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1.  Sleep‐disordered breathing after stroke: a randomised controlled trial of continuous positive airway pressure 
Background
Sleep‐disordered breathing (SDB) is common after stroke, but it is unclear whether it should be treated.
Objective
To conduct a randomised controlled trial of continuous positive airway pressure (CPAP) after stroke.
Methods
Patients with stroke with ⩾30 apnoeas and hypopnoeas per hour ((A+H)/h) with predominant obstructive sleep apnoea or hypopnoea were randomised to either CPAP treatment or conservative treatment for 8 weeks. Outcomes were measured blind to treatment allocation at 8 weeks and 6 months after the stroke. The primary outcome was physical function on the Nottingham Extended Activities of Daily Living Scale.
Results
Of 658 patients with stroke screened, only 71 (10.7%) were eligible and consented to a sleep study 14–19 days after stroke. 66 patients completed the sleep study (21 women; mean age 72 years), 33 (50%) had ⩾30 (A+H)/h that were predominantly obstructive. 15 were randomised to CPAP treatment and 15 to conventional treatment. Despite intensive efforts, objective use of CPAP was poor, averaging 1.4 h a night. CPAP treatment resulted in no significant improvements (p>0.1) in the primary outcome or in neurological function or sleepiness, and in poorer health status on some measures.
Conclusions
This trial showed no benefit from CPAP treatment, the relevance of the observed detrimental effects is questionable. Even in our highly selected patients with stroke, use of CPAP was poor. At present, CPAP treatment should be advocated for patients with stroke only if they have symptoms of SDB.
doi:10.1136/jnnp.2005.086686
PMCID: PMC2077531  PMID: 16772358
2.  Sleep · 4: Sleepiness, cognitive function, and quality of life in obstructive sleep apnoea/hypopnoea syndrome 
Thorax  2004;59(7):618-622.
Sleepiness, cognitive performance, and quality of life are overlapping aspects of daytime function that may be affected in patients with obstructive sleep apnoea/hypopnoea syndrome. The evidence is compatible with hypotheses that these deficits are reversible with treatment, particularly for patients with severe disease.
doi:10.1136/thx.2003.015867
PMCID: PMC1747057  PMID: 15223874
3.  Partners of patients with sleep apnoea/hypopnoea syndrome: effect of CPAP treatment on sleep quality and quality of life 
Thorax  2001;56(7):513-518.
BACKGROUND—The sleep apnoea/hypopnoea syndrome (SAHS) causes snoring, apnoeas, and restlessness during sleep which partners frequently complain about. A study was undertaken to determine the impact on partners of SAHS and of treatment of the patient with continuous positive airway pressure (CPAP).
METHODS—Forty nine partners and patients with SAHS booked for CPAP treatment completed in house and validated questionnaires (Pittsburgh sleep quality index, Short Form 36 self-reported health status) before the patient started treatment. Twenty three couples in whom the index SAHS patient had no driving problems were recruited to a randomised crossover trial with 1 month limbs of CPAP and placebo capsule. At the end of each limb the partners' sleep was monitored by home polysomnography (PSG) and questionnaires were completed.
RESULTS—Before treatment partners frequently reported moderate to severe disturbance from patient snoring/apnoeas/restlessness and had poor sleep quality and self-reported health status. In the crossover study (22 completed) the partners' objective sleep quality did not differ between CPAP and placebo, but they reported benefit from treatment of the patients with CPAP in subjective sleep quality (p=0.05) and disturbance to sleep (p=0.03). The reported change in partners' sleep quality between pre-study and following CPAP treatment correlated positively with CPAP use (r=0.5, p=0.01).
CONCLUSIONS—Partners of patients with SAHS have poor sleep quality and self-reported health status but only subjective sleep quality benefits from treatment of the patient with CPAP.


doi:10.1136/thorax.56.7.513
PMCID: PMC1746105  PMID: 11413348
4.  CPAP therapy: outcomes and patient use 
Thorax  1998;53(Suppl 3):S47-S48.
