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Prevalence of sleep-disordered breathing in the general population: the HypnoLaus study

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Summary

Background

Sleep-disordered breathing is associated with major morbidity and mortality. However, its prevalence has mainly been selectively studied in populations at risk for sleep-disordered breathing or cardiovascular diseases. Taking into account improvements in recording techniques and new criteria used to define respiratory events, we aimed to assess the prevalence of sleep-disordered breathing and associated clinical features in a large population-based sample.

Methods

Between Sept 1, 2009, and June 30, 2013, we did a population-based study (HypnoLaus) in Lausanne, Switzerland. We invited a cohort of 3043 consecutive participants of the CoLaus/PsyCoLaus study to take part. Polysomnography data from 2121 people were included in the final analysis. 1024 (48%) participants were men, with a median age of 57 years (IQR 49–68, range 40–85) and mean body-mass index (BMI) of 25·6 kg/m2 (SD 4·1). Participants underwent complete polysomnographic recordings at home and had extensive phenotyping for diabetes, hypertension, metabolic syndrome, and depression. The primary outcome was prevalence of sleep-disordered breathing, assessed by the apnoea-hypopnoea index.

Findings

The median apnoea-hypopnoea index was 6·9 events per h (IQR 2·7–14·1) in women and 14·9 per h (7·2–27·1) in men. The prevalence of moderate-to-severe sleep-disordered breathing (≥15 events per h) was 23·4% (95% CI 20·9–26·0) in women and 49·7% (46·6–52·8) in men. After multivariable adjustment, the upper quartile for the apnoea-hypopnoea index (>20·6 events per h) was associated independently with the presence of hypertension (odds ratio 1·60, 95% CI 1·14–2·26; p=0·0292 for trend across severity quartiles), diabetes (2·00, 1·05–3·99; p=0·0467), metabolic syndrome (2·80, 1·86–4·29; p<0·0001), and depression (1·92, 1·01–3·64; p=0·0292).

Interpretation

The high prevalence of sleep-disordered breathing recorded in our population-based sample might be attributable to the increased sensitivity of current recording techniques and scoring criteria. These results suggest that sleep-disordered breathing is highly prevalent, with important public health outcomes, and that the definition of the disorder should be revised.

Funding

Faculty of Biology and Medicine of Lausanne, Lausanne University Hospital, Swiss National Science Foundation, Leenaards Foundation, GlaxoSmithKline, Ligue Pulmonaire Vaudoise.

Introduction

Sleep-disordered breathing is a chronic disorder caused by repeated upper-airway collapse during sleep, resulting in recurrent nocturnal asphyxia, fragmented sleep, major fluctuations in blood pressure, and increased sympathetic nervous system activity.1 Furthermore, patients with untreated sleep-disordered breathing are at increased risk of hypertension, stroke, heart failure, diabetes, car accidents, and depression.2, 3, 4, 5, 6, 7, 8, 9 Polysomnography is the gold standard to diagnose sleep-disordered breathing. However, despite the important effect of sleep-disordered breathing on public health, only a few attempts have been made to screen the general population for this disorder using polysomnography. In the late 1980s and early 1990s, three large cohort studies were done in the USA: the Wisconsin Sleep Cohort Study,10 the Sleep Heart Health Study,11 and the Penn State Cohort.12 From these studies, the prevalence of sleep-disordered breathing—defined by an apnoea-hypopnoea index greater than five events per h—was estimated to be between 6·5% and 9% in women and between 17% and 31% in men.10, 12 However, this prevalence has since been revised to around 34% in men aged 30–70 years and 17% in women aged 30–70 years.13 Although these studies provide important epidemiological data, they included an enriched selection of people at risk for sleep-disordered breathing (based on questionnaires) or cardiovascular disease. Therefore, the prevalence of sleep-disordered breathing could not be measured directly but was estimated through complex statistical calculations with reference to other population-based studies.

Researchers on subsequent epidemiological studies have either selected specific ethnic groups14, 15 or high-risk populations.16 To record nocturnal breathing, all except a few13, 17 used less sensitive technology (eg, pen and paper recorders, thermocouples, or respiratory inductive plethysmography)16, 18 than nasal pressure technology, which is now the standard of care. Furthermore, pulse oximeters have improved considerably over the years. Both technical developments have increased sensitivity for diagnosis of sleep-disordered breathing. Moreover, the American Academy of Sleep Medicine (AASM) has revised criteria used to define nocturnal respiratory events.19, 20, 21 Because most clinical settings now use recording techniques with increased sensitivity and the new definitions for respiratory events, the prevalence of sleep-disordered breathing and its association with important health outcomes needs to be revisited.

We designed the HypnoLaus Sleep Cohort study to assess the prevalence of sleep-disordered breathing using state-of-the-art polysomnographic recording techniques and updated definitions in a general unselected population. Furthermore, the clinical relevance of the revised definition of sleep-disordered breathing was also investigated by examining its associations with cardiovascular, metabolic, and psychiatric comorbidities.

Section snippets

Participants

We selected participants for our study from individuals included in the population-based CoLaus/PsyCoLaus cohort study, described previously.22, 23 Briefly, the CoLaus/PsyCoLaus study was undertaken between 2003 and 2006 and included a sample of 6733 people aged 35–75 years, who were selected at random (using Stata version 9.1) from the population register of the city of Lausanne, Switzerland (altitude approximately 490 m).22 The distribution of age groups, sex, and postal codes in

Results

Between Sept 1, 2009, and June 30, 2013, a consecutive sample of 3043 people from the CoLaus/PsyCoLaus study cohort were invited to undergo polysomnography overnight at their home (appendix p 1). Of these, 2168 (71%) individuals accepted the invitation and underwent polysomnography. Of the 2168 polysomnographic recordings, 60 (3%) had technical problems resulting in insufficient data; 54 participants underwent a second recording and six people declined. 41 individuals with a total sleep time

Discussion

To our knowledge, the HypnoLaus Sleep Cohort study is the largest study to assess the prevalence of sleep-disordered breathing in a population-based sample using the most recent polysomnographic recording techniques and scoring criteria. We recorded a much higher than previously estimated prevalence of sleep-disordered breathing and an independent association between the disorder and diabetes, hypertension, metabolic syndrome, and depression, albeit mainly in the highest severity quartile of

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