title: Supine position and REM dependence in obstructive sleep apnea : Critical model considerations.
abstract: BACKGROUND
  When considering supine position and REM dependence, many studies refer to the traditional definition in which obstructive sleep apnea (OSA) severity is at least doubled in the corresponding position/sleep stage (Cartwright index). The lack of consideration of the time spent in that particular sleep situation can lead to clinical bias.
  
  
  METHODS
  Two cohorts of patients with at least moderate OSA were analyzed retrospectively for anthropometric associations and correlations with OSA severity. One group consisted of 48 patients diagnosed using a polygraph, and the other group of 222 patients underwent polysomnography. First, the conventional Cartwright index was used, and a modified index was later applied to integrate the relative time component for REM sleep and the supine position.
  
  
  RESULTS
  Less than a fifth of the patients fulfilled the classic conditions for supine position or REM sleep dependency. There were no definitive cut-offs in the classic or modified Cartwright index with regard to daytime sleepiness. Both indices show there was a correlation between OSA severity and being overweight.
  
  
  CONCLUSIONS
  The modified Cartwright index allowed us to identify borderline cases that were characterized by a very low or high amount of time spent in the supine position or REM sleep situation. Therapy effects that could have been biased only by varying amounts of time spent in the supine position could be better controlled for. Future studies will possibly include various other ratios besides the previously accepted 2:1 ratio when different statistical parameters are considered, such as the reduction of OSA severity or therapy adherence.
authors.affiliation: Department for Otorhinolaryngology, Head and Neck Surgery, University of Luebeck, Ratzeburger Allee 160, 23538, Lübeck, Germany. armin.steffen@uksh.de.
authors.forename: A
authors.initials: A
authors.lastname: Steffen
authors.affiliation: Department for Otorhinolaryngology, Head and Neck Surgery, University of Luebeck, Ratzeburger Allee 160, 23538, Lübeck, Germany.
authors.forename: L
authors.initials: L
authors.lastname: Maibücher
authors.affiliation: Institute of Medical Biometry and Statistics, University of Luebeck, Ratzeburger Allee 160, 23538, Lübeck, Germany.
authors.forename: I R
authors.initials: IR
authors.lastname: König
mesh_terms: D003936:Diagnosis, Computer-Assisted / Q000379:methods; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D017286:Polysomnography / Q000379:methods; D020187:REM Sleep Behavior Disorder / Q000150:complications / Q000503:physiopathology*; D015203:Reproducibility of Results; D012189:Retrospective Studies; D012680:Sensitivity and Specificity; D012720:Severity of Illness Index; D020181:Sleep Apnea, Obstructive / Q000150:complications / Q000175:diagnosis* / Q000503:physiopathology*; D012895:Sleep, REM; D016683:Supine Position
keywords: Polysomnography; Sleep apnea syndromes; Sleep stages; Sleep-disordered breathing; Supine position