PMCID: PMC1765912  PMID: 10193362
5.  Randomised placebo controlled trial of daytime function after continuous positive airway pressure (CPAP) therapy for the sleep apnoea/hypopnoea syndrome 
Thorax  1998;53(5):341-345.
BACKGROUND—Patients with the sleep apnoea/hypopnoea syndrome (SAHS) report improved sleepiness, cognitive function, and psychological well being after continuous positive airway pressure (CPAP) therapy, and it is for these daytime features that CPAP is usually given. However, few randomised or controlled studies exist on the effects of CPAP on daytime function.
METHODS—A prospective, randomised, single blind, placebo controlled, crossover trial of daytime function after CPAP was conducted in 23 patients with SAHS, all with ⩾15 apnoeas+hypopnoeas/hour and ⩾2 symptoms of SAHS. All patients spent four weeks on CPAP therapy and four weeks on oral placebo treatment, following randomisation to treatment order. With ethics committee approval, patients were told the placebo tablet might improve upper airway function. Average effective CPAP use was monitored using hidden time clocks. Assessments of objective and subjective sleepiness, symptoms, cognitive performance, and psychological well being were performed on the last day of each treatment and compared.
RESULTS—Objective sleepiness measured by sleep onset latency on the multiple sleep latency test improved with CPAP (mean difference from placebo +2.4 min, 95% CI 0.8 to 4.0; p<0.001) as did subjective sleepiness on the Epworth scale (mean difference -6, 95% CI -3 to -9; p = 0.001). Symptom total score also fell with CPAP (mean difference -1.6, 95% CI -2.2 to -1.0; p<0.001). No determinants of these changes with active treatment were identified, and no significant enhancements to cognitive function or psychosocial well being were found in this small sample.
CONCLUSIONS—These findings provide further evidence for clinically significant benefits to daytime function from CPAP.


PMCID: PMC1745223  PMID: 9708223
6.  Effect of CPAP therapy on daytime function in patients with mild sleep apnoea/hypopnoea syndrome 
Thorax  1997;52(2):114-119.
BACKGROUND: Continuous positive airway pressure (CPAP) is an effective treatment in patients with moderate and severe sleep apnoea/hypopnoea syndrome (SAHS), but the minimum illness severity at which patients obtain benefit from CPAP is unclear. A study was therefore undertaken to investigate whether CPAP improves symptoms and daytime function in patients with mild SAHS. METHODS: Sixteen consecutively recruited patients with mild SAHS (5.0-14.9 apnoeas + hypopnoeas per hour slept and two or more symptoms of SAHS) participated in a prospective placebo controlled randomised crossover trial to assess the effects of CPAP on symptoms and daytime function. Patients spent four weeks on placebo and four weeks on CPAP, undergoing assessments of sleepiness, symptoms, cognitive performance, and well being on the last day of each treatment. Data from the placebo and CPAP assessments were compared. RESULTS: The mean (SE) objective effective use of CPAP was 2.8 (0.7) hours per night. Significant improvements in symptom score (-1.7 (0.5), p < 0.01), mental flexibility (-14 (5) seconds, p = 0.02), and depression rating (-1.6 (0.8), p = 0.03) on CPAP were observed. However, no significant differences in subjective or objective sleepiness were found. Ten of the 16 patients preferred CPAP and opted to continue with this treatment, although this proportion was non- significant (p > 0.4). The eight patients with best CPAP use showed an additional CPAP related improvement in quality of life (-4.4 (1.8), p = 0.03). Those who complied better with CPAP therapy also had a higher average microarousal frequency (p < 0.01) and apnoea+hypopnoea index (p = 0.02) than the poorer compliers. CONCLUSIONS: The results of this study provide evidence for improvements in symptoms and daytime function for patients with mild SAHS treated with CPAP. 



PMCID: PMC1758499  PMID: 9059469
7.  Self assessment of daytime sleepiness: patient versus partner. 
Thorax  1995;50(9):994-995.
