• Sleep Medicine and Psychophysiology
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• v.24 no.2
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• pp.106-117
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• 2017

Objectives: Obstructive sleep apnea (OSA) is a sleep-related breathing disorder that is characterized by repetitive collapse or partial collapse of the upper airway during sleep in spite of ongoing effort to breathe. It is believed that OSA is usually worsened in REM sleep, because muscle tone is suppressed during REM sleep. However, many cases showed a higher apnea-hypopnea index (AHI) during NREM sleep than during REM sleep. We aimed here to determine the characteristics of REM sleep-dependent OSA (REM-OSA) and NREM sleep-dependent OSA (NREM-OSA). Methods: Five hundred sixty polysomnographically confirmed adult OSA subjects were studied retrospectively. All patients were classified into 3 groups based on the ratio between REM-AHI and NREM-AHI. REM-OSA was defined as REM-AHI/NREM-AHI > 2, NREM-OSA as NREM-AHI/REM-AHI > 2, and the rest as sleep stage-independent OSA (IND-OSA). In addition to polysomnography, questionnaires related to subjective sleep quality, daytime sleepiness, and emotion were completed. Chi-square test, ANOVA, and ANCOVA were performed. Results: There was no age difference among subgroups. The REM-OSA group was comprised of large proportions of mild OSA and female OSA patients. These patients experienced poor sleep and more negative emotions than other two groups. The AHI and oxygen desaturation index (ODI) were lowest in REM-OSA. Sleep efficiency and N3 percentage of REM-OSA were higher than in NREM-OSA. The percentage of patients who slept in a supine position was higher in REM-OSA than other subgroups. IND-OSA showed higher BMI and larger neck circumference and abdominal circumference than REM-OSA. The patients with IND-OSA experienced more sleepiness than the other groups. AHI and ODI were highest in IND-OSA. NREM-OSA presented the shortest total sleep time and the lowest sleep efficiency. NREM-OSA showed shorter sleep latency and REM latency and higher percentage of N1 than those of REM-OSA and the highest proportion of those who slept in a lateral position than other subgroups. NREM-OSA revealed the highest composite score on the Horne and ${\ddot{O}}stberg$ questionnaire. With increased AHI severity, the numbers of apnea and hypopnea events during REM sleep decreased, and the numbers of apnea and hypopnea events during NREM sleep increased. The results of ANCOVA after controlling age, sex, BMI, NC, AC, and AHI showed the lowest sleep efficiency, the highest AHI in the supine position, and the highest percentage of waking after sleep onset in NREM-OSA. Conclusion: REM-OSA was associated with the mild form of OSA, female sex, and negative emotions. IND-OSA was associated with the severe form of OSA. NREM-OSA was most closely related to position and showed the lowest sleep efficiency. Sleep stage-dependent characteristics could provide better understanding of OSA.

• Journal of Oral Medicine and Pain
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• v.41 no.3
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• pp.126-132
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• 2016

Purpose: The aims of this study were to analyze the association between inflammatory cytokine and obstructive sleep apnea (OSA), and to evaluate treatment outcome and changes of plasma inflammatory cytokine levels after oral appliance therapy. Methods: Twenty-seven subjects who visited Department of Oral Medicine in Seoul National University Dental Hospital were performed nocturnal polysomnography and analyzed plasma C-reactive protein (CRP), interleukin (IL)-$1{\beta}$, IL-6, IL-10, and tumor necrosis factor (TNF)-${\alpha}$ levels. Each subject was evaluated with Pittsburgh Sleep Quality Index (PSQI) and Epworth Sleepiness Scale (ESS). The subjects were classified into 12 OSA patients (apnea-hypopnea index [AHI] >5) and 15 control (AHI ${\leq}5$) groups. The OSA group was treated with mandibular advancement device (MAD) for 3 months and re-evaluated nocturnal polysomnography and plasma inflammatory cytokine levels. Results: Plasma TNF-${\alpha}$, IL-10, and IL-6 levels were significantly higher in OSA patients compared to controls. Total AHI showed significant positive correlations with plasma IL-6 and TNF-${\alpha}$ levels. Percentage time of $SpO_2$ <90 and lowest $SpO_2$ were significantly correlated with plasma TNF-${\alpha}$ level. ESS showed significant positive correlation with plasma IL-10 level. Total AHI, percentage time of $SpO_2$ <90, lowest $SpO_2$, and mean $SpO_2$ were significantly improved after the MAD therapy. Plasma TNF-${\alpha}$ level was significantly decreased after MAD therapy. Conclusions: We suggest that MAD therapy is an effective treatment modality for patients with OSA and can decrease plasma cytokine level.

