What's new in sleep medicine

The following represent additions to UpToDate from the past six months that were considered by the editors and authors to be of particular interest. The most recent What's New entries are at the top of each subsection.

SLEEP-RELATED BREATHING DISORDERS

Vibratory devices for supine-predominant obstructive sleep apnea (April 2024)

The efficacy of chest or neck vibratory alarm devices as therapy for patients who primarily develop obstructive sleep apnea (OSA) in the supine position is poorly studied. Recently, a randomized trial of 66 such patients reported that using a vibratory device for six to eight weeks reduced sleepiness by a similar degree to continuous positive airway pressure (CPAP) therapy (-1.9 versus -2.4 points on the Epworth Sleepiness Scale score) [1]. However, despite greater adherence to the vibratory device, CPAP resulted in a greater reduction in the apnea hypopnea index. While vibratory devices restrict supine sleep, they should not be relied upon as the sole therapy for OSA but may be useful as a supplement to CPAP. (See "Obstructive sleep apnea: Overview of management in adults", section on 'Nonsupine sleep position'.)

Long-term outcomes from surgery in obstructive sleep apnea (March 2024)

In patients with moderate or severe obstructive sleep apnea (OSA) in whom positive airway pressure (PAP) therapy has failed, short-term benefit occurs after multilevel surgery (ie, reconstructive uvulopalatopharyngoplasty combined with minimally invasive tongue volume reduction). Long-term outcomes from a previously reported trial now demonstrate persistent improvement at 3.5 years in the apnea hypopnea index (mean difference 24 fewer events per hour compared with baseline) and sleepiness as measured by the Epworth sleepiness scale (mean difference 6.8 compared with baseline) [2]. These results are encouraging for patients with moderate or severe OSA in whom PAP therapy has failed. Careful patient selection is critical for success. (See "Surgical treatment of obstructive sleep apnea in adults", section on 'UPPP and variants'.)

Uncertain role of adaptive servo-ventilation in patients with heart failure with reduced ejection fraction (February 2024)

In a prior trial (SERVE-HF), positive airway pressure therapy with adaptive servo-ventilation (ASV) increased mortality in patients with central sleep apnea (CSA) due to heart failure with reduced ejection fraction (HFrEF). In the subsequent ADVENT-HF trial, among 731 patients with sleep-disordered breathing (obstructive- or central-predominant) and HFrEF, ASV resulted in similar all-cause mortality relative to standard care for both the overall study population and the subgroup with CSA [3]. However, the number of patients with CSA was small and confidence intervals were wide for all outcomes. Thus, we continue to avoid use of ASV in patients with CSA due to HFrEF. (See "Central sleep apnea: Treatment", section on 'Patients with ejection fraction ≤40 percent'.)

Management of residual excessive sleepiness in obstructive sleep apnea (January 2024)

The first expert consensus statement on the management of residual excessive sleepiness (RES) in patients with obstructive sleep apnea (OSA) was recently published [4]. Key points include the assessment of RES at regular intervals throughout the patient's life, use of the Epworth Sleepiness Scale and detailed clinical sleep (including sleep deprivation and inadequate sleep), neurologic evaluation to comprehensively investigate non-OSA RES etiologies, and evaluation of adequate adherence to and optimal application of positive airway therapy before embarking on wakefulness-promoting agents. We agree with these recommendations. (See "Evaluation and management of residual excessive sleepiness in adults with obstructive sleep apnea", section on 'Evaluation'.)