BACKGROUND--Patients with the sleep apnoea/hypopnoea syndrome (SAHS) and their spouses often differ in their assessment of the patient's sleepiness. A study was therefore undertaken to investigate whether either the patient's or partner's rating on the Epworth sleepiness scale (ESS) was better related to illness severity. METHODS--Nocturnal variables (apnoeas+hypopnoeas/hour (AHI) and arousals/hour) and patient and partner ESS scores were compared in 103 new patients attending the sleep clinic. RESULTS--Mean patient and partner ESS scores were not different. In the whole population neither patient nor partner ESS variables correlated with AHI or arousal frequency. In the patients with SAHS (AHI > or = 15), partner ESS correlated weakly with AHI, but patient ESS did not. CONCLUSIONS--This study suggests that neither patient nor partner ESS ratings are strong predictors of SAHS severity.
PMCID: PMC1021317  PMID: 8539684
9.  Compliance with CPAP therapy in patients with the sleep apnoea/hypopnoea syndrome. 
Thorax  1994;49(3):263-266.
BACKGROUND--Continuous positive airway pressure (CPAP) therapy is the treatment of choice for the sleep apnoea/hypopnoea syndrome. Compliance with this relatively obtrusive therapy has not been well studied. METHODS--Usage of CPAP was investigated in 54 patients with sleep apnoea/hypopnoea syndrome (median 36 (range 7-129) apnoeas + hypopnoeas/hour slept) over the first 1-3 months after starting CPAP therapy. In all cases CPAP usage was monitored by hidden time clocks that indicated for how long the machines were switched on--that is, the CPAP run time. In 32 patients the time at which the CPAP mask pressure was at the therapeutic level of CPAP pressure set for that patient--that is, the mask time--was also monitored. In all patients objective daytime sleepiness was assessed by multiple sleep latency before and after CPAP therapy. RESULTS--The mean (SE) nightly CPAP run time was 4.7 (0.4) hours. There was no correlation between run time and severity of the sleep apnoea/hypopnoea syndrome as assessed by apnoea + hypopnoea frequency or multiple sleep latency, and no correlation between CPAP usage and improvement in multiple sleep latency. Thirty two patients in whom mask time was recorded had therapeutic CPAP pressures for 89% (3%) of their CPAP run times. Patients who experienced side effects from CPAP used their CPAP machines significantly less than those who did not. CONCLUSIONS--Patients with sleep apnoea/hypopnoea syndrome used CPAP for less than five hours/night on average with no correlation between severity of sleep apnoea/hypopnoea syndrome and CPAP usage. Patients who complained of side effects used their CPAP therapy less. It is recommended that, as a minimum, CPAP run time should be regularly recorded in all patients receiving CPAP therapy.
PMCID: PMC1021157  PMID: 8202884
10.  Daytime sleepiness, cognitive performance and mood after continuous positive airway pressure for the sleep apnoea/hypopnoea syndrome. 
Thorax  1993;48(9):911-914.
BACKGROUND--Patients with the sleep apnoea/hypopnoea syndrome often receive continuous positive airway pressure to improve their symptoms and daytime performance, yet objective evidence of the effect of this treatment on cognitive performance is lacking. METHODS--A prospective parallel group study was performed comparing the change in objective daytime sleepiness as assessed by multiple sleep latency, cognitive function, and mood in 21 patients (mean (SE) number of apnoeas and hypopnoeas/hour 57 (6)) who received continuous positive airway pressure for three months and 16 patients (49(6) apnoeas and hypopnoeas/hour) who received conservative treatment for a similar period. RESULTS--Both groups showed significant within group changes in cognitive function between baseline and three months, but when comparisons were made between groups the only significant difference was a greater improvement in multiple sleep latency with continuous positive airway pressure. However, the improvement in sleep latency with continuous positive airway pressure was relatively small (3.5 (0.5) to 5.6 (0.7) min). The group treated with continuous positive airway pressure was divided into those who complied well with treatment (> 4.5 hours/night) and those who did not. Those who complied well (n = 14) showed significant improvement in mean sleep latency and also in depression score compared with the controls but no greater improvement in cognitive function. CONCLUSION--This study confirms significant improvements in objective sleepiness and mood with continuous positive airway pressure, but shows no evidence of major improvements in cognitive function.