• Journal of Oral Medicine and Pain
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• v.41 no.4
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• pp.180-187
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• 2016

Purpose: The aims of this study were to evaluate the differences of clinical and polysomnographic features between rapid eye movement (REM)-related obstructive sleep apnea (OSA) and not-REM-related OSA, and to suggest the pathogenesis according to the REM dependency of OSA. Methods: One hundred ninety consecutive patients diagnosed with OSA were evaluated clinical features and performed full night polysomnography. The patients were divided into REM-related (REM apnea-hypopnea index [AHI] at least two times higher than their non-REM AHI) and not-REM-related (a REM AHI less than two times higher than their non-REM AHI) OSA groups and evaluated the differences in age, body mass index (BMI), neck circumference, Ep-worth Sleepiness Scale score, and parameters of polysomnography. Results: REM-related patients were younger and showed higher sleep efficacy, low percentage of light sleep stage (stage 1 sleep), and low rate of positional OSA. Age was significantly associated with REM dependency of OSA and REM AHI were significant correlated with BMI, neck circumference, percentage of sleep in supine position, and percentage time of snoring. Conclusions: Our results showed that REM-related OSA patients showed less severe polysomnographic parameters than not-REM-related patients. However, significant risk factors were differed depending on the REM dependency and OSA severity, and the clinical features correlated with REM AHI and non-REM AHI were also showed differently. We suggest that the occurrence of OSA according to the REM dependency can be based on different mechanisms.

• Journal of Biomedical Engineering Research
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• v.35 no.4
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• pp.95-98
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• 2014

The baroreflex is one kind of homeostatic mechanisms to regulate acute blood pressure (BP) changes by controlling heartbeat interval (HBI). To quantify the effect of baroreflex, we suggested a new approach of analyzing Granger causality between systolic BP (SBP) and HBI. The index defined as baroreflex effectiveness (BRE) was generated by the hypothesis that more effectual baroreflex would be related to more effective Granger causal influence of SBP on HBI. Six obstructive sleep apnea (OSA) patients (apnea-hypopnea index, AHI ${\geq}5$ events/hr) and six normal subjects participated in the study. Their SBP and HBI during nocturnal sleep were obtained from a non-invasive continuous BP measurement device. While the BRE ($mean{\pm}SD$) of normal subjects was $47.0{\pm}4.0%$, OSA patients exhibited the BRE of $34.0{\pm}3.8%$. The impaired baroreflex function of OSA patients can be explained by the physiological mechanism associated with recurrent hypoxic episodes during sleep. Thus, the significantly lower BRE in OSA patients verified the availability of Granger causality analysis to evaluate baroreflex during sleep. Furthermore, the range of BRE obtained from normal subjects was not overlapped with that obtained from OSA patients. It suggests the potential of BRE as a new helpful tool for diagnosing OSA.

• Journal of Korean Medicine Rehabilitation
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• v.34 no.3
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• pp.65-74
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• 2024

Objectives This study aims to establish a protocol for a systematic review to evaluate the effectiveness and safety of manual therapy (MT) for obstructive sleep apnea (OSA). Methods We will conduct a search for relevant randomized controlled trials using seven databases, including MEDLINE/PubMed, Embase, and the Cochrane Central Register of Controlled Trials. The study includes patients with OSA treated with MT. Comparators include all other treatments excluding MT. The primary outcome is the apnea-hypopnea index; secondary outcomes include mean peripheral oxygen saturation, snoring index, quality of sleep, quality of life, peak nasal inspiratory flow, and adverse events. Results Two independent researchers will select studies based on inclusion criteria and extract necessary data. Risk of bias (RoB) will be assessed using the Cochrane RoB 2.0 tool. Meta-analysis will be conducted if there are two or more studies with the same outcome measure; otherwise, a qualitative analysis will be performed. Subgroup analysis will be conducted based on the type of MT, and evidence certainty will be evaluated using the Grading of Recommendations Assessment, Development, and Evaluation approach. Conclusions This study will evaluate the effect of MT on OSA. By systematically reviewing various MTs, it aims to refine application methods in clinical practice and provide a foundation for future research.

