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Kim, Eom, Yoon, Kim, Kim, and Cho: Clinical Analysis of Daytime Sleepiness and Insomnia in Patients with Obstructive Sleep Apnea
ORIGINAL ARTICLE

J Rhinol 2018;25(2):69-74.

Published online: 19 January 2018

DOI: https://doi.org/10.18787/jr.2018.25.2.69

Clinical Analysis of Daytime Sleepiness and Insomnia in Patients with Obstructive Sleep Apnea

In Sik Kim, MD, Ji Hun Eom, MD, Hyung Joon Yoon, MD, Dong Hwan Kim, MD, Kyung Rae Kim, MD, Seok Hyun Cho, MD, PhD

Department of Otolaryngology-Head and Neck Surgery, College of Medicine, Hanyang University, Seoul, Korea

교신저자：조석현, 04763 서울 성동구 왕십리로 222-1 한양대학교 의과대학 이비인후과학교실 Tel: +82-2-2290-8580, Fax: +82-2-2290-9192, E-mail: shcho@hanyang.ac.kr

Received 28 June 2017       Revised 18 October 2017       Accepted 19 October 2017

Copyright © 2018 Journal of Rhinology

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

Background and Objectives:

Sleep disturbances and excessive daytime sleepiness (EDS) are the major symptoms of obstructive sleep apnea (OSA). This study aimed to investigate clinical implications of insomnia and EDS in patients with OSA using the Pittsburgh Sleep Quality Index (PSQI) and Epworth Sleepiness Scale (ESS).

Materials and Method:

We evaluated 131 subjects with suspected OSA who were undergoing polysomnography (PSG) and performing the PSQI and ESS surveys. OSA was diagnosed when the apnea-hypopnea index was five or more. EDS was defined when ESS score was 11 points or higher. Detailed history and questionnaire were used to categorize insomnia. We compared clinical variables and PSG results in subgroups with or without insomnia and EDS.

Results:

There were no significant differences of PSQI and ESS score between controls and OSA. OSA with insomnia had significantly increased total score (p<0.001) and decreased total sleep time (p=0.001) and sleep efficiency (p=0.001) on the PSQI compared to those without insomnia. OSA with EDS showed significantly increased PSQI score (p=0.022) and decreased total sleep time (p=0.018) on PSG compared to those without EDS. Neither PSQI nor ESS score had a correlation with respiratory variables such as AHI and oxygen saturation. Total sleep time had a significant effect on both insomnia and EDS in patients with OSA.

Conclusion:

Decreased total sleep time had important effects on subjective symptoms of OSA and comorbid insomnia. Therefore, restoration of decreased sleep time is important in the management of OSA.

Keywords: Obstructive sleep apnea, Insomnia, Daytime sleepiness.

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Table 1.
Clinical variables and polysomnographic results of controls and patients with obstructive sleep apnea (OSA)
Clinical variables Controls (n=31) OSA (n=100) p-value
Age 39.2±13.1 47.0±13.3 0.006
Sex (male:female) 15:16 89:11 ＜0.001
Alcohol 13 (41.9%) 62 (62.0%) 0.056
Smoking 8 (25.8%) 29 (29.0%) 0.730
Comorbidity
  Hypertension 4 (12.9%) 44 (44.0%) 0.024
  DM 1 (3.2%) 15 (15.0%) 0.081
Anthropometric measure
  BMI (kg/m2) 24.7±3.81 26.2±3.59 0.052
  Neck circumference (cm) 36.4±6.3 39.8±3.04 ＜0.001
  Waist circumference (cm) 86.0±9.23 95.5±9.4 ＜0.001
  WHR 0.87±0.07 0.94±0.05 ＜0.001
ESS 7.9±5.0 9.2±5.8 0.218
PSQI 6.65±3.73 7.75±3.75 0.156
  Total sleep time (min) 351.1±70.2 368.9±76.2 0.250
  Sleep efficiency (%) 84.6±12.5 86.6±11.5 0.411
Polysomnography
  Total sleep time (min) 286.5±57.8 229.3±82.1 ＜0.001
  Sleep efficiency (%) 79.7±11.1 74.7±13.6 0.040
  Arousal index 15.6±10.1 36.1±16.96 ＜0.001
  Mean SpO2 97.3±1.3 95.2±2.2 ＜0.001
  Lowest SpO2 90.8±4.4 78.4±11.6 ＜0.001
  Apnea hypopnea index 2.0±1.4 37.5±27.1 ＜0.001