PMCID: PMC464776  PMID: 8236074
11.  Morbidity in nocturnal asthma: sleep quality and daytime cognitive performance. 
Thorax  1991;46(8):569-573.
Most patients with asthma waken with nocturnal asthma from time to time. To assess morbidity in patients with nocturnal asthma nocturnal sleep quality, daytime sleepiness, and daytime cognitive performance were measured prospectively in 12 patients with nocturnal asthma (median age 43 years) and 12 age and intellect matched normal subjects. The median (range) percentage overnight fall in peak expiratory flow rate (PEF) was 22 (15 to 50) in the patients with nocturnal asthma and 4 (-4 to 7) in the normal subjects. The patients with asthma had poorer average scores for subjective sleep quality than the normal subjects (median paired difference 1.1 (95% confidence limits 0.1, 2.3)). Objective overnight sleep quality was also worse in the asthmatic patients, who spent more time awake at night (median difference 51 (95% CL 8.1, 74) minutes), had a longer sleep onset latency (12 (10, 30) minutes), and tended to have less stage 4 (deep) sleep (-33 (-58, 4) minutes). Daytime cognitive performance was worse in the patients with nocturnal asthma, who took a longer time to complete the trail making tests (median difference 62 (22, 75) seconds) and achieved a lower score on the paced serial addition tests (-10 (-24, -3)). Mean daytime sleep latency did not differ significantly between the two groups (2 (-3, 7) minutes). It is concluded that hospital outpatients with stable nocturnal asthma have impaired sleep quality and daytime cognitive performance even when having their usual maintenance asthma treatment.
PMCID: PMC463276  PMID: 1926025
12.  Cerebrospinal fluid pressure in pyogenic meningitis. 
Archives of Disease in Childhood  1989;64(6):814-820.
The pressure of cerebrospinal fluid taken at lumbar puncture was recorded objectively by strain gauge pressure measurement in 35 infants and children with pyogenic meningitis. Raised pressures were found in 33 children. The median pressure was 15 mm Hg (range 4-70 mm Hg) in all age groups. The pressure level varied throughout the infection, but a higher median pressure (19 mm Hg) was found when this was measured on the day of admission. The clinical features of the meningitis in these patients suggest that many of the presenting symptoms and signs are those of pressure. These results show that high pressure is frequently present in childhood meningitis, not just in those who die from cones or who have radiological evidence of hydrocephalus. We conclude that raised cerebrospinal fluid pressure is a frequent accompaniment of childhood meningitis and may need treatment in its own right and is therefore one further important factor influencing the course and outcome of childhood meningitis.
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PMCID: PMC1792580  PMID: 2673052
13.  Symptoms and signs of progressive hydrocephalus. 
Archives of Disease in Childhood  1989;64(1):124-128.
The clinical features of 107 cases of children with hydrocephalus and measured raised intraventricular pressure were analysed retrospectively. Fifty one children had recently been diagnosed as having hydrocephalus, and the remainder had had shunts injected to direct the cerebrospinal fluid. The most common symptoms in the group were vomiting, behavioural changes, drowsiness, and headaches. The most common clinical signs were inappropriately increasing occipitofrontal head circumferences, tense anterior fontanelles, splayed sutures, and distension of the scalp veins. Half the infantile cases of hydrocephalus were without symptoms, and a quarter of the cases with cerebrospinal fluid shunts and measured raised intraventricular pressure were without signs. There were no fewer than 33 different clinical signs including several unusual ones, such as macular rash and sweating. We believe that the presentation of hydrocephalus with raised intraventricular pressure is sufficiently variable, unusual, or even absent to justify the direct measurement of intracranial pressure.
PMCID: PMC1791823  PMID: 2923462

Results 1-13 (13)