Special article
Upcoming Scenarios for the Comprehensive Management of Obstructive Sleep Apnea: An Overview of the Spanish Sleep NetworkEscenarios futuros en el manejo integral de la apnea obstructiva del sueño: perspectiva del Spanish Sleep Network

https://doi.org/10.1016/j.arbres.2019.05.017Get rights and content

Abstract

Sleep is considered an essential part of life and plays a vital role in good health and well-being. Equally important as a balanced diet and adequate exercise, quality and quantity of sleep are essential for maintaining good health and quality of life. Sleep-disordered breathing is one of the most prevalent conditions that compromises the quality and duration of sleep, with obstructive sleep apnea (OSA) being the most prevalent disorder among these conditions. OSA is a chronic and highly prevalent disease that is considered to be a true public health problem. OSA has been associated with increased cardiovascular, neurocognitive, metabolic and overall mortality risks, and its management is a challenge facing the health care system. To establish the main future lines of research in sleep respiratory medicine, the Spanish Sleep Network (SSN) promoted the 1st World Café experts’ meeting. The overall vision was established by consensus as “Sleep as promoter of health and the social impact of sleep disturbances”. Under this leitmotiv and given that OSA is the most prevalent sleep disorder, five research lines were established to develop a new comprehensive approach for OSA management: (1) an integrated network for the comprehensive management of OSA; (2) the biological impact of OSA on comorbidities with high mortality, namely, cardiovascular and metabolic diseases, neurocognitive diseases and cancer; (3) Big Data Analysis for the identification of OSA phenotypes; (4) personalized medicine in OSA; and (5) OSA in children: current needs and future perspectives.

Resumen

El sueño se considera una parte esencial de la vida y es vital para una buena salud y para el bienestar. De igual importancia que una dieta equilibrada y una adecuada actividad física, la calidad y la cantidad del sueño son esenciales para mantener una buena salud y calidad de vida. Las alteraciones respiratorias del sueño son los trastornos más prevalentes que comprometen la calidad y duración del sueño, siendo el síndrome de la apnea obstructiva del sueño (SAHS) el más frecuente. El SAHS es una enfermedad de elevada prevalencia que se considera un problema de salud pública. Se ha asociado con aumento del riesgo cardiovascular, neurocognitivo, metabólico y especialmente de mortalidad, y su manejo representa un reto para el sistema de salud. Para establecer las principales líneas futuras de investigación en medicina respiratoria del sueño, el Spanish Sleep Network promovió la primera edición del World Cafe experts’ meeting. El mensaje principal «El sueño como promotor de la salud y el impacto social de los trastornos del sueño» se estableció por consenso. Bajo este lema y dado que el SAHS es el trastorno del sueño más prevalente, se establecieron cinco líneas de investigación para desarrollar una aproximación completa para el manejo de este síndrome: 1) Una red integrada para el manejo del SAHS; 2) El impacto biológico del SAHS en las comorbilidades con elevada mortalidad como la enfermedad cardiovascular, las enfermedades metabólicas y neurocognitivas y el cáncer; 3) El análisis de grandes bases de datos para la identificación de fenotipos del SAHS; 4) Medicina personalizada en el SAHS, y 5) El SAHS en niños: necesidades actuales y perspectivas futuras.

Introduction

Worldwide, obesity, physical inactivity, and poor diet quality are creating an unsustainable burden of chronic disease. Good sleep quality is also essential for maintaining good health and quality of life. Among the sleep disorders (SD), sleep-disordered breathing (SDB) is one of the most prevalent conditions that compromise sleep quality. The predominant condition associated with SDB is obstructive sleep apnea (OSA), which affects at least 10% of the middle-aged population.1, 2, 3

The management of OSA is challenging the health care system. Diagnosis and treatment of this condition are expensive and require complex tools that are not available in all areas. This chronic and highly prevalent disease has been associated with increased cardiovascular, neurocognitive, metabolic and overall mortality risks, which have contributed to an increasing interest in new strategies for its management.