• Sleep Medicine and Psychophysiology
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• v.24 no.2
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• pp.86-96
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• 2017

Objectives: This study aimed to analyze causality among sleep apnea, depression and cognitive function in patients with obstructive sleep apnea. Methods: We reviewed the medical records of 105 patients with sleep apnea and snoring who underwent overnight polysomnography (PSG). We analyzed various biological data, sleep variables (sleep duration and percentage) and respiratory variables [arousal index (AI), periodic leg movement index (PLM index), snoring Index (SI), mean SpO2, minimum SpO2, apnea-hypopnea index (AHI), and respiratory disturbance index (RDI)]. We also analyzed various data by sleep, cognition, and mood related scales: Pittsburgh sleep quality index (PSQI), Epworth sleepiness scale (ESS), snoring index by scale (SIS), Montreal Cognitive Assessment-Korean (Moca-K), Mini-mental State Examination-Korean (MMSE-K), clinical dementia rating (CDR), and Beck Depression Inventory (BDI). We analyzed causation among sleep, and respiratory, mood, and cognition related scales in obstructive sleep apnea patients. We analyzed the mediating effects of depression on sleep apnea patient cognition. Results: As Duration N1 increased and Total sleep time (TST) decreased, MOCA-K showed negative causality (p < 0.01). As BDI and supine RDI increased, causality was negatively related to MOCA-K (p < 0.01). As PSQI (p < 0.001) and SIS (p < 0.01) increased and as MMSE-K (p < 0.01) decreased, causality was positively related to BDI. BDI was found to mediate the effect of age on MOCA-K in patients with obstructive sleep apnea. Conclusion: Duration N1, total sleep time, BDI, and supine RDI were associated with cognitive function in obstructive sleep apnea patients. Depression measured by BDI partially mediated cognitive decline in obstructive sleep apnea patients.

• Sleep Medicine and Psychophysiology
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• v.21 no.1
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• pp.21-28
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• 2014

Objective: Few studies have evaluated the personality characteristics of patients with obstructive sleep apnea (OSA) and simple snoring. We investigated the personality characteristics of OSA and simple snoring patients and compared differences in personality between the two groups using the Eysenck Personality Questionnaire (EPQ). Materials and Methods: Two hundred and thirty-seven patients who were suspected to have OSA or simple snoring participated in this study. A self-questionnaire which included the EPQ was administered to all participants. All subjects underwent polysomnography in a sleep laboratory and those with an apnea-hypopnea index (AHI) ${\geq}5$ were included in the OSA group, while those with an AHI <5 were included in the simple snoring group. Results: OSA patients had significantly lower scores for Psychoticism (F=4.563, p=0.034) than simple snorers. There were no significant differences in Extraversion (F=3.029, p=0.083), Lie (F=0.398, p=0.529), or Neuroticism (F=3.367, p=0.068) scores between the two groups. In the correlation analysis of the OSA group, AHI was positively correlated with Extraversion score (r= 0.16, p=0.029) and negatively correlated with Lie score (B=-0.31, p<0.001). Using multiple stepwise linear regression analysis with the four EPQ parameter scores as dependent variables, Lie score was associated with older age (B=0.14, p<0.001) and lower AHI (B=-0.05, p<0.001), Psychoticism score was associated with higher Pittsburgh Sleep Quality Index (PSQI ; B=0.14, p<0.001), Neuroticism score was associated with higher PSQI (B=0.34, p=0.001) and female sex (B=3.15, p=0.003), and Extraversion score was associated with younger age (B=-0.08, p=0.020) and higher body mass index (B=0.26, p=0.023). Conclusion: This study suggests that patients with OSA are significantly less prone to psychotic personality characteristics than those with simple snoring. Among OSA patients, higher AHI was correlated with low falsehood and high extraversion tendencies.

