagnosed with OSA underwent a separate single CPAP auto-titration home session.

PMID: 28636405

Obstructive Sleep Apnea: Treatment

Sullivan CE, Berthon-Jones M, Issa FQ et al. Reversal of obstructive sleep apnea by continuous positive airway pressure applied through the nares. Lancet 1981 April 18; 1(8225):862-5. First description of CPAP in the treatment of OSA.

PMID: 6112294

McEvoy RD, Antic NA, Heeley E, et al. CPAP for prevention of cardiovascular events in obstructive sleep apnea. N Engl J Med. 2016; 375: 919-31. 2717 adults between 45 and 75 years of age with moderate-to-severe OSA and established coronary or cerebrovascular disease were randomized to CPAP treatment plus usual care or usual care alone and followed for an average of 3.7 years. There was no difference in death from cardiovascular causes, myocardial infarction, stroke, hospitalization for unstable angina, heart failure, or transient ischemic attack, and no difference in a composite of these outcomes.  CPAP significantly reduced snoring and daytime sleepiness and improved health-related quality of life and mood.

PMID: 27571048

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Weaver TE, Mancini C, Maislin G, 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;186:677-83. This prospective blinded trial of sleepy patients with mild obstructive sleep apnea found improvement in functional outcome after 8 weeks with CPAP when compared with sham CPAP.

PMID: 22837377

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Barbe F, Duran-Cantolla J, Sanchez-de-le-Torre M, et al. Effect of continuous positive airway pressure on the incidence of hypertension and cardiovascular events in non-sleepy patients with obstructive sleep apnea: a randomized controlled trial. JAMA. 2012;307:2161-2168.The efficacy of CPAP in non-sleepy patients with OSA is unclear. This trial of 725 patients with low Epworth scores and AHI > 20 found no reduction in the incidence of hypertension or cardiovascular events over a median 4-year follow-up, although the authors note the study may have been underpowered.

PMID: 22618923

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Phillips CL, Grunstein RR, Darendeliler MA, 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; 187:879-87. Crossover study of predominantly moderate OSA patients found better subjectively-reported adherence with use of a mandibular advancement device and no overall difference in daytime sleepiness and quality of life despite greater reduction in AHI with CPAP. Blood pressure was unchanged in both groups but patients were normotensive at baseline. Patients with severe OSA still had moderate OSA while using an oral appliance.


Strollo PJ Jr, Soose RJ, Maurer JT et al. Upper-airway stimulation for obstructive sleep apnea. N Engl J Med 2014; 370: 139-49. This uncontrolled cohort study assessed the efficacy of  hypoglossal nerve stimulation in a highly selected group of patients with difficulty accepting or adhering to CPAP. Subjects had moderate-to-severe sleep apnea, and those with a BMI > 32 were excluded. In addition to PSG, bronchoscopy during propofol-induced sleep was part of the evaluation. They found a decrease in mean AHI from 29 to 9 and improvement in QoL measures. Although these results suggest treatment efficacy, randomized comparative trials are needed to clarify the role of hypoglossal nerve stimulator in OSA management.

PMID: 24401051

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Central sleep apnea

Bradley TD, Logan AG, Kimoff RJ, et al. Continuous positive airway pressure for central sleep apnea and heart failure. N Engl J Med 2005; 353:2025-33. The oft-cited, randomized CANPAP study of 258 patients found use of CPAP in patients with CHF and Cheyne-Stokes Respirations did not improve mortality. Some believe the lack of benefit compared to previous studies is due to advances in CHF treatment with beta blockers.

PMID: 16282177

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Cowie MR, Woehrle H, Wegscheider K, et al. Adaptive servo-ventilation for central sleep apnea in systolic heart failure. New Engl J Med 2015; 373:1095-1105. A randomized trial of guideline based medical care with and without ASV in patients with depressed EF, AHI> 15 and predominance of central apneas. There was no significant difference in composite of death from any cause, lifesaving cardiovascular intervention or unplanned hospitalization for worsening heart failure. There was, however, a significant increase in both all cause and cardiovascular mortality in the ASV group. This unexpected finding has been cause for reassessing the previously rapid growth of ASV for treatment of this population.

PMID: 26323938

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Obesity hypoventilation syndrome

Mokhlesi B, Masa JF, Brozek JL, et al. Evaluation and management of obesity hypoventilation syndrome. An official American Thoracic Society clinical practice guideline. Am J Respir Crit Care Med. 2019; 200:e6-e24. This article reviews the current evidence supporting different modes of positive airway pressure therapy used in managing individuals with OHS and includes a recommendation for CPAP as firs-tline treatment rather than noninvasive ventilation in stable OHS patients with concomitant severe OSA.

PMID: 31368798

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Sleep deprivation

Landrigan CP, Rothschild JM, Cronin JW, et al. Effect of reducing interns' work hours on serious medical errors in intensive care units. N Engl J Med. 2004; 351:1838-48. Prospective, randomized study determined that interns made substantially more serious medical errors when they worked frequent shifts of 24 hours or more than when they worked shorter shifts.

PMID: 15509817

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Carney CE, Edinger JK, Kuchibhatla M et al. Cognitive behavioral insomnia therapy for those with insomnia and depression: a randomized controlled clinical trial. Sleep. 2017;40(4):zsx019. This study randomized 107 participants to either antidepressant and CBT-I versus placebo and CBT-I, versus antidepressant and sleep hygiene control sessions. All groups self-reported better sleep after treatment without significant group differences. Both CBT-I groups had improved objective sleep on polysomnogram, but the third group had worsened objective sleep. As in prior studies, this study demonstrated improvement in depression with CBT-I alone, highlighting the bidirectional association between insomnia and depression.

PMID: 28199710

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Mahowald MW. Parasomnias. Med Clin North Am 2004; 88:669-78.This article reviews the most common parasomnias: disorders of arousal, the REM behavior disorder (RBD), and nocturnal seizures.

PMID: 15087210

Circadian rhythm disorders

Auger RR, Burgess HJ, Emens JS, et al. Clinical practice guideline for the treatment of intrinsic circadian rhythm sleep-wake disorders: advanced sleep-wake phase disorder (ASWPD), delayed sleep-wake phase disorder (DSWPD), non-24-hour sleep-wake rhythm disorder (N24SWD), and irregular sleep-wake rhythm disorder (ISWRD). an update for 2015: An American Academy of Sleep Medicine Clinical Practice Guideline. J Clin Sleep Med. 2015; 11:1199-236. This is an update to the previous American Academy of Sleep Medicine guidelines on intrinsic circadian rhythm sleep-wake disorders.

PMID: 26414986