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Correspondence |

Excessive Daytime Sleepiness in Women Without OSA FREE TO VIEW

Pierluigi Carratú, MD, PhD; Ersilia Tedeschi, MD; Onofrio Resta, MD, FCCP
Author and Funding Information

University of Bari Bari, Italy

Pierluigi Carratú, MD, PhD, Pulmonary Medicine, University of Bari, Piazza G. Cesare 12, Bari 70100, Italy; e-mail: pierluigicarratu@yahoo.com


The authors have reported to the ACCP that no significant conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (www.chestjournal.org/site/misc/reprints.xhtml).


© 2009 American College of Chest Physicians


Chest. 2009;136(2):648-649. doi:10.1378/chest.09-0175
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To the Editor:

We read with great interest the recent article in CHEST (November 2008) entitled “Daytime Sleepiness Relates to Snoring Independent of the Apnea-Hypopnea Index in Women From the General Population.”1 In their article, Svensson and colleagues1 demonstrated that both excessive daytime sleepiness (EDS) and daytime fatigue are related to habitual snoring independently of the apnea-hypopnea index (AHI). Previous reports2,3 have shown a possible correlation among AHI, EDS, and snoring. More recently, Young and colleagues4 reported daytime sleepiness in snoring men and women from a general population without sleep apnea; on the other hand, Gottlieb and colleagues5 showed an increased Epworth sleepiness scale (ESS) score in snoring men and women in different categories of apnea-hypopnea frequency. In addition, sleep apnea symptoms were also reported to occur at a lower AHI in women compared with men.4

The pathophysiology of sleep-related disorders is likely to be different between women and men. Our group has previously evaluated, in a population of women with a body mass index of > 30 kg/m2, the relationships between EDS, AHI, and snoring. We showed that habitual snoring and EDS were present in 47% and 35%, respectively, of obese women without obstructive sleep apnea (OSA), while women with habitual snoring showed the highest ESS score. Conversely, no correlations were observed among ESS, AHI, body mass index, and body fat distribution. Similar results were also reported by Klink et al,6 who showed that snoring was a significant risk factor for EDS in the general population.

The relationship between EDS and both snoring and OSA remains unclear. Svensson and colleagues1 hypothesized that snoring-related daytime sleepiness might be due to upper airway resistance syndrome, which is characterized by episodes of increased respiratory effort followed by arousals and daytime sleepiness. Other authors6,7 have demonstrated nocturnal hyperarousability and daytime hypoarousability in obese women. In our article,7 we showed a lower percentage of sleep in the rapid eye movement phase and lower sleep efficiency in obese snoring subjects compared with control subjects. On the other hand, the relationship between snoring and EDS in women from the general population needs to be elucidated. One possible explanation is that the upper airway vibrations from snoring may cause inflammation. Indeed, the levels of systemic inflammatory cytokines positively correlated with EDS and fatigue.8 Based on these results, it would seem conceivable to treat the snoring.

In this regard, many authors7,9 have shown that the presence of habitual snoring strongly correlates with cardiovascular morbidity, independently of sleep apnea. Taken together, these results suggest that a simple evaluation of snoring history may be a useful indicator of EDS in obese snoring women without OSA.

Svensson M, Franklin KA, Theorell-Haglöw J, et al. Daytime sleepiness relates to snoring independent of the apnea-hypopnea index in women from the general population. Chest. 2008;134:919-924. [PubMed] [CrossRef]
 
Guilleminault C, Stoohs R, Duncan S. Snoring (I): daytime sleepiness in regular heavy snorers. Chest. 1991;99:40-48. [PubMed]
 
Hoffstein V, Mateika JH, Mateika S. Snoring and sleep architecture. Am Rev Respir Dis. 1991;143:92-96. [PubMed]
 
Young T, Hutton R, Finn L, et al. The gender bias in sleep apnea diagnosis: are women missed because they have different symptoms? Arch Intern Med. 1996;156:2445-2451. [PubMed]
 
Gottlieb DJ, Yao Q, Redline S, et al. Does snoring predict sleepiness independently of apnea and hypopnea frequency. Am J Respir Crit Care Med. 2000;162:1512-1517. [PubMed]
 
Klink ME, Dodge R, Quan SF. The relation of sleep complaints to respiratory symptoms in a general population. Chest. 1994;105:151-154. [PubMed]
 
Resta O, Foschino Barbaro MP, Bonfitto P, et al. Low sleep quality and daytime sleepiness in obese patients without obstructive sleep apnoea syndrome. J Intern Med. 2003;253:536-543. [PubMed]
 
Vgontzas AN, Papanicolaou DA, Bixler EO, et al. Sleep apnea and daytime sleepiness and fatigue: relation to visceral obesity, insulin resistance, and hypercytokinemia. J Clin Endocrinol Metab. 2000;85:1151-1158. [PubMed]
 
Hedner J, Ejnell H, Caidahl K. Left ventricular hypertrophy independent of hypertension in patients with obstructive sleep apnoea. J Hypertens. 1990;8:941-946. [PubMed]
 

Figures

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References

Svensson M, Franklin KA, Theorell-Haglöw J, et al. Daytime sleepiness relates to snoring independent of the apnea-hypopnea index in women from the general population. Chest. 2008;134:919-924. [PubMed] [CrossRef]
 
Guilleminault C, Stoohs R, Duncan S. Snoring (I): daytime sleepiness in regular heavy snorers. Chest. 1991;99:40-48. [PubMed]
 
Hoffstein V, Mateika JH, Mateika S. Snoring and sleep architecture. Am Rev Respir Dis. 1991;143:92-96. [PubMed]
 
Young T, Hutton R, Finn L, et al. The gender bias in sleep apnea diagnosis: are women missed because they have different symptoms? Arch Intern Med. 1996;156:2445-2451. [PubMed]
 
Gottlieb DJ, Yao Q, Redline S, et al. Does snoring predict sleepiness independently of apnea and hypopnea frequency. Am J Respir Crit Care Med. 2000;162:1512-1517. [PubMed]
 
Klink ME, Dodge R, Quan SF. The relation of sleep complaints to respiratory symptoms in a general population. Chest. 1994;105:151-154. [PubMed]
 
Resta O, Foschino Barbaro MP, Bonfitto P, et al. Low sleep quality and daytime sleepiness in obese patients without obstructive sleep apnoea syndrome. J Intern Med. 2003;253:536-543. [PubMed]
 
Vgontzas AN, Papanicolaou DA, Bixler EO, et al. Sleep apnea and daytime sleepiness and fatigue: relation to visceral obesity, insulin resistance, and hypercytokinemia. J Clin Endocrinol Metab. 2000;85:1151-1158. [PubMed]
 
Hedner J, Ejnell H, Caidahl K. Left ventricular hypertrophy independent of hypertension in patients with obstructive sleep apnoea. J Hypertens. 1990;8:941-946. [PubMed]
 
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