INSOMNIA

Lack of efficacy of insomnia therapies for patients on dialysis (February 2024)

Although insomnia may affect nearly half of patients on dialysis, relatively few studies have evaluated the efficacy of commonly used insomnia therapies in this population. In a trial in which over 120 patients on hemodialysis with insomnia were randomly assigned to treatment with cognitive behavior therapy for insomnia (CBT-I), trazodone, or placebo for six weeks, there were no significant differences in the change in Insomnia Severity Index scores from baseline among the three groups after 7 or 25 weeks, but serious cardiovascular events were more frequent in the trazodone group [5]. The inclusion of patients with obstructive sleep apnea and other factors may have masked a potential benefit of CBT-I. Based on these data and previous studies reporting associations between the use of hypnotic medications and adverse outcomes in patients on dialysis, we prefer nonpharmacologic therapy for the treatment of insomnia in patients with end-stage kidney disease; more studies are needed to delineate the role of CBT-I in these patients. (See "Sleep disorders in end-stage kidney disease", section on 'Treatment'.)

Risk of fractures with benzodiazepine receptor agonists (January 2024)

Benzodiazepine receptor agonists (BZRAs), including benzodiazepines and nonbenzodiazepine BZRAs such as zolpidem, can cause excess drowsiness and imbalance leading to falls and fractures. In a recent meta-analysis of 20 observational studies in over six million individuals, BZRAs were associated with increased risk of osteoporotic fractures across a range of drug classes and fracture types, with odds ratios ranging from 1.2 to 1.4 [6]. Most but not all studies included adults 50 years of age or older. These data reinforce the need for caution in prescribing BZRAs for insomnia and other indications, particularly in older adults. (See "Pharmacotherapy for insomnia in adults", section on 'Special populations'.)

PEDIATRIC SLEEP MEDICINE

Management of post-adenotonsillectomy obstructive sleep apnea in children (February 2024)

A new clinical practice guideline on management of persistent obstructive sleep apnea after adenotonsillectomy in children is available from the American Thoracic Society [7]. The guideline endorses a multidisciplinary evaluation, which may include drug-induced sleep endoscopy and cine magnetic resonance imaging to identify sites of obstruction and guide further interventions. It also provides conditional recommendations based on low certainty of evidence for interventions ranging from weight loss and continuous positive airway pressure to orthodontic treatments and adjuvant surgical procedures. (See "Adenotonsillectomy for obstructive sleep apnea in children", section on 'Positive airway pressure'.)

Management of children with mild sleep-disordered breathing (February 2024)

For children with mild sleep-disordered breathing (SDB) and relevant symptoms, little evidence has been available to guide a choice between adenotonsillectomy and watchful waiting. In a randomized trial in 459 children 3 to <13 years with tonsillar hypertrophy and mild SDB (defined by habitual snoring with occasional episodes of obstruction with apnea per hour of sleep), executive function and attention were similar for individuals assigned to adenotonsillectomy compared with watchful waiting at 12 months follow-up [8]. However, children treated with adenotonsillectomy had greater decrease in snoring, obstruction with apnea or hypopnea, blood pressure, and caregiver-reported symptoms (sleep symptoms, behavioral problems, sleepiness) as well as increased quality of life. These findings support our suggestion to offer adenotonsillectomy to children with mild obstructive sleep apnea and relevant symptoms although watchful waiting is a reasonable alternative. (See "Management of obstructive sleep apnea in children", section on 'Adenotonsillectomy'.)

GENERAL SLEEP MEDICINE

Effect of short-term sleep restriction on insulin sensitivity in females (January 2024)

Short sleep duration has been associated with risk of type 2 diabetes, but whether this reflects a causal relationship is uncertain. In a crossover study in 38 females aged 20 to 75 years with baseline sleep duration of seven to nine hours nightly, participants underwent sequential, six-week phases of sleep maintenance (usual sleep time maintained) and sleep restriction (sleep time reduced by 1.5 hours nightly) [9]. Sleep restriction led to increases in fasting insulin concentration and homeostasis model assessment of insulin resistance (HOMA-IR), indicating diminished insulin sensitivity. These changes were independent of changes in adiposity and were more pronounced in postmenopausal compared with premenopausal participants. Further studies are needed to verify the findings in a larger cohort of patients, including males, and to determine whether prolonged sleep restriction causes progressive worsening of glucose homeostasis. (See "Type 2 diabetes mellitus: Prevalence and risk factors", section on 'Sleep duration'.)