Values are mean±SD. OSA: Obstructive Sleep Apnea, DM: Diabetes mellitus, BMI: Body Mass Index, WHR: Waist Hip ratio, ESS: Epworth Sleepiness Scale, PSQI: Pittsburgh Sleep Quality

Table 2.
Effect of comorbid insomnia in patients with obstructive sleep apnea
Clinical value Insomnia (+) (n=22) Insomnia (-) (n=78) p-value
Age 46.2±11.4 47.2±13.9 0.734
Sex (male:female) 18:4 71:7 0.227
ESS 9.3±6.8 9.2±5.5 0.692
PSQI 12.0±3.6 6.5±2.7 ＜0.001
  Total sleep time (min) 313.0±76.9 370.9±70.8 0.001
  Sleep efficiency (%) 76.9±14.1 89.2±11.3 0.001
Polysomnography
Total sleep time (min) 313.6±83.7 384.5±76.2 0.002
  Sleep efficiency (%) 77.4±12.4 89.2±11.5 0.037
  Arousal index 30.1±15.3 37.8±17.0 0.425
  Mean SpO2 (%) 95.5±1.7 95.2±2.2 0.791
  Lowest SpO2 (%) 81.0±8.8 77.7±11.6 0.605
  AHI 26.7±23.3 40.7±27.4 0.017

Values are mean±SD. ESS: Epworth Sleepiness Scale, PSQI: Pittsburgh Sleep Quality Index, AHI: Apnea Hypopnea Index

Table 3.
Effect of excessive daytime sleepiness in patients with obstructive sleep apnea
Clinical value ESS≥11 (n=31) ESS＜11 (n=69) p-value
Age 49.5±12.4 45.9±13.6 0.188
Sex (male:female) 28:3 61:8 0.774
ESS 16.3±3.8 6.1±3.0 ＜0.001
PSQI 8.9±3.0 7.2±3.9 0.022
  Total sleep time (min) 364.2±65.2 385.6±71.2 0.149
  Sleep efficiency (%) 79.5±10.1 87.5±12.5 0.702
Polysomnography
  Total sleep time (min) 342.1±72.1 365.4±76.8 0.018
  Sleep efficiency (%) 85.8±12.4 86.8±13.3 0.532
  Arousal index 31.9±14.1 38.0±17.9 0.491
  Mean SpO2 (%) 95.2±2.2 95.3±2.3 0.939
  Lowest SpO2 (%) 77.5±13.4 78.9±10.7 0.634
  AHI 35.5±25.9 38.4±27.7 0.615

Values are mean±SD. ESS: Epworth Sleepiness Scale, PSQI: Pittsburgh Sleep Quality Index, AHI: Apnea Hypopnea Index

Table 4.
Pearson's correlation analysis between respiratory variables and subjective symptoms of PSQI and ESS in patients with OSA
  r p value
Correlation with PSQI
  AHI -0.028 0.749
  Low SpO2 -0.067 0.450
  Mean SpO2 -0.093 0.291
Correlation with ESS
  AHI 0.100 0.254
  Low SpO2 -0.166 0.058
  Mean SpO2 -0.145 0.098

ESS: Epworth Sleepiness Scale, PSQI: Pittsburgh Sleep Quality Index, AHI: Apnea Hypopnea Index

Table 5.
Cross tabulation analysis of insomnia and excessive daytime sleepiness in patients with obstructive sleep apnea (p=0.67)
  Insomnia (+) Insomnia (-) Total
ESS ≥11 6 25 31
ESS ＜11 16 53 69
Total 22 78 100
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