Diagnostics and therapeutic options in obstructive and central sleep apnea syndrome

Abstract

Chapter 1 General introduction Chapter 2 Validity and predictive value of a portable two-channel sleepscreening tool in the identification of sleep apnea in patients with heart failure Response: A portable device as sleep-screening tool in the identification of obstructive sleep apnea in chronic heart failure: which value should we consider as cutoff? Chapter 3 Cardiovascular effects of oral appliance therapy in obstructive sleep apnea: A systematic review and meta-analysis Chapter 4 Clinical-and cost-effectiveness of a mandibular advancement device versus continuous positive airway pressure in moderate obstructive sleep apnea Chapter 5 Long-term objective compliance of a mandibular advancement device versus continuous positive airway pressure in patients with moderate obstructive sleep apnea Chapter 6 Continuous positive airway pressure and oral appliance hybrid therapy in obstructive sleep apnea: patient comfort, compliance, and preference: A pilot study Chapter 7 Usage of positional therapy in adults with obstructive sleep apnea Chapter 8 Summary Chapter 9 General discussion and future perspectives Chapter 10 Nederlandse samenvatting Chapter 11 Dankwoord Chapter 1 General introduction 10 Screening and diagnostic tools Patients with sleep apnea present with a wide range of (co-)morbidities prior to their diagnosis. 32 These neurobehavioral and cardiovascular morbidities may support the consideration of having sleep apnea. Yet, establishing the diagnosis still frequently takes several years, leaving many subjects undiagnosed 33,34. Considering the abovementioned consequences of untreated sleep apnea and the impact on societal costs 33 , early diagnosis of sleep apnea is imperative. To date, sleep apnea remains underdiagnosed as it is difficult to recognize, despite the known risk factors. Polysomnography (PSG) is considered the gold standard for diagnosing sleep apnea and is typically performed in a sleep laboratory or ambulatory in a home setting. It entails recordings of (oro)nasal airflow, oxygen saturation, respiratory effort, sleep stages, snoring, eye-and leg movements, heart rate, and body position. Based on PSG, the severity of sleep apnea is classified by the number of apneas and/or hypopneas per hour of sleep (i.e. apneahypopnea index; AHI). Accordingly, sleep apnea can be classified as mild (AHI 5-15 events/h), moderate (AHI 15-30 events/h), or severe (AHI>30 events/h). As PSG is a time-consuming, costly, and specialized procedure, valid and simple alternatives are required. Polygraphy represents an alternative, but lacks the ability to identify sleep and sleep stages. Other diagnostic-and screening tools exist, for example: exclusively monitoring nasal flow and oxygen saturation, sometimes complemented with measurements of respiratory effort and pulse rate. Such devices have shown satisfactory results in terms of identifying patients with sleep apnea. Furthermore, several questionnaires, such as the Berlin questionnaire 34,35 , Epworth sleepiness scale 36 , STOP(-Bang) 37-39 , and several prediction ...