ATS Reading List

Sleep Medicine

Obstructive sleep apnea: Epidemiology

Young T, Peppard PE, Gottlieb DJ. Epidemiology of obstructive sleep apnea: a population health perspective. Am J Respir Crit Care Med 2002; 165:1217-39. This article reviews the epidemiologic studies identifying a high prevalence of undiagnosed OSA in the general population, as well as the association between OSA and increased likelihood of hypertension, cardiovascular disease, and stroke.
PMID: 11991871

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.

Portable monitoring vs in-lab polysomnography remains a controversial issue. The following articles include guidelines from the AASM as well as recent studies suggesting a more streamlined approach to diagnosis and treatment achieves outcomes similar to laboratory testing in patients with a high pre-test probability of moderate to severe OSA.

Collop NA, Anderson WM, et al. Clinical guidelines for the use of unattended portable monitors in the diagnosis of obstructive sleep apnea in adult patients. Portable Monitoring Task Force of the American Academy of Sleep Medicine. J Clin Sleep Med. 2007; 3:737-47.. The use of portable monitors is likely to increase in the U.S. now that it is reimbursed by Medicare. The task force recommends use of unattended portable monitoring studies be limited to patients with a high likelihood of moderate to severe OSA and at minimum record airflow, respiratory effort, and oxygen saturation. The evaluation should be supervised by a board-certified or eligible sleep physician.
PMID: 18198809
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Chung F, Yegneswaran B, Liao P, et al. STOP Questionnaire: A Tool to Screen Patients for Obstructive Sleep Apnea. Anesthesiology. 2008; 108:812-21. Originally developed as an OSA screening tool in pre-op clinics, the STOP-Bang questionnaire asks 8 dichotomous questions regarding snoring, tiredness, observed apnea, high BP, BMI, age, neck circumference, and male gender.  The likelihood of moderate to severe OSA increases proportionate to the score. STOP-Bang has been widely incorporated as a screening tool in several other settings. While useful as screening tool, STOP-Bang has a lower specificity (43%).
PMID: 18431116
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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

Haentjens P, Van Meerhaeghe A, Moscariello A, et al. The impact of continuous positive airway pressure on blood pressure in patients with obstructive sleep apnea syndrome: evidence from a meta-analysis of placebo-controlled randomized trials. Arch Intern Med. 2007; 167:757-64. In this meta-analysis of data from 12 randomized controlled trials, the pooled estimate of the effect of the CPAP intervention on 24-hour mean arterial blood pressure was a net decrease of 1.69 mm Hg (95% confidence interval, -2.69 to -0.69), with greater treatment-related reductions among patients with a more severe OSA and a better adherence to CPAP therapy.
PMID: 17452537
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Marin JM, Carrizo SJ, Vicente E, et al. Long-term cardiovascular outcomes in men with obstructive sleep apnoea-hypopnea with or without treatment with continuous positive airway pressure: an observational study. Lancet 2005; 365: 1046-53. The best of a growing number of observational studies indicating that non-adherence to CPAP therapy is associated with increased cardiovascular morbidity and mortality. Patients adherent to CPAP for severe sleep apnea had cardiovascular morbidity and mortality similar to that in a weight- and age-matched control group. However, this type of study design has been criticized for being prone to a "healthy user" bias.
PMID: 15781100

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. 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, Kryger MH, Grunstein RR. Assessment and management of patients with obesity hypoventilation syndrome. Proc Am Thorac Soc. 2008; 5:218-25. Reviews the clinical presentation, pathophysiology, morbidity, mortality, and currently available treatment of obesity hypoventilation syndrome.
PMID: 18250215
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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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Passarella S, Duong MT. Diagnosis and treatment of insomnia. Reviews the diagnostic criteria for insomnia as well as non-pharmacologic and pharmacologic treatment. Am J Health Syst Pharm. 2008; 65:927-34.
PMID: 18463341

Morgenthaler T, Kramer M, Alessi C, et al. Practice parameters for the psychological and behavioral treatment of insomnia: an update. An American Academy of Sleep Medicine report. Sleep 2006; 29:1415-9. A comprehensive literature review since 1999 that grades the evidence for various non-pharmacological treatments of insomnia.
PMID: 17162987


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

Lu BS, Zee PC. Circadian rhythm sleep disorders. Chest 2006; 130:1915-23. This review focuses on the clinical approach to the diagnosis and management of the various circadian rhythm sleep disorders, including delayed sleep phase disorder, advanced sleep phase disorder, non-entrained type, irregular sleep-wake rhythm, shift work sleep disorder and jet lag disorder.
PMID: 17167016
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Last Reviewed: June 2017