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Volume 14 No. 05
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Accepted Papers

Scientific Investigations

Prevalence, Associated Clinical Features, and Impact on Continuous Positive Airway Pressure Use of a Low Respiratory Arousal Threshold Among Male United States Veterans With Obstructive Sleep Apnea

Andrey Zinchuk, MD1; Bradley A. Edwards, PhD2,3; Sangchoon Jeon, PhD4; Brian B. Koo, MD5; John Concato, MD1,6; Scott Sands, PhD7; Andrew Wellman, MD, PhD7; Henry K. Yaggi, MD, MPH1
1Department of Medicine, Yale University School of Medicine, New Haven, Connecticut; 2Department of Physiology, Monash University, Melbourne, Victoria, Australia; 3School of Psychological Sciences and Monash Institute of Cognitive and Clinical Neurosciences, Monash University, Melbourne, Victoria, Australia; 4Division of Acute Care/Health Systems, Yale School of Nursing, New Haven, Connecticut; 5Department of Neurology, Yale University, New Haven, Connecticut; 6Clinical Epidemiology Research Center (CERC), VA Connecticut Healthcare System, West Haven, Connecticut; 7Department of Medicine and Department of Neurology, Division of Sleep and Circadian Disorders, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts

Study Objectives:

Determine the prevalence of, and clinical features associated with, a low respiratory arousal threshold (ArTH) among patients with obstructive sleep apnea (OSA), and to assess whether a low ArTH is associated with reduced long-term CPAP use.


Cross-sectional and longitudinal analyses were performed in an observational study conducted among 940 male Veterans with OSA. Data for clinical characteristics, polysomnography characteristics, and long-term (5 ± 2 years) CPAP use were obtained from clinical records. Logistic regression was used to assess the associations between low ArTH and clinical features, including regular CPAP use.


A low ArTH was observed in 38% of participants overall, and was more common among nonobese (body mass index < 30 kg/m2) patients (55%).

In adjusted analyses, increasing body mass index (per 5 kg/m2) and antihypertensive medication use were negatively associated with low ArTH, with odds ratio (OR) (95% confidence interval [CI]) of 0.77 (0.69, 0.87) and 0.69 (0.49, 0.98), respectively. Conversely, increasing age (per 10 years) and antidepressant use—OR (95% CI) 1.15 (1.01,1.31) and 1.54 (1.14,1.98), respectively—were positively associated with low ArTH. Nonobese patients with low ArTH were less likely to be regular CPAP users—OR (95% CI) 0.38 (0.20, 0.72)—in an adjusted model.


Low ArTH is a common trait among Veterans with OSA and is more frequent among those who are older and nonobese and those taking antidepressants, but is less frequent among patients taking antihypertensive medications. A marked reduction of long-term CPAP use in nonobese patients with low ArTH highlights the importance of understanding a patient's physiologic phenotype for OSA management, and suggests potential targets to improve CPAP adherence.


A commentary on this article appears in this issue on page 713.


Zinchuk A, Edwards BA, Jeon S, Koo BB, Concato J, Sands S, Wellman A, Yaggi HK. Prevalence, associated clinical features, and impact on continuous positive airway pressure use of a low respiratory arousal threshold among male United States Veterans with obstructive sleep apnea. J Clin Sleep Med. 2018;14(5):809–817.

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