The SSN is a multidisciplinary research group that has contributed to the identification of OSA impacts and management over the last 20 years. Its main objective has been to promote research in the field of sleep and was developed based on three fundamental pillars: friendship, generosity, and collaborative work. As a result, this network has generated numerous and outstanding contributions in this area that have been pioneering, especially in the development of some of the leading randomized studies in our field. The aim of the 1st World Café, that occurred in March 2017 in Guadalajara (Spain), was to assemble the talent needed to promote the exchange of knowledge and creation of new ideas with the purpose of establishing the main future investigation lines for sleep respiratory medicine for the next 5 years. This meeting attempted to bring together the main scientific societies associated with sleep disorders in Spain: Sociedad Española de Neumología y Cirugía Torácica (SEPAR), Sociedad Española de Sueño (SES), Centro de Investigaciones Biomédicas en Red (CIBER), Federación Española de Medicina del Sueño (FESMES) and a representation of the most relevant Spanish sleep researchers. To assure generational renewal during this meeting, a group of young researchers assumed the lead of the future actions of the SSN. The overall vision was established by consensus as “Sleep as promoter of health and the social impact of sleep disturbances”. Under this focus and with OSA being the most prevalent SD, five research lines were discussed: (1) to incorporate and involve all levels of care; (2) to explore the biological impact of OSA on diseases with high mortality; (3) to cluster and phenotype OSA; (4) to personalize OSA management using current m-Health and smart technologies; and (5) to study the impact of OSA and specific management of the disease in children.

The purpose of this paper is to document the discussions and conclusions from this important meeting (Fig. 1) for dissemination to the scientific community.

Section snippets

Integrated network for the comprehensive management of OSA

In recent years, there has been an increase in the demand for consultations and diagnostic studies in sleep units, which has resulted in long waiting lists and high costs.4, 5 It is unrealistic to assume that adequate management of a chronic and highly prevalent disease such as OSA can be accomplished by sleep specialists alone. There is a need for a new care model for OSA management, namely, an integrated network that involves all healthcare levels. The involvement of primary care in OSA

Biological impact of OSA on comorbidities with high mortality: cardiovascular disease, neurocognitive disease and cancer

SD have been strongly associated with an increased risk for several diseases associated with high mortality and social impacts, such as cardiovascular disease,16 neurocognitive impairment,17 and cancer.18

The presence of OSA leads to pathophysiological mechanisms that include intermittent hypoxia (IH), sleep fragmentation and changes in intrathoracic pressure. These alterations seem to activate inflammation, sympathetic activation, hypercoagulability, endothelial dysfunction, oxidative stress

Big data analysis for the identification of OSA phenotypes

Efficient tools should be used to characterize the population to predict patients at high risk of suffering from the consequences of OSA. One of the current tools is the analysis of large data sets through a big data methodological approach. This type of analysis has had a significant impact on the medical field. It permits accurate modeling of complex diseases and offers new opportunities for innovative clinical applications to subsequently benefit the patient. The increasing availability of

Personalized medicine in OSA

As mentioned, OSA requires personalized medicine to classify the different phenotypes of the disease to prescribe precise and adequate treatment that is targeted to the needs of individual patients on the basis of their genetic, biomarker, phenotypic, or psychosocial characteristics. Efforts to perform unbiased clustering have suggested that additional parameters in the classification approaches may be of value in more clearly defining the subjects.

The gold standard for OSA diagnosis is

OSA in children: current needs and future perspectives

The relevance of OSA in childhood is linked to two fundamental aspects: its prevalence and its important health consequences.43, 44, 45 The prevalence of OSA in children ranges from 0.2 to 4.1%43, 44, 45 and 21.5 to 46.6%46 in obese children. The pathogenesis of childhood OSA is multifactorial.43, 44, 45 Adenotonsillar hypertrophy is the most frequent cause,43, 44, 45 but craniofacial alterations, functional factors, abnormal neurological control and obesity are also implicated. The NANOS-Study

Conclusions

The main conclusions of these five lines of study are summarized as Key points in Table 1.

Conflict of interests

Olga Mediano, Irene Cano-Pumarega, Manuel Sánchez-de-la-Torre, María Luz Alonso-Álvarez, María Fernanda Troncoso, Francisco García-Río, Carlos Egea, Joaquín Durán Cantolla, Joaquín Terán-Santos, Juan Fernando Masa, Josep María Montserrat: none declared.

Ferran Barbé: received a research grant from ResMed Foundation USA, Philips USA, the Health Research Fund, Spanish Ministry of Health, the Spanish Respiratory Society (SEPAR) and Oxigen Salud Spain.

Acknowledgements

To the Sociedad Española de Neumología y Cirugía Torácica (SEPAR), the Sociedad Española de Sueño (SES), the Centro de Investigaciones Biomédicas en Red (CIBER) and the Spanish Sleep Network (SSN) members, especially those who participated in the 1st World Café meeting (Guadalajara, Spain). This work is especially dedicated to our dear friend Joaquin Teran, one of the fathers and architects of the SSN who gave us a life of friendship, affection, enthusiasm and exemplary professionalism.

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    The authors of the Spanish Sleep Network are included in Appendix A.

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