• Sleep Medicine and Psychophysiology
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• v.23 no.1
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• pp.16-24
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• 2016

Background and Objectives: Obstructive sleep apnea (OSA) is often undiagnosed but is an important risk factor affecting the health of an individual. The level of awareness of the illness among patients with OSA is low and is not correlated with severity of the illness. This study was conducted to compare awareness of OSA symptoms and illness between patients with OSA and simple snorers. Materials and Methods: Two hundred eighty-two patients who were suspected of having OSA participated in this study. All subjects underwent overnight polysomnography. Those with an apnea-hypopnea index (AHI) ${\geq}5$ were classified as the OSA group, while those with an AHI < 5 were classified as the simple snoring group. A sleep questionnaire, which included items on awareness of the illness, OSA, and sleep symptoms, was administered to all subjects and their bed-partners. Results: Simple snorers were much more aware of their symptoms such as snoring, irregular breathing, and apnea than were patients with OSA. Bed-partners of simple snorers were also more aware of the participants' sleep symptoms than were partners of patients with OSA. However, the duration of OSA symptoms was longer in the OSA group. In the correlation analysis, the level of awareness of OSA symptoms was negatively correlated with AHI, age, body mass index, and Epworth Sleepiness Scale score. Among the sleep questionnaire and polysomnography results, only Pittsburgh Sleep Quality Index was positively correlated with level of awareness of OSA symptoms. The minority of the respondents had heard about the treatment methods of continuous positive airway pressure and oral appliance and preferred them as treatment options. Conclusion: This study suggests that simple snorers are more aware of their symptoms than are patients with OSA. A higher severity of OSA, represented by a higher AHI, is correlated with lower awareness of one's OSA symptoms.

• Journal of Clinical Otolaryngology Head and Neck Surgery
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• v.29 no.2
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• pp.190-197
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• 2018

Background and Objectives : Positional OSAS is characterized by an apnea-hypopnea index (AHI) score >5, which, while sleeping in the supine position, is double that in non-supine position. This study was performed to compare the clinical characteristics of positional OSAS and non-positional OSAS patients, and the effects of the modified jaw thrust maneuver during drug-induced sleep endoscopy (DISE) between positional OSAS and non-positional OSAS patients. Materials and Methods : 68 positional OSAS patients and 19 non-positional OSAS patients were included. They all underwent full-night polysomnography and DISE. The modified jaw thrust maneuver was introduced during DISE. Airway structural changes induced by the modified jaw thrust maneuver were evaluated and documented. Results : There were no statistically significant differences in Friedman stage or tonsil grade, body mass index, Epworth sleepiness scale (ESS) score, blood pressure, AHI, or obstructive pattern between the positional and non-positional OSAS patients. However, mean arterial oxygen saturation (SaO2), lowest SaO2, and total arousal index values were more severe in the non-positional OSAS patients. After introduction of the modified jaw thrust maneuver, retrolingual level obstruction showed a tendency toward a higher rate of airway opening in positional OSAS patients than in non-positional OSAS patients. Conclusions : The effects of a mandibular advancement device (MAD) can be estimated by carrying out a modified jaw thrust maneuver during DISE. The tendency toward a higher rate of airway opening in positional OSAS patients than non-positional OSAS patients in retrolingual level obstruction after jaw thrust maneuver introduced during DISE may be clinically important for MAD.

• Journal of Oral Medicine and Pain
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• v.41 no.1
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• pp.7-15
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• 2016

Purpose: Mandibular advancement device (MAD) is widely recognized as an important treatment option for obstructive sleep apnea (OSA) and is readily accepted than any other treatment options owing to its simplicity and ambulatory nature. At this time, there are a multitude of MAD designs and their efficacies may be influenced by adjustment and retention mechanism. The MAD with the anterior connector (anteriorly adjustable mandibular advancement device, AAMAD) was newly developed in the Department of Oral Medicine, Dankook University Dental Hospital (Cheonan, Korea) and was prescribed for the OSA patients including snoring patients. Thus, this study was aimed to objectively investigate the effectiveness of the AAMAD on the OSA patients using the self-applied portable device (ApneaLink), and evaluate the treatment outcomes among patients with various severity of OSA level. Methods: Results of the treatment of fourteen patients (13 male, 1 female) with the AAMAD were retrospectively analyzed. Each patient underwent home sleep test before treatment and were divided into two groups, i.e., those with mild (apnea-hypopnea index [AHI] ${\geq}5$ and <15) to moderate OSA (AHI ${\geq}15$ and <30) and severe OSA (AHI ${\geq}30$). After treatment, home sleep test was conducted again and treatment outcomes were compared between mild to moderate and severe OSA patients. Results: Of all patients, 78.6% showed more than 50% AHI reduction. We found a significant reduction (85.3%) of AHI in the severe OSA patients. Patients with mild to moderate OSA showed the reduced AHI (56.1%). Conclusions: We concluded that AAMAD is an effective oral appliance for the majority of OSA patients.