Is NREM-predominant obstructive sleep apnea syndrome a different clinical entity?
Background/aim: This study aimed to evaluate whether NREM-predominant obstructive sleep apnea syndrome (OSAS) patients
(NREM AHI < REM AHI) have distinct clinical and polysomnographic features compared to REM-predominant OSAS patients (REM
AHI > NREM AHI).
Materials and methods: A total of 342 patients (93 females and 249 males) who were admitted to the Sleep Disorders Unit at the Gazi
University Faculty of Medicine and underwent polysomnography between January 2011 and April 2016 were retrospectively reviewed.
Patient data, symptoms related to OSAS, Epworth Sleepiness Scale (ESS) scores, and polysomnographic findings were recorded. The
patients were divided into two groups according to the apnea-hypopnea index (AHI) as patients with NREM-predominant OSAS and
patients with REM-predominant OSAS.
Results: The total AHI in the NREM-predominant group was significantly higher than in the REM-predominant group (P < 0.001). The
patients with severe OSAS constituted the majority in both groups, and the rate of patients with severe OSAS was significantly higher
in the NREM-predominant group than in the REM-predominant group (P < 0.001). Arousal index and sleep time spent under 90%
SaO2 was higher in the NREM-predominant group (P = 0.005, P = 0.001), whereas nocturnal mean and minimum O2 saturation values
were lower in the NREM-predominant group compared to patients with REM-predominant OSAS (P < 0.001, P = 0.013). In evaluating
systemic disorders, the prevalence of coronary artery disease was significantly higher in the NREM-predominant OSAS group (P <
0.001).
Conclusion: Our results showed that patients with NREM-predominant OSAS had a more severe course than patients with REMpredominant
OSAS. However, we found no significant difference in sleep-specific symptoms, suggesting that the two groups represented
distinct entities.
___
- Young T, Peppard PE, Gottlieb DJ. Epidemiology of obstructive
sleep apnea: a population health perspective. Am J Resp Crit
Care 2002; 165: 1217-1239.
- Lindberg E, Janson C, Svardsudd K, Gislason T, Hetta J, Boman
G. Increased mortality among sleepy snorers: a prospective
population based study. Thorax 1998; 53: 631-637.
- McNicholas WT, Bonsigore MR. Sleep apnoea as an
independent risk factor for cardiovascular disease: current
evidence, basic mechanisms and research priorities. Eur Respir
J 2007; 29: 156-178.
- Engleman HM, Douglas NJ. Sleep. 4: Sleepiness, cognitive
function, and quality of life in obstructive sleep apnoea/
hypopnoea syndrome. Thorax 2004; 59: 618-622.
- Siddiqui F, Walters AS, Goldstein D, Lahey M, Desai H. Half
of patients with obstructive sleep apnea have a higher NREM
AHI than REM AHI. Sleep Med 2006; 7: 281-285.
- Eckert DJ, Malhotra A. Pathophysiology of adult obstructive
sleep apnea. Proceedings of the American Thoracic Society
2008; 5: 144-153.
- Findley LJ, Wilhoit SC, Suratt PM. Apnea duration and
hypoxemia during REM sleep in patients with obstructive
sleep apnea. Chest 1985; 87: 432-436.
- Series F, Cormier Y, La Forge J. Influence of apnea type and
sleep stage on nocturnal postapneic desaturation. Am Rev
Respir Dis 1990; 141: 1522-1526.
- Sauerland EK, Harper RM. The human tongue during sleep:
electromyographic activity of the genioglossus muscle. Exp
Neurol 1976; 51: 160-170.
- Smith CA, Henderson KS, Xi L, Chow C, Eastwood PR,
Dempsey JA. Neural-mechanical coupling of breathing in REM
sleep. J Appl Physiol 1997; 83: 1923-1932.
- Liu Y, Su C, Liu R, Lei G, Zhang W, Yang T, Miao J, Li Z. NREM-
AHI greater than REM-AHI versus REM-AHI greater than
NREM-AHI in patients with obstructive sleep apnea: clinical
and polysomnographic features. Sleep Breath 2011; 15: 463-
470.
- Muraki M, Kitaguchi S, Ichihashi H, Haraguchi R, Iwanaga T,
Kubo H, Higashiyama A, Tohda Y. Apnoea-hypopnoea index
during rapid eye movement and non-rapid eye movement sleep
in obstructive sleep apnoea. J Int Med Res 2008; 36: 906-913.
- Grigg-Damberger MM. The AASM Scoring Manual four years
later. J Clin Sleep Med 2012; 8: 323-332.
- Boudewyns A, Punjabi N, Van de Heyning PH, De Backer
WA, O’Donnell CP, Schneider H, Smith PL, Schwartz AR.
Abbreviated method for assessing upper airway function in
obstructive sleep apnea. Chest 2000; 118: 1031-1041.
- Loadsman JA, Wilcox I. Is obstructive sleep apnoea a rapid eye
movement-predominant phenomenon? Brit J Anaesth 2000;
85: 354-358.
- Duce B, Kulkas A, Langton C, Töyräs J, Hukins C. The
prevalence of REM-related obstructive sleep apnoea is reduced
by the AASM 2012 hypopnoea criteria. Sleep Breath 2018; 22:
57-64.
- Joosten SA, Hamza K, Sands S, Turton A, Berger P, Hamilton G.
Phenotypes of patients with mild to moderate obstructive sleep
apnoea as confirmed by cluster analysis. Respirology 2012; 17:
99-107.
- Verginis N, Jolley D, Horne RS, Davey MJ, Nixon GM.
Sleep state distribution of obstructive events in children: is
obstructive sleep apnoea really a rapid eye movement sleep-
related condition? J Sleep Res 2009; 18: 411-414.
- Yamauchi M, Fujita Y, Kumamoto M, Yoshikawa M, Ohnishi
Y, Nakano H, Strohl KP, Kimura H. Nonrapid eye movement-
predominant obstructive sleep apnea: detection and
mechanism. J Clin Sleep Med 2015; 11: 987-993.
- Terrill PI, Edwards BA, Nemati S, Butler JP, Owens RL, Eckert
DJ, White DP, Malhotra A, Wellman A, Sands SA. Quantifying
the ventilatory control contribution to sleep apnoea using
polysomnography. Eur Respir J 2015; 45: 408-418.
- Chiu HY, Chen PY, Chuang LP, Chen NH, Tu YK, Hsieh YJ,
Wang YC, Guilleminault C. Diagnostic accuracy of the Berlin
questionnaire, STOP-BANG, STOP, and Epworth sleepiness
scale in detecting obstructive sleep apnea: a bivariate meta-
analysis. Sleep Med Rev 2017; 36: